8.9 Radiotherapy: health system implications and discussion
Health system implications
The current recommendations do not change the way in which radiotherapy (RT) services are organised.
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.
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.
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.
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.
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.
- Radiotherapy – Introduction
- Radiotherapy with or without surgical treatment for keratinocyte cancer
- Radiotherapy for basal cell carcinoma
- Radiotherapy for cutaneous squamous cell carcinoma
- Radiotherapy for regional (nodal) metastatic disease (non-distant)
- Radiotherapy for actinic keratosis and cutaneous squamous cell carcinoma in situ
- Radiotherapy for keratoacanthoma
- Management of side effects of radiotherapy
- Recent advances in the radiotherapy of skin cancer
- 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).
- 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/29454311.
- 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24484999.
- 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20697521.