Risk Factors for the Development of Acute Radiation Dermatitis in Breast Cancer Patients

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Jennifer J Parker
Alfred Rademaker
Eric Donnelly
Jennifer Choi


acute radiation dermatitis, breast cancer, hypofractionation, BMI


Objective:  Adjuvant breast radiation increases the risk of acute dermatitis and we aimed to identify patient and treatment characteristics that may increase this risk to help individualize the prevention and management of radiation-induced skin toxicities.

Methods/Materials:  We analyzed 320 women with breast cancer who received adjuvant radiation for increased risk of acute dermatitis based upon age, BMI, histology, stage, chemotherapy, radiation fractionation, whole breast dose, tumor bed boost dose, total dose, diuretics use, smoking, diabetes, autoimmune disease, and chronic immunosuppression.  Univariate logistic regression was used to compare each factor across the dermatitis groups.  Significant factors were analyzed in a multivariate analysis.

Results:  On univariate analysis, grade 3 dermatitis was more likely with a 1 unit BMI increase (OR 1.084, p=0.005).  Grade 2 dermatitis risk increased with each 100 cGy increase in breast dose (OR 1.14, p=<0.001).   Every 100 cGy total dose increase resulted in higher grade 2 and 3 dermatitis risks (OR 1.13 and 1.45, p=<0.001).  There was decreased risk of grade 2 and 3 dermatitis with hypofractionated radiation (grade 2: OR 0.16, p=<0.0001; grade 3: OR 0.08, p=0.017). 

On multivariate analysis, higher risk of grade 2 (OR 1.06, p=0.014) and 3 dermatitis (OR 1.12, p=<0.001) remained with increasing BMI.  Higher total dose increased grade 3 dermatitis (OR 1.35, p=0.019).  Hypofractionated radiation continued to decrease the risk of grade 2 dermatitis (OR 0.08, p=<0.001).

Conclusion:  Lower BMI, lower total dose, and hypofractionated radiation were beneficial to decrease dermatitis risk.  The other risk factors were not significant within our patient population. 



1. Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347:1233-1241.

2. Poggi MM, Danforth DN, Sciuto LC, Smith SL, Steinberg SM, Liewehr DJ, et al. Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer Institute Randomized Trial. Cancer. 2003;98:697-702.

3. Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for breast cancer. N Engl J Med. 2002;347:1227-1232.
4. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet. 2011; 378:1707-1716.

5. Wapnir IL, Dignma JJ, Fisher B, Mamounas EP, Anderson SJ, Julian TB, et al. Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst. 2011;103:478-488.

6. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast. J Natl Cancer Inst Monogr. 2010; 41:162-177.

7. Salvo N, Barnes E, Van Draanen J, Stacey E, Mitera G, Breen D, et al. Prophylaxis and management of acute radiation-induced skin reactions: a systematic review of literature. Curr Oncol. 2010;17:94-112.

8. Schnur JB, Love B, Scheckner BL, Green S, Wernicke AG, Montgomery GH. A systematic review of patient-rated measures of radiodermatitis in breast cancer radiotherapy. Am J Clin Oncol. 2011; 34:529-536.

9. Lilla C, Ambrosone CB, Kropp S, Helmbold I, Schmezer P, Von Fournier D, et al. Predictive factors for late normal tissue complications following radiotherapy for breast cancer. Breast Cancer Res Treat. 2007;106:143-150.

10. Pignol JP, Olivotto I, Rakovitch E, Gardner S, Sixel K, Beckham W, et al. A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol. 2008;26:2085-2092.

11. Harsolia A, Kestin L, Grills I, Wallace M, Jolly S, Jones C, et al. Intensity-modulated radiotherapy results in significant decrease in clinical toxicities compared with conventional wedge-based breast radiotherapy. Int J Radiat Oncol Biol Phys. 2007;68:1375-1380.
12. Formenti SC, Gidea-Addeo D, Goldberg JD, Roses DF, Guth A, Rosenstein BS, et al. Phase I-II trial of prone accelerated intensity modulated radiation therapy to the breast to optimally spare normal tissue. J Clin Oncol. 2007;25:2236-2242.

13. Haviland, J.S., Owen, J.R., Dewar, J.A., Agrawal, R.K., Barrett, J., Barrett-Lee, P.J., Dobbs, H.J., Hopwood, P., Lawton, P.A., Magee, B.J., Mills, J., Simmons, S., Sydenham, M.A., Venables, K., Bliss, J.M., Yarnold, J.R. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomized controlled trials. The Lancet Oncology. 2013; 14:1086-1094.

14. Register S, Takita C, Reis I, Zhao W, Amestoy W, Wright, J. Deep Inspiration breath hold technique for left sided breast cancer: An analysis of predictors for organ-at-risk sparing. Med Dosim. 2015;40:89-95.

15. Freedman GM, Anderson PR, Li J, Eisenberg DF, Hanlon AL, Wang L, et al. Intensity modulated radiation therapy (IMRT) decreases acute skin toxicity for women receiving radiation for breast cancer. Am J Clin Oncol. 2006;29:66-70.

16. De Langhe S, Mulliez T, Velderman L, Remouchamps V, Van Greveling A, Gilsoul M, et al. Factors modifying the risk of developing acute skin toxicity after whole-breast intensity modulated radiotherapy. BMC Cancer. 2014;14:711-719.

17. Kraus-Tiefenbacher U, Sfintizky A, Welzel G, Simeonova A, Sperk E, Siebenlist K, et al. Factors of influence on acute skin toxicity of breast cancer patients treated with standard three-dimensional conformal therapy (3D-CRT) after breast conserving surgery (BCS). Radiation Oncology. 2012;7:217-225.