Adam Friedman, MD, Director of Supportive Oncodermatology, Professor and Interim Chair of Dermatology at the GW Cancer Center talks about the side affects cancer patients suffer through and how oncoderatology can relieve some of that pain.
Interview conducted by Ivanhoe Broadcast News in September 2019.
Many people probably have not heard the term oncodermatology. Can you tell me what it is?
FRIEDMAN: Sure. So oncodermatology encompasses every facet of oncology and dermatology. This can mean skin cancer and these include non melanoma, like basal cell and squamous cell carcinoma, melanoma skin cancer, Merkel cell carcinoma, but also include cutaneous T cell lymphoma. But oncodermatology goes well beyond actual cancer itself. It has to do with the prevention, the mitigation, and the treatment of these cancers, but also more specific to what I do, it focuses on taking care of and even hopefully preventing a lot of the adverse events we see with the management of all types of cancers because the hair, skin and nails are often off site targets for a lot of these treatments.
And that was my next question. If you could describe for our viewers when you’re going through the cancer treatment, what other side effects and impacts on the skin are patients seeing?
FRIEDMAN: Cancer therapies, whether it be chemotherapy which hits everything, versus the targeted therapies which are more biologically based – all cancer therapies are going after cells that are turning over too quickly, that are making themselves way too fast, and unfortunately hair skin and nails are doing the same thing. So in all cases, these cells are the targets, inappropriately so, for these therapies. So there’s a whole host of different side effects that we can see, common ones being severely dry skin, hair loss, loss of nails or brittle nails. But depending on what treatment you’re talking about, whether it be certain chemotherapies or even some of the biologics – these protein based therapies or small inhibitors that people take by mouth or receive through intravenous line – that gets a little more particular depending on what they’re targeting and what they’re doing. So we can see unique kind of skin things such as a rash that looks like acne. We can see new onset vitiligo meaning loss of skin pigment or even blistering diseases depending on what medicine you’re talking about.
This is not a new problem for cancer patients.
FRIEDMAN: No. This has been something that’s been going on probably since they’ve started treating cancer. The issue though is that there’s been a gap in education and care as this is not often the focus from the medical perspective. And oncologists – they’re focused on treating the cancer, not to say that they shouldn’t have tunnel vision. They’re trying to keep people alive. But the skin side effects – those very often are treated as secondary. They want to treat that cancer and get rid of it. Even more importantly and more recently, a lot of the new targeted therapies – those skin side effects are markers of treatment success. So not only are they kind of tunnel vision focused on treating that cancer, when they see these skin side effects, often oncologists are encouraged. They’re happy because it means the treatment is working. However, data has shown that while they may be happy and they may not consider these skin rashes or hair loss or nail findings too concerning, the patient is finding these side effects even more disabling than the cancer itself. So there is a disconnect between what the patient is experiencing and what the oncologist is seeing.
As an oncodermatologist, what is it that you do?
FRIEDMAN: So the mission of supportive oncodermatology program is twofold. First and foremost, it’s to try to prevent some of these reactions for which there is some evidence that we can do, if and only if we see patients before they start their therapy. But more often than not, it’s treating it once it happens. Being at an academic center, there is ease of communication between the cancer center and dermatology, so we can get these patients in pretty quickly. We have a dedicated clinic to seeing these patients. And so my goal is to lessen the burden. You know, having cancer is tough enough, but dealing with these hair nails and skin side effects can be extraordinarily disabling. It also can signal to the world that, hey, I have cancer and everyone is entitled to their own privacy. So it is my responsibility to lessen that blow, but also to maintain patients on their treatment. Very often oncologists will stop or lower treatment courses because of these skin side effects. So if I can prevent that and get a patient through their regimen to treat and possibly cure their cancer, that is of the utmost importance. The second part of this mission is survivorship. You survive cancer, which is a tremendous hurdle. Now you’ve got to live with possible sequelae or consequences of that treatment, and that includes increased risk for skin cancer or persistent hair nail and skin findings.
So oncodermatology isn’t just about treating skin cancers. It’s can involve all forms of cancer given treatments will almost always impact the skin.
FRIEDMAN: Correct. This is thinking of oncology from the perspective of the dermatologist. So it’s skin cancer. It’s how cancers can manifest in the skin, meaning other cancers in the body can actually spread to the skin, and it’s also the management and hopefully prevention of the side effects associated with treatments for all forms of cancer.
How new is this school of thought? How new is this department? And is there anything else like this in the United States?
