TKIs are being studied in patients with additional types of tumor, possibly in the adjuvant setting, as well as in combinations. Because these drugs are administered orally, with a decreased (compared with conventional cytotoxic agents) frequency of nurse– or doctor–patient interactions, patients must be very well-informed of any potential toxicities with the TKIs.
At present, there are no evidence-based treatment guidelines for the prevention or management of HFSR. However, HCPs most involved in the day-to-day care of patients with HFSR have made great progress in establishing preventive and treatment strategies and in identifying ancillary products likely to decrease the incidence and/or severity of symptoms. Prevention, which includes preventing HFSR entirely as well as preventing progression from its initial appearance, is a key component of HFSR management.
The Oncology Nurse's Viewpoint
The nurse's viewpoint begins with patient education and empowerment. The goal is to prevent adverse effects from occurring while managing any adverse effects that do occur so that the patient has the best chance of staying on anticancer therapy. This requires a strong partnership between the HCP team and the patient. Although not all cases of HFSR can be prevented, experience suggests that symptom incidence and severity can be alleviated by educating patients to recognize the signs and symptoms of HFSR and report these to their HCPs. HFSR typically occurs early in the course of therapy, so it is prudent to be especially vigilant during the first 6 weeks. Providing the patient with a brochure about HFSR to refer to at home may facilitate identification of HFSR.
To address the lack of evidence-based guidelines to prevent or treat HFSR, an international, interdisciplinary expert panel has provided a set of consensus recommendations for the management of TKI-associated HFSR.45 One component of these recommendations can be phrased simply for the patients as a “3C” approach to management: control calluses, comfort with cushions, and cover with creams.
Prior to treatment, the patient should receive a full-body examination, with emphasis on the condition of the hands and feet. Evaluation should be performed by a qualified HCP who can determine whether there are physical conditions that may predispose a patient to areas of increased friction or rubbing. For all patients, especially those with comorbid conditions (eg, diabetes, poor circulation), a pretreatment pedicure is highly recommended. Patients should also be educated on the proper use of tools (eg, a pumice stone) to aid in callus removal. Such tools are considered beneficial because patients can control the frequency of their use and the extent of skin removed. However, because areas of hyperkeratosis are often extremely tender and painful, patients are cautioned against overuse of these tools, including the aggressive “paring” or “cutting” of callused areas. Finally, patients should be advised of the need for clean tools to guard against infection.
Other protective measures include the use of thick cotton gloves and/or socks, which may also help the skin to retain moisture, and avoidance of warm and/or hot water or objects, tight-fitting shoes, or other items that may rub, pinch, or cause friction in affected areas. Tender areas, pressure points, and pressure-sensitive areas of the hands and feet should be protected. For example, weight lifters might be advised to wear gloves. These recommendations hold true both before and after development of HFSR.[3], [33] and [35] Well-padded but nonconstrictive footwear should be worn, and the use of insole cushions or inserts (eg, silicone or gel) should be encouraged. Foot soaks with lukewarm water and magnesium sulfate may be soothing. Tender areas should be protected at all times, and patients should be encouraged not to walk barefoot.
Use of over-the-counter and prescription-strength creams and moisturizers during treatment with TKIs has also been recommended (Table 4).[40], [45], [46], [47], [48] and [49] Moisturizing agents should be applied liberally, immediately after bathing. Cotton gloves and/or socks can also be worn, to help retain moisture and to provide an additional layer of protection. When applied liberally, these products soften areas of thick and hardened skin, help keep the skin pliable, and may prevent cracks or breaks in skin integrity, which could cause additional discomfort. Prescription-strength topical agents have also shown anecdotal benefit (Table 4). These topical agents are typically applied twice daily to affected areas only because they may irritate unaffected skin. Data on the use of topical/systemic corticosteroids in the treatment of HFS remain inconclusive; the literature primarily includes case studies in patients with PPE treated with chemotherapeutic agents including pegylated liposomal doxorubicin.2 Finally, a qualified HCP must always be consulted to ensure proper diagnosis and treatment of HFSR.