Preventing Skin Injury From Radiation Treatment
In an article he coauthored in the April 2014 issue of AJR, Stephen Balter, clinical associate professor at Columbia University Medical Center, looks at skin injuries that may result from fluoroscopy treatment. He talked with AJR InBrief about managing the risks.
Are patients currently being informed of the possibility of skin injury as part of the standard informed consent process?
The informed consent process is intended to give patients sufficient information about the risks and expected benefits of a proposed procedure to permit them to make informed decisions. Patients should be appropriately informed of radiation use and its consequences, in the context that radiation is only one of several risks. In comparison to other procedure risks, including the risk of not having the procedure, any form of radiation injury is a rare occurrence. Major injuries are extremely rare, but can be devastating.
Unlike other types of skin injury, skin damage from fluoroscopy treatments can take months—even a year—to manifest. How does this delayed presentation affect diagnosis and treatment of these injuries?
When neither the patient nor the patient’s health care providers are aware that substantial amounts of radiation were used during an intervention, radiation injuries may be misdiagnosed, diagnosis may be delayed, and treatment may be inadequate or inappropriate. This is why it is so important for the interventionalist to inform the patient, and his/her family and health care providers about substantial radiation use. Combining information with appropriate follow-up will help to ensure that any subsequent radiation injury is identified promptly and managed appropriately.
What ancillary factors can affect a patient's susceptibility to skin reactions?
Defects in DNA-repair genes, such as the ataxia telangiectasia and the Rad3-related gene, predispose individuals to increased radiation sensitivity. These defects are rare. Some preexisting autoimmune and connective tissue disorders can predispose patients to the development of severe radiation effects in an unpredictable fashion. Hyperthyroidism and diabetes mellitus are also associated with increased radiation sensitivity. Physical and patient-related factors that affect the expression of the injury include smoking, poor nutritional status, compromised skin integrity, obesity, overlapping skin folds, and the location of the irradiated skin.
What are we missing in terms of training interventionalists to ensure that protocols are being strictly followed?
Interventionalists who perform potentially high-dose procedures need specific training in tissue reactions (deterministic effects, such as skin injuries), patient dose monitoring, and clinical radiation management. This type of training differs from the standard fluoroscopy training, which usually focuses on staff safety and such stochastic effects as cancer induction.
How should patients receiving fluoroscopy be followed posttreatment?
The practice in my department is to inform patients and their families, before discharge, when a substantial amount of radiation was used. They are told to check the patient’s back and look for a red patch the size of a hand one month after the procedure. A telephone number for our lab is provided so that they can report anything suspicious that they see. If there is any possibility that there is a radiation reaction, the provider who takes the call will schedule a visit with the interventionalist who performed the procedure. Patients who received a somewhat higher dose are called by our quality assurance (QA) department about 6 weeks after the procedure. In the past 7 years, our QA department has not identified a patient with a radiation reaction who had not already called us. This simple process works.