FRIEDMAN: Sure. So supportive oncodermatology is somewhat fledgling. There are only a handful, probably under 10 centers in the country that offer these unique services. And while I think that’s so important to offer this to our patients, it’s also very important to train future physicians on this area. And as Residency Program Director, another hat that I wear, it is my goal to have my residents as they graduate go into the community and be able to manage these side effects, these expected outcomes in all types of cancer patients. But in terms of overall onco dermatology, depending on what facet, you know, it’s been around for quite some time and thinking about non melanoma, melanoma skin cancers, that has been bread and butter in dermatology. All dermatologists participate in skin cancer surveillance and diagnosis. We do full body skin exams, and early detection is key. Finding a melanoma before it spreads throughout the body – well that is a manageable disease. Metastatic melanoma, while we have a lot of new treatments, not so much. The success rates of these treatments are highly variable and still portend a bad prognosis, at least at this point in time. So we all play a role in oncodermatology. But the element of managing the side effects of these various drugs, both old and new, that is still somewhat fresh. And we really need to get the word out there that this should be a core compentency for all trainees – this should be part of their training so they can enter the workforce and be able to help with this. But also the public should know that these services are available. There are those who focus on this specifically and they don’t need to suffer through their treatment. We can help with that.
And that was my next question. What do people do if they’ve had cancer and are having these side effects? What do you do? This is not something that’s commonly available in most hospitals or most physicians’ offices.
FRIEDMAN: I think the expectation that the oncologist manages all elements of cancer treatment needs to be pushed aside. You know, the patient has to be an advocate for themselves. So even the more common and not specific side effects – skin dryness or thickening of the palms and soles, nail issues, hair loss – these are things that hopefully any dermatologist can help manage. It’s important the oncologist refers these patients or the patient, once again, is a self advocate and goes to a dermatologist to help manage these. The sooner you get in, the better the outcomes will be. The longer this damage occurs, the harder it is to actually go backwards in time and reverse these outcomes.
Can you tell me a little bit about George?
FRIEDMAN: Sure. George is a perfect example of why it’s so important to offer these services, not just at academic center, but within the community. George was put in touch with me through his oncologist at the cancer center at GW. And he was actually having multiple skin side effects associated with his treatment. This included radiation dermatitis, a really painful ulcerating skin rash that occurs, and we expect it to occur, from external beam radiation. But he also had a very unique skin eruption that we see with some of the newer treatments called the papulo-pustular eruption that we see with a class of medications called epidermal growth factor receptor inhibitors. These are used for several different types of cancers, like colon and advanced squamous cell carcinoma. The reaction looks like acne, and It can be very symptomatic and disabling, sometimes resulting in patients go off the medication. Somewhat unique to this story is that this was right before the holidays, and he was devastated that this would potentially impact his ability to spend time with his family . But we were able to intervene and get him on a really effective regimen, which included oral medications, topical therapy and supportive measures, and he was actually clear within a matter of weeks and he was able to go on and enjoy that holiday.
Are you able to tell me what his prognosis is now? He’s cleared of the cancer, how does everything look?
FRIEDMAN: Sure. Compared to when we first started, George’s skin manifestations associated with his treatment are remarkably improved, but that doesn’t mean that the door’s shut and then the story is over. Since that time, he’s been maintained on certain treatments. He’s actually had some recurrences. He actually had a very unique recurrence, something called radiation recall, where in the area where he had his radiation, an itchy rash erupted. It actually came back associated with another treatment. So the message here is that we aim to establish an ongoing relationship as these adverse events can manifest throughout the treatment course or even after therapy is over. And I encourage that ongoing relationship with all cancer patients because forgetting even these unique rashes, he’s also a much higher risk for skin cancer now. And so following him over time, doing the appropriate surveillance and making sure we catch things early – that’ll play a big role in his survivorship and overall well-being.
What kind of things did you treat him with? You mentioned a couple that was topical.
FRIEDMAN: One of the medicines we use for a visit for the very severe form of this papulo-pustual eruption is something called isotretinoin, a medication meant for acne. This is not acne, but because of the way this medicine works and what we know is happening with the treatment that’s causing this eruption, we have found this to be very effective and it works very quickly. We use topical steroids to combat inflammation of the skin. We use moisturizers and actually even now he’s still noticing severe skin dryness, which is a common complaint of a lot of cancer survivors. This needs to be a major focus before, during, and after treatment. That means thick creams/ointments to damp skin. It also means using mild soaps if at all to these very dry areas because soaps can be very dry and irritating as well.
Is there anything I didn’t ask you did you would want to make sure that people know?
FRIEDMAN: I think it’s really important that the public and most specifically cancer patients, cancer survivors, and their families know that we are focusing on this, that this is not something that is being pushed the side, that we’re not looking just at the elephant in the room – the cancer – but rather that we’re here to help with the entire experience. And it’s important to ask for help. You know, it is a collaborative approach in that the patient needs to come forward, but we also need to step forward and say that we do this, that this subspecialty exists, and that people are entering the workforce who know how to handle these very disabling side effects of cancer therapy.
How long has the practice been open?
FRIEDMAN: The supportive onco dermatology program here at GW has been open a little over two years. I also want to comment that given that this is such an emerging and important field, we have partnered with industry. We have an unrestricted grant by La Roche Posay to help support the administrative elements and even the research efforts to better not just treat patients but also that prophylactic part, trying to come up with ways to actually prevent these skin eruptions, hair issues, nail issues from even happening. We don’t want patients to worry about these side effects, they and their oncologists already have enough on their plates.
END OF INTERVIEW
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