Laffin, N., Smyth, W., Heyer, E., Fasugba, O., Abernethy, G., & Gardner, A. (2015). Effectiveness and acceptability of a moisturizing cream and a barrier cream during radiation therapy for breast cancer in the tropics. Cancer Nursing, 38, 205–214. 

To compare the effectiveness of Cavilon Durable Barrier Cream (Cavilon) and 100% Pure Sorbolene Cream (Sorbolene) for the prevention of moist desquamation in patients with breast cancer receiving radiation in a tropical setting, and to explore patient preference of the two products

Patients applied Cavilon or Sorbalene to intact skin at least twice daily from day 1 of treatment until 4 weeks post completion of treatment. Nurse assessment of skin reactions occurred weekly during treatment, with final skin assessment via telephone one month after completion of the treatment. If moist desquamation occurred, cream was stopped and dressings were applied, which was standard practice.

• N = 245 completed radiation, 218 competed radiation and follow-up interview  
• MEAN AGE = 55.5 years (SD = 11.6 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer with treatment to the breast (173 patients) or to the chest wall (72 patients)
• OTHER KEY SAMPLE CHARACTERISTICS: All patients received 42 Gy/16 fractions to the breast or 50 Gy/25 fractions to the chest wall. Bolus was applied to 70.8% of patients with treatment to the breast wall and 6.9% of patients with treatment to the breast. Bra size, BMI, smoking status, and classification of skin type were obtained at the time of patient consent to participate.

• SITE: Single site    
• SETTING TYPE: Not specified    
• LOCATION: Townsville Cancer Centre, Queensland, Australia

PHASE OF CARE: Active antitumor treatment

Patients were stratified by breast or chest wall radiation with random allocation to barrier (Cavilon) or moisturizing (Sorbolene) cream.

Skin type was determined by using the validated Fitzpatrick Skin Type Scale. Weekly skin assessment was completed using the Common Terminology Criteria and Adverse Events (CTCAE), version 4, scoring criteria. Acceptability of cream was determined by a five-question acceptability survey.

Cavalon was found to significantly reduce moist desquamation during treatment in patients with chest wall radiation (p = 0.047). Participants preferred Cavalon over Sorbolene during treatment (p = 0.02), but no statistical difference in preference of cream existed at follow-up. At the end of treatment, 15% of patients had moist desquamation, and 26% of patients self-reported moist desquamation at telephone follow-up. With pooled data of breast and chest wall treatment, no significant difference existed between skin treatment groups experiencing moist desquamation during treatment and at follow-up. Statistically significant risk factors for moist desquamation were larger breast cup size, i.e., larger than a C cup (p = 0.003); higher BMI (p = 0.01); and prior chemotherapy (p = 0.04). No statistical significance existed with skin type, smoking, or effects of tropical weather measured by the Fitzpatrick scale.

A high incidence for moist desquamation existed in patients receiving radiation for breast cancer, particularly in patients receiving radiation to the chest wall.

• Risk of bias (no blinding)
• Key sample group differences that could influence results
• Measurement validity/reliability questionable
• Intervention expensive, impractical, or training needs
• Patients and nurses could not be blinded to different creams because of differences in texture, smell, and amount needed for application.  
• The sample size for breast treatment was not reached, which may have influenced statistically significant differences in that strata. The sample size for chest wall treatment was sufficient.  
• While higher BMI was found to be a risk factor for the development of moist desquamation, the authors did not define or quantify the BMI that was associated with the toxicity.
• Despite education, possible inconsistencies in nurse grading based on assessment criteria were acknowledged.
• Patient self-reporting at four weeks post treatment completion is a known limitation.
• Barrier cream would be three times the cost of moisturizing cream without use of grant money, a potential factor for ongoing use.

Nurses should discuss risk factors that pertain to patients when educating on the skin effects of radiation. As many patients develop moist desquamation following completion of treatment, discharge information and management plans are needed.