Many life-saving chemotherapies are also associated with adverse effects that can greatly impact patients’ quality of life, especially women. In a recent review, Jonathan Leventhal, MD, and colleagues overviewed common adverse effects and treatment options for women who are receiving treatment for breast or gynecologic cancers. In this podcast, Dr Leventhal discusses some of the common dermatologic adverse effects, therapies for treating these patients, and the importance of onco-dermatology in treating patients with cancer.
Melissa: Hello, I am Melissa, associate editor of The Dermatologist. Today, we are going to be speaking with Dr Jonathan Leventhal about his latest study, “Dermatologic Conditions in Women Receiving Systemic Cancer Therapy,” published in the International Journal of Women’s Dermatology.
Dr Leventhal is an assistant professor of dermatology, associate director of the residency program, and director of the onco-dermatology clinic at Yale School of Medicine in New Haven, Connecticut. Thank you for speaking with us today, Dr Leventhal.
Dr Leventhal: Of course. Thank you for having me.
Melissa: Why did you and your team decide to do this review?
Dr Leventhal: We thought this was a really important topic. I work as a dermatologist at the Yale Cancer Center. Over there, I commonly see dermatologic reactions to cancer treatments. In particular, I see how they affect women very commonly and they can really have an impact on their lives.
We felt that the International Journal of Women’s Dermatology would be just a great platform to review this topic. In particular, the journal really champions women’s health. We were very happy to be able to contribute to the issue.
Melissa: What are some of the common dermatologic toxicities that you found in your review?
Dr Leventhal: We found that there are many different toxicities to cancer drugs. This really depends on the regimen that’s used. In general, alopecia or anagen effluvium from cytotoxic cancer drugs is, perhaps, the most common of all the toxicities. We really see these reactions in the regimens used to treat the gynecologic and breast cancers in women.
Also, especially for women’s cancer, is nail changes, including onycholysis and paronychia, were very common, especially with the cytotoxic cancer regimens, as well as targeted chemotherapies such as the epidermal growth factor receptor inhibitors, MEK inhibitors, and HER 2 inhibitors, all of which are frequently used to treat women with cancer.
A papular pustular rash was also something that we found and was very common from targeted cancer drugs, such as EGFR inhibitors, MEK inhibitors, and HER 2 inhibitors. Probably, the other very frequent toxicity that we found was hand-foot syndrome, also referred to as toxic erythema chemotherapy. That was really common in the cytotoxic cancer drugs that are used to treat gynecologic and breast cancers.
Melissa: What would be some treatment options for addressing these toxicities?
Dr Leventhal: Fortunately, dermatologists really have the opportunity to make a diagnosis and offer management to patients with cancer. Really, the type of treatment depends on the rash that we’re talking about.
In general, a lot of the mild eruptions usually respond to topical cortical steroids. For instance, the acneiform eruption from EGFR inhibitors usually responds in low grade presentations to topical steroids and topical antibiotics.
At higher grade presentations, patients are treated with oral antibiotics and higher strength topical steroids. Really, only at the higher grade presentations or if a rash has grown intolerable are systemic cortical steroids used and cancer therapy might be interrupted temporarily. For other conditions, such as nail infections or paronychia from cytotoxic or targeted cancer drugs, we usually culture the infection and we’ll often recommend antiseptic soaps, as well as topical antibiotics and even oral antibiotics in more severe presentations.
Interestingly, other conditions like alopecia or hair loss, studies have shown that using topical agents such as minoxidil can actually increase the rate of hair growth. Unfortunately, this doesn’t prevent hair loss. More recently, some randomized control studies suggested that scalp cooling can prevent hair loss from cytotoxic chemotherapy. This is really important for oncologists to know about.
Melissa: What are some rare cutaneous toxicities dermatologists should keep in mind when treating cancer patients?
Dr Leventhal: Rarely, severe reactions can occur, including the severe cutaneous adverse reactions known as the SCARs in dermatology. These include Stevens-Johnson, toxic epidermal necrolysis, acute generalized exanthematous pustulosis, and DRESS. These rarely occur in a minority of patients on systemic cancer drugs.
We found that [these occur] in patients who are on immune checkpoint inhibitors, and as you know, they can have a diversity of presentations. Patients can, rarely, present with bullous pemphigoid reactions, which occur in a minority of patients, perhaps around 1%. That can present with intense itching, pruritus, and intense blistering reaction as well. Fortunately, all of these severe reactions don’t happen very commonly.
Melissa: Several toxicities you discuss in your review were found to impact women more significantly than men. Could you elaborate further on how these toxicities lower quality of life and could potentially impact disease outcomes, as well as the importance of addressing quality of life concerns among female patients?
Dr Leventhal: Absolutely. It’s really important to address the quality of life in a patient with cancer, especially when they have a reaction that a toxicity that’s impacting your functional activities of life and even the way that they view themselves and their emotional health and wellbeing.
Many studies have shown that a lot of the toxicities that we see, such as alopecia, nail changes, the papular pustular rash, and hand-foot syndrome frequently impact patient’s quality of life, and in particular women.
Studies have shown that when they do impact women’s quality of life, they can lower a woman’s self-image, reduce sexuality, and even psychological symptoms, such as depression, can occur. So, it’s very important to address not just the physical complaints but also the emotional wellbeing of our patients.
I might also add that the field of supportive onco-dermatology has really emerged to address this very important need of treating dermatologic conditions in cancer patients. By having a timely diagnosis and management for these toxicities, patients can remain on these potentially life-saving cancer drugs and we can also improve the quality of life for patients with cancer.
Melissa: Why is it important for dermatologists to be a part of a patient’s cancer treatment team?
Dr Leventhal: That’s a really great question. As I mentioned before, the field of onco-dermatology has become such an important component in multidisciplinary care of patients with cancer because we see in cancer centers that patients who are on chemo, radiation, or other cancer treatments, frequently have toxicities that affect their skin, hair, nails, and mucosa.
Dermatologists are more likely to understand the type of rash that’s occurring and give a very accurate diagnosis and grade. I think dermatologists, in general, are more likely to recommend patients remaining on their cancer treatments and being able to treat a certain toxicity as promptly and in the most targeted way as possible, which I think is really important.
We’ve seen that dermatologists can just make a tremendous impact on patients who have cancer and are treated by oncologists.
Melissa: Any other thoughts or comments you would like to leave us with?
Dr Leventhal: Thank you for talking to me. I think it’s great that dermatologists have taken such an interest in treating patients with cancer and it can really make an impact on their overall care. I think the field of onco-dermatology is going to continue to grow. It’s just been a pleasure to be a part of that.
Melissa: It was a pleasure speaking with you, Dr Leventhal.
Dr Leventhal: Absolutely. Thank you for having me.
Melissa: Thank you for listening. Please let us know your thoughts or questions in the comments box above. You can read Dr Leventhal’s study by visiting this link as well. Be sure to share this podcast with your friends and colleagues.