Assessment of individual patient and carer needs

To provide care appropriate to patient need requires first assessing and establishing what that need is. Inadequate assessment of the patient’s physical symptoms and psychosocial needs may lead to a failure to recognize their need, with the result that necessary services may be denied to them. However, one of the challenges for today’s cancer care is that effective assessment is dependent on providing appropriate training and education for healthcare professionals to allow them to appreciate the complexity of support needs. This presents another challenge for cancer and radiotherapy services because, in many instances, there is a lack of available supportive care services for the healthcare professional to call on.

So what aspects of the patient’s well being should be assessed? While it is vital that the needs of the patient, in respect of their medical and physical condition, are addressed, it is important that all healthcare professionals acknowledge that central to this process should be asking patients how they are feeling and coping from an emotional and psychological level. In doing this, consideration should be given to patients’ and carers’ needs in relation to:

Physical and psychological symptoms do not sit in isolation from each other and can, indeed, be synergistic. Patients have varying coping mechanisms and family support available to them and this is something that must be considered when supportive care is being addressed.

Patients’ quality of life is affected not only by the physical and emotional impact of their cancer but also the treatments prescribed to treat their condition. Since radiotherapy causes a degree of damage to the normal tissues of the body and can cause local and systemic side effects, this aspect of their management should be considered of pivotal importance. These side effects can be acute or delayed, with acute (early effects) occurring during radiation treatment and continuing after treatment or in the weeks and months following. Although side effects of radiotherapy are to an extent unavoidable, they can be kept to a minimum if patients are well supported and appropriate advice is given as they progress through treatment. Such support and education should be an essential component of the management process for all patients receiving radiotherapy.

Skin reactions

One such side effect is the reaction of skin to radiotherapy. Although there have been recent advances in the technical delivery of radiotherapy which have resulted in the use of higher energy beams, customised treatment shapes and escalated dose, skin toxicity still remains a challenge. Indeed the situation may also be further enhanced with the increasing trend of combined adjuvent therapies. All patients receiving external beam therapy are at some risk of skin damage [3] and as such, in most departments this is addressed by offering suitable advice and support by monitoring and recording the severity of these reactions during treatment.

Skin reactions range from mild erythema to moist desquamation and occur more frequently in the head and neck area, breast and chest wall and areas with skin folds. The most widely used assessment tool is the Radiation Therapy Oncology Group grading (Table 34.1).

Table 34.1 Radiation Therapy Oncology Group grading of acute skin reactions

The severity of skin reactions has been attributed to a number of extrinsic (treatment related) and intrinsic (how people react to radiotherapy) factors [4] and these may well have a genetic basis. However, the goal of good management is to have a system in place which facilitates the identification of risk and delays the onset of skin reactions. This can be facilitated by having a patient review process that includes the assessment grading and recording of skin reactions.

Patients should be provided with information explaining:

Involving patients in the prevention/care of skin reactions is an important element of the management process and reducing irritants to irradiated skin is a part of this self-care strategy. Skin can be exposed to a number of irritants which, if avoided, can lessen the likelihood of a troublesome reaction (Table 34.2) [5, 6].

Table 34.2 Recommendations for reducing irritants to irradiated skin during a course of radiotherapy

How to care for radiation skin reactions once they have occurred and what products to recommend in this event requires a knowledge of the more general wound care literature. It is important that advice and treatment given to patients is evidence based and that advice such as ‘no washing’ is now seen as inappropriate. Sadly this remains an area which lacks robust evidence from the literature, which in turn, creates challenges when making recommendations, Table 34.3 provides some small detail of skin-care products which can be utilized.

Table 34.3 Characteristics of skin-care products for each stage of radiation skin reactions

Other sources which may be useful include published national skin-care guidelines [7]. When moist desquamation becomes infected or infection is suspected, use of a silver or iodine based antimicrobial dressing may be used. Care should be taken to ensure the dressing is designed to prevent silver being absorbed by the wound (check manufacturer’s information) and the dressing should be removed daily before treatment.

Nutrition

Related posts:

Principles of management of patients with cancer Radiation treatment planning: immobilization, localization and verification techniques Thyroid cancer Imaging with radionuclides Radiotherapy beam production Imaging with x-ray, MRI and ultrasound

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