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Radiation therapy is a common component in the treatment of breast cancer. Unfortunately, radiation therapy may cause side effects, often to the site that it is delivered. Side effects to the skin within the area to which the radiation is delivered are among the most common side effects caused by radiation therapy. Dermatitis is an inflammation of the skin, which may cause redness, pain, itching and even blisters or cracked skin. If dermatitis becomes severe enough, optimal dosing and scheduling of radiation is interrupted to allow the skin to heal.

Treatment for early-stage breast cancer often involves breast-conserving surgery (lumpectomy), which may be followed by radiation therapy to decrease risk of recurrence. The objective of radiation therapy to the breast is to kill cancer cells that could otherwise persist after therapy and cause breast cancer to relapse locally in the breast, surrounding chest wall, or axilla. Radiation therapy uses high-energy X-rays to kill cancer cells that remain in the breast or surrounding lymph nodes after surgery. Radiation therapy is often delivered to the breast and surrounding lymph nodes from a machine outside the body; this is called external beam radiation therapy.

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Unfortunately, radiation therapy may cause side effects, often to the site where it is delivered. Side effects to the skin are among the most common side effects caused by radiation therapy. Dermatitis is an inflammation of the skin, which may cause redness, pain, itching, and even blisters or cracked skin. If dermatitis becomes severe enough, optimal dosing and scheduling of radiation is interrupted to allow the skin to heal. Although topical creams are available to help manage skin irritation, many patients may still experience dermatitis caused by radiation therapy. Researchers are evaluating different agents in order to reduce side effects to the skin and allow for optimal delivery of radiation therapy.

Melatonin

Early-stage breast cancer patients undergoing radiation therapy following breast-conserving surgery experienced significantly less skin irritation when they used a melatonin-containing cream compared with a placebo (a cream without melatonin). The results of this study were recently presented at the 2010 Breast Cancer Symposium.[1]

In the current randomized, double-blind study, researchers evaluated the efficacy of melatonin-containing cream in managing radiation-induced skin reactions compared with placebo among early-stage breast cancer patients. Forty-seven patients were enrolled in the study after undergoing breast-conserving surgery and staging procedures.  Participants received either melatonin-containing cream or placebo during radiation therapy. In order to determine efficacy of the cream, patients provided self-reported data in the form of a questionnaire weekly and two weeks following radiation therapy. Patients were also photographed and examined in order to identify skin irritation.

Fifty-nine percent of the patients in the melatonin group experienced acute dermatitis compared with 90% in the placebo group. All skin reactions were mild or moderate (grade 1 or 2). Women over the age of 50 appeared to derive more of a benefit from the melatonin cream than younger women.

The researchers concluded that melatonin cream appeared to be effective in preventing skin irritations due to radiation therapy in this small study. Additional,  larger studies are warranted to confirm these findings.

Calendula

According to a recent article published in The Journal of Clinical Oncology, calendula (Calendula Officinalis) appears more effective than trolamine (Biafine®) at reducing or preventing the incidence of dermatitis caused by radiation in the treatment of breast cancer.

 Trolamine is a topical agent that is often used to prevent or reduce dermatitis caused by radiation therapy. However, approximately half of the patients using trolamine may still experience dermatitis caused by radiation therapy and researchers are evaluating different agents in order to reduce side effects to the skin, allowing for the optimal delivery of radiation therapy.

Researchers from France conducted a clinical trial to compare topical calendula, often known as the marigold, to trolamine in the reduction or prevention of radiation-induced dermatitis in breast cancer patients. This trial included 254 patients who were to receive radiation following surgery in the treatment of breast cancer. Approximately half of the patients were treated with calendula, and the other half with trolamine to the site of radiation following each session. The rate of severe dermatitis (grade II or higher) was only 41% in the patients treated with calendular, compared with 63% of those treated with trolamine. In addition, fewer patients who were treated with calendula had a disruption in their radiation schedule, compared to those treated with trolamine. Patients treated with calendula also experienced less pain caused by radiation than those treated with trolamine.

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The researchers concluded that calendula appears to be more effective than trolamine at reducing or preventing severe radiation-induced dermatitis in patients with breast cancer. By preventing acute dermatitis, more patients were able to maintain optimal radiation schedules, proving an improved chance for superior long-term outcomes. Patients who are to undergo radiation therapy may wish to speak with their physician about the risks and benefits of participating in a clinical trial evaluating calendula or other novel approaches to reducing dermatitis.

Reference: Pommier P, Gomez F, Sunyach M, et al. Phase III randomized trial of Calendula Officinalis compared with trolamine for the prevention of acute dermatitis during irradiation for breast cancer. The Journal of Clinical Oncology. 2004; 22: 1447-1453.

Reference:

Ben-David MA, Elkayam R, Galarenter I and Pfeffer RM. A prospective, double-blind, randomized study of a melatonin-containing cream for radiation-induced breast dermatitis. Presented at the 2010 Breast Cancer Symposium, Washington, DC, October 1-3, 2010. Abstract 123.

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Aloe Vera 

According to an article recently published in Cancer Nursing, aloe vera gel did not significantly reduce radiation-induced skin side effects in women undergoing treatment for breast cancer.

Aloe vera is a succulent plant native to Africa. Its leaves are long, green and fleshy, containing a gel inside that has been used by herbalists for centuries to sooth dry and damaged skin. It has also been used historically to treat minor cuts and burns. Little research has been conducted to investigate the efficacy of aloe vera in a clinical trial context.

A Phase III study conducted in Australia investigated the effectiveness of aloe vera gel on irradiated breast tissue. In addition, the study also explored which patients were most likely to experience skin side effects from radiation. Two hundred twenty-five breast cancer patients who had undergone lumpectomy or partial mastectomy and were undergoing radiation therapy participated in the study. Patients were randomized to receive either aloe vera gel or an aqueous cream, each applied three times daily during treatment and for two weeks following treatment completion. Nurses evaluated and recorded skin conditions once a week.

This trial reported that aqueous cream was significantly more effective than aloe vera gel at reducing dry, peeling skin and its accompanying pain. The data also suggested that women with breasts D cup or larger were significantly more likely to have erythema (skin redness) than women with smaller breasts, regardless of which treatment they used. Smokers who used aqueous cream were significantly more likely to experience itching than nonsmokers using it. Patients using aloe vera gel who had one or more lymphocele drainages after surgery were significantly more likely to experience erythema (skin redness) and itching than those who had not undergone any drainages and used aloe vera gel. Overall, patients undergoing lymphocele drainage that used aloe vera gel were significantly more likely to experience pain than those using aqueous cream. The is no clear explanation for these associations and further research is needed to clarify their implications.

These researchers concluded that aquaeous cream, but not aloe vera gel, appeared useful in reducing radiation-induced skin side effects in breast cancer patients. Patients with breast cancer may wish to speak with their physician about the risks and benefits of CAM or about participation in a clinical trial further evaluating CAM therapies.

Reference: Heggie S, Bryant Gp, Tripcony L, et al. A Phase III study on the efficacy of topical aloe vera gel on irradiated breast tissue. Cancer Nursing. 2002;25:442-51.