Two US cancer nurses have researched the evidence behind a commonly applied rule that cancer patients should not apply skin creams or lotions for four hours before having radiotherapy treatment and found there is little evidence to support this belief and that practice varies widely.

Trish Bieck and Shannon Phillips from the James P. Wilmot Cancer Center, University of Rochester Medical Center, New York, wrote about their research in the journal Clinical Journal of Oncology Nursing; their paper appeared in the January online issue.

Although it might seem like a minor matter compared to the complexity of cancer treatment, skin care is important to radiotherapy patients because the procedure can lead to excessive skin dryness and damage that can lead to infection.

Bieck, who prompted and led the research, has worked in radiation oncology for 20 years. She noticed how skin issues were a constant source of anxiety for patients receiving radiotherapy and began to wonder about how much myth as opposed to evidence lay behind the routine advice they were giving patients about not applying skin creams and lotions in the four hours prior to treatment (as also recommended by the National Cancer Institute).

"It always bothered me that there didn't seem to be any rationale behind restricting lotions during that particular timeframe," she said in a press statement on Tuesday.

"When I looked into it, I discovered little evidence to support the four-hour policies. Instead, the practice was based on historical practice - in other words, 'just because, that's the way we do it', " she added.

For their study, Bieck and Shannon conducted a comprehensive literature review of relevant articles published between 1992 and 2009, interviewed clinical experts, reviewed benchmarks used at international cancer centers and consulted professional nursing organizations.

They found no scientific evidence to support the idea that patients should not apply creams and lotions in the four hours leading up to the radiotherapy treatment, and there was also no evidence that lotions or topical agents like deodorants made the treatment less effective.

They also found wide variation in practice throughout the US. For instance, in five different centers around the country, the advice ranged from no lotion restrictions at all, through avoidance one hour prior to treatment, to complete avoidance of lotions.

The US National Cancer Institute has now revised its recommendations as a result of this study and rewritten its widely distributed brochure, Radiation Therapy and You to incorporate Bieck's and Shannon's findings. (However their webpage on skin changes, retrieved this morning, still mentions the four-hour rule).

Bieck said they have had a lot of feedback about their findings.

"We're very pleased we could explore a topic that makes a difference for patients going through cancer treatment," she told the media.

The research also revealed that practice was influenced by some views that supported use of creams and others that did not.

For example, one widely held theory is that the presence of lotion or cream on the skin during radiotherapy can increase the risk of a bad skin reaction due to a "bolus" effect that inadvertently makes the skin thicker and thereby boosts the surface dose of the radiation.

But on the other hand, there is a view that if you don't apply lotion or cream you risk skin damage and dryness. This can result in infection and pain, which then interrupts the treatment and increases the risk that cancer cells will come back when the skin heals.

This quandary left patients wondering what the best approach should be: use the lotion before treatment and worry that it may reduce its effect, or skip the lotion and risk a bad skin reaction which could interrupt the treatment and increase the risk of the cancer returning?

As a compromise, many institutions like the National Cancer Institute and the University of Rochester Medical Center's Wilmot Cancer Center settled on the four-hour rule: where patients were advised not to apply skin lotions or creams in the four hours prior to receiving radiotherapy.

Following this study, the Wilmot Cancer Center revised its advice and staff there now generally allow patients to maintain control over their usual skin care regimen but recommend they avoid applying lotions immediately before treatment.

"Appraising the Evidence for Avoiding Lotions or Topical Agents Prior to Radiation Therapy."
Trish Bieck and Shannon Phillips.
Clinical Journal of Oncology Nursing, Volume 14, Number 1 / 2010, pp 103-105.
DOI: 10.1188/10.CJON.103-105

Source: University of Rochester Medical Center

Written by: Catharine Paddock, PhD