Dermatologic conditions in women receiving systemic cancer therapy

Abstract

As advances in cancer therapies have improved cancer-related survival, novel therapeutics have also introduced a variety of dermatologic toxicities, and an increased number of patients are living with these sequalae. Women with cancer in particular experience a spectrum of dermatologic conditions that affect their skin, hair, nail, and mucosal surfaces. Studies have shown that these toxic effects can significantly affect quality of life and alter a woman’s self-image, cultural identity, femininity, sexuality, and mental health. In severe instances, dermatologic toxicities may even disrupt cancer therapy and can therefore affect overall survival and treatment response. In this article, we review the dermatologic adverse effects from traditional chemotherapy, targeted therapy, immune checkpoint inhibitors, and endocrine therapy that disproportionately affect women. The timely diagnosis and management of these dermatologic conditions is crucial in the multidisciplinary care of women with cancer.

Art of prevention: The importance of dermatologic care when using aromatase inhibitors

“…More than 3.8 million women in the United States have a history of breast cancer (BC; Biglia et al, 2015 ; Ferreira et al, 2019 ; Kharb et al, 2020 ; Sussman et al, 2019 ). The majority of BCs in premenopausal (∼60%) and postmenopausal (∼75%) women are estrogen receptor positive ( Augusto et al, 2018 ), and treatment may include a combination of surgical resection, radiation therapy, endocrine therapy, and traditional chemotherapy ( Ferreira et al, 2019 ; Sussman et al, 2019 ).…”

“…More than 3.8 million women in the United States have a history of breast cancer (BC; Biglia et al, 2015 ; Ferreira et al, 2019 ; Kharb et al, 2020 ; Sussman et al, 2019 ). The majority of BCs in premenopausal (∼60%) and postmenopausal (∼75%) women are estrogen receptor positive ( Augusto et al, 2018 ), and treatment may include a combination of surgical resection, radiation therapy, endocrine therapy, and traditional chemotherapy ( Ferreira et al, 2019 ; Sussman et al, 2019 ). Endocrine therapies include aromatase inhibitors (AIs)—the most common of which are anastrozole, letrozole, and exemestane—and tamoxifen, a selective estrogen receptor modulator ( Pistelli et al, 2018 ), although AIs are preferred in postmenopausal women due to their favorable side-effect profile.…”

“…AIs may be either steroidal or nonsteroidal ( Table 1 ) and have been successfully used in the treatment of estrogen receptor–positive BC in multiple settings, including the treatment of metastatic disease, as an adjuvant treatment, and as chemoprevention for patients at high risk ( Chumsri, 2015 ). AIs are also indicated in a wide variety of other conditions other than BC, including in the treatment of male gynecomastia, infertility, fibrocystic breast disease, and endometriosis ( Ferreira et al, 2019 ; Kharb et al, 2020 ; Peters and Tadi, 2020 ). Of note, third-generation nonsteroidal AIs (i.e., anastrozole, letrozole) may interact with tamofixen, and thus it is preferable to avoid co-administration of these therapies ( Lønning et al, 2003 ).…”

“…Dermatologic adverse events (dAEs) associated with AIs are highly clinically variable ( Biglia et al, 2015 ; 2017 ); they may negatively affect patient quality of life (QoL), ultimately leading to oncologic treatment interruption or even discontinuation ( Biglia et al, 2015 ; 2017 ; Ferreira et al, 2019 ; Sussman et al, 2019 ; Woodford et al, 2019 ). Herein, we characterize dAEs of AIs and discuss preventative management to potentially reduce AI therapy interruption and improve patient outcomes.…”

“…Given the high expression of estrogen receptors in the vulva, antiestrogen therapy with AIs may result in mucosal and lichenoid vulvovaginal effects. Mucosal dAEs, such as vulvovaginal atrophy (also known as genitourinary syndrome of menopause [GSM]), may occur in up to 74% of patients receiving AI therapy ( Balagula et al, 2011 ; Biglia et al, 2015 ; 2017 ; Ferreira et al, 2019 ; Moegele et al, 2012 ; Witherby et al, 2011 ). In the setting of low estrogen levels, there may be reduced blood flow to the vulvovaginal area, thinning of the epithelium with loss of vaginal rugae, and reduced collagen and elastin, all of which may contribute to GSM symptoms (e.g., dryness, itching, burning, dysuria, dyspareunia, and postcoital bleeding; Biglia et al, 2015 ; 2017 ; Cook et al, 2017 ; Ferreira et al, 2019 ; Sussman et al, 2019 ).…”