Nurses Play Important Part in Recognizing Skin Toxicities, Abnormalities

Krista M. Rubin, MS, RN

As part of our coverage of the Oncology Nursing Society 41^st Annual Congress held April 28–May 1 in San Antonio, Texas, today we are speaking with Krista Rubin, MS, RN, a nurse practitioner in the Center for Melanoma at the Massachusetts General Hospital Cancer Center. At this year’s meeting, Ms. Rubin, along with Dr. Jennifer Wargo, of surgical oncology at MD Anderson, will be participating in apre-Congress session discussing common dermatologic issues in oncology patients.

 - Interviewed by Leah Lawrence

Cancer Network: Ms. Rubin, thanks so much for speaking with us today.

Krista Rubin: Thank you for having me.

Cancer Network: When one thinks of cancer and oncology, dermatologic issues are not always front of mind. What are some of the common skin-related issues that patients with cancer might experience?

Krista Rubin: In the past, oncology nurses have not really had the ability to really be independent in managing some of these toxicities. More recently, in the areas of targeted therapies and immune therapies, we are seeing much more toxicity that is involving the skin. Oncology nurses now have to really have a  better understanding of how to manage these, which are quite prevalent in the oncology population.

Cancer Network: Can you give us a few examples of what some of these skin-related toxicities might be?

Krista Rubin: One of the most common toxicities is the acneiform rash that is associated with EGFR inhibitors. This is extraordinarily common and extraordinarily challenging to manage. Patients are extraordinarily bothered by this as well, and it impacts so many aspects of their care. Nurses, because they are on the frontline, are really the ones that are the first people that can assess and understand how much of an impact it’s having not only on quality of life or body image, but how much of an impact it’s having on patients staying on therapy as well.

That is one example. The other example that has become quite prominent is with the use of immune therapies, in particular the anti-CTLA antibodies as well as PD-1 inhibitors. These are now being used not only in melanoma, but in many other cancers. One of the most common side effects is skin-related, whether that be rash, or itch, or some type of dermatitis. That is the most common side effect of the immune therapies that would typically be seen by an oncology nurse. This too can be limiting and extraordinarily bothersome to patients. Those are two examples of many that we are seeing in these patients.

Cancer Network: What are some of the most common assessment techniques used to identify skin-related issues that you discussed?

Krista Rubin: Unlike much else in oncology we don’t need a CT scan, or really anything else other than our eyes, to assess these toxicities. For many, the skin toxicity related to some of the targeted therapies is primarily from the shoulders up. So, it really doesn’t take too much to examine the patient. We now have more and more tools to assist nurses in managing some of these toxicities. For example, if we go back to the EGFR inhibitor where the acneiform rash is typically on the face and back, nurses are now really able to grade that toxicity. There are algorithms that have been developed, a lot based on nursing literature, that can help assist in the management of these toxicities. A patient often doesn’t have to say anything to present what the symptom is. These rashes can be quite bothersome and itchy, and for many patients they need to come off therapy for a short time. That is quite prominent in the oncology arena.

It doesn’t take much as far as testing to diagnosis these. You can see it, but it is also important that nurses are assessing and asking patients about some of these bothersome toxicities. Looking at the skin and getting a sense of where the rashes are, or what other skin toxicities may be in the forefront of the mind of the patient.

Another classic example is alopecia or hair loss. It has always been associated with oncology and chemotherapy, but we are finding that there is hair loss in other ways. We also see something called vitiligo, which is whitening of the hair with some of these immune therapies-whitening of the eyelashes or whitening of any hair on the body. We have to think about the skin not just being skin, but also cutaneous tissue-eyelashes, eyebrows, hair, and nails in particular. This is the type of assessment that needs to be done regularly.

Cancer Network: What is the role of oncology nurses in identifying and managing these dermatology issues? Where do they fit into the multidisciplinary care team for these toxicities?

Krista Rubin: That is a great question because with specialty care there are a lot of cooks in the kitchen, and the last thing that some of these patients want or need is to have to seek out another specialty, ie, dermatology.

Luckily, in the era of these targeted therapies and immune therapies, there has been a significant recognition of the impact of having dermatology involved in the care of these patients. Still, only about one-third of patients will see a dermatologist, even if they are having toxicity related to the skin. Being able to assess skin, hair, and nails has essentially become a responsibility of the oncology nurse. It gets a little tricky.

I think the advanced practice nurses in oncology seem to take on this role of the oncology/dermatology provider in these patients. The nurse’s role is to identify patients who would benefit from dermatology intervention and help facilitate that transition or referral to dermatology. Or, perhaps network with some of the dermatology nurses and have a streamlined process for getting these patients to specialty care, as they need it, particularly in the community where the dermatology provider may not be located at the same site as the oncology clinic. It is important that oncology nurses advocate for their patients that are bothered by dermatologic issues. This is something that oncology nurses need to be part of in the multidisciplinary team.

Cancer Network: Can you tell us a little bit about how nurses can distinguish what might be regular abnormalities of the skin vs some of the things that might appear when related to cancer treatment?

Krista Rubin: Sure. I get a tremendous amount of questions from colleagues about a specific lesion of concern on the body. One of the questions that I often get is, “How do I know if this is something to worry about or not, and when do I refer?”

In our lecture, we are covering a significant amount of what is a mole vs a freckle, what is a normal bump or a lump that one could expect on the skin, such as a seborrheic keratosis or a pre–skin cancer. Nurses, just using their eyes, are in a great position to be able to look at the skin and assess the skin, and make a determination about whether or not something is new, changing, or different, and then help to get that patient to the right provider to be able to get a diagnosis. As an oncology nurse, you don’t have to diagnosis the lesion, you just have to know whether or not it should be seen by a specialty provider. That is the nursing role at its best.

Cancer Network: What would you say is the most important take-away message when discussing the management of these common issues?

Krista Rubin: It needs to be recognized. The take-home message is that oncology nurses are absolutely in a position where they can make a difference in terms of enhancing quality of life and being able to provide education and anticipatory guidance regarding these toxicities. Let patients know that there are interventions that can help and make them feel better. Provide them with the knowledge that this is an expected side effect, why it happens, what is the reasoning behind it, what is happening on the cellular level that is causing these rashes. It is really important for patients to understand what the management is going to be. It is important for patients to understand that if they need their therapy to be put on hold for a little while, how that is going to impact their care in general, and that is a tremendous role that oncology nurses play in the management of these patients.

Cancer Network: Thank you again for taking a few minutes to speak with us about some of these skin-related toxicities related to patients with cancer.

Krista Rubin: Absolutely.