8.9 Radiotherapy: health system implications and discussion

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Clinical practice guidelines for keratinocyte cancer > 8.9 Radiotherapy: health system implications and discussion


Health system implications

Clinical practice

The current recommendations do not change the way in which radiotherapy (RT) services are organised.

Resourcing

Modern RT techniques, particularly volumetric modulated arc therapy (VMAT), require significant resources for provisioning, commissioning and training.

For patients with KCs at sites where preservation of function, cosmesis, or both are high priority, fully fractionated RT requires multiple visits to a radiation facility.

Barriers to implementation

Lack of adequate training, provision and commissioning of modern RT techniques is a potential barrier to the implementation of these recommendations, particularly in non-metropolitan and remote regions.

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Discussion

Unresolved issues

The role of RT among, and in combination with, other treatment modalities for keratinocyte cancers (KCs) is not well defined. Well-designed Australian randomised clinical trials (RTCs) are needed.

The role of RT in the management of incompletely excised KC is even more contentious and ill-defined that that of surgical re-excision.

Studies currently underway

The use VMAT in the treatment of extended skin field cancerisation (ESFC) is currently being evaluated in a RCT comparing it with current therapy. Other RCTs in patients with ESFC are in progress.[1]

A randomised controlled trial (RCT) comparing a new non-woven silicon dressing (Mepitel Film) with standard care in the treatment of radiation dermatitis in patients with head and neck cancer has been registered.[2]

Future research priorities

There is an urgent need for high-quality RCTs in the treatment of KCs in the Australian setting, as we have a unique skin cancer population.

Prospective studies are needed to guide the care of patients with basal cell carcinomas as surgery and radiotherapy techniques improve.

More investigation is needed on the extent of therapy and the appropriate use of RT for the management of cutaneous squamous cell carcinoma with regional spread to the parotid.

Despite the frequency of RT side effects, there is still much research that needs to be done to inform their prevention and management.[3][4]

Basic laboratory work on the radiobiology of skin cancers would be a comparative advantage for Australia and may have implications for the radiation treatment of other cancers.

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References

  1. Fogarty GB, Christie D, Spelman LJ, Supranowicz MJ, Sinclair RS.. Can Modern Radiotherapy be used for Extensive Skin Field Cancerisation: An Update on Current Treatment Options. Biomed J Sci &Tech Res 2018;4(1).
  2. Narvaez C, Doemer C, Idel C, Setter C, Olbrich D, Ujmajuridze Z, et al. Radiotherapy related skin toxicity (RAREST-01): Mepitel® film versus standard care in patients with locally advanced head-and-neck cancer. BMC Cancer 2018 Feb 17;18(1):197 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/29454311.
  3. Chan RJ, Webster J, Chung B, Marquart L, Ahmed M, Garantziotis S. Prevention and treatment of acute radiation-induced skin reactions: a systematic review and meta-analysis of randomized controlled trials. BMC Cancer 2014 Jan 31;14:53 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24484999.
  4. Salvo N, Barnes E, van Draanen J, Stacey E, Mitera G, Breen D, et al. Prophylaxis and management of acute radiation-induced skin reactions: a systematic review of the literature. Curr Oncol 2010 Aug;17(4):94-112 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20697521.


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