Prevention and Management of Dermatologic Adverse Events Associated With Tumor Treating Fields in Patients With Glioblastoma

Our plain-English summary of Prevention and Management of Dermatologic Adverse Events Associated With Tumor Treating Fields in Patients With Glioblastoma, by M.E. Lacouture, M.J. Anadkat, M.T. Ballo, et al (Frontiers in Oncology, 2020).

The study

• Authors: M.E. Lacouture, M.J. Anadkat, M.T. Ballo, F. Iwamoto, S.A. Jeyapalan, R.V. La Rocca, M. Schwartz, J.N. Serventi, M. Glas
• Journal: Frontiers in Oncology
• Published: 2020;10:1045
• Type of article: Review
• Cited by: 64 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Importance: Tumor Treating Fields (TTFields) are an anti-mitotic treatment approved for treating newly diagnosed and recurrent glioblastoma, and mesothelioma. TTFields in glioblastoma comprise alternating electric fields (200 kHz) delivered continuously, ideally for ≥18 h/day, to the tumor bed via transducer arrays placed on the shaved scalp. When applied locoregionally to the tumor bed and combined with systemic temozolomide chemotherapy, TTFields improved overall survival vs. temozolomide alone in patients with newly diagnosed glioblastoma. Improved efficacy outcomes with TTFields were demonstrated, while maintaining a well-tolerated and manageable safety profile. The most commonly-reported TTFields-associated adverse events (AEs) are beneath-array dermatologic events. Since survival benefit from TTFields increases with duration-of-use, prevention and management of skin AEs are critical to maximize adherence. This paper describes TTFields-associated dermatological AEs and recommends prevention and management strategies based on clinical trial evidence and real-world clinical experience. Observations: TTFields-associated skin reactions include contact dermatitis (irritant/allergic), hyperhidrosis, xerosis or pruritus, and more rarely, skin erosions/ulcers and infections. Skin AEs may be prevented through skin-care and shifting (~2 cm) of array position during changes. TTFields-related skin AE management should be based on clinical phenotype and severity. Depending on diagnosis, recommended treatments include antibiotics, skin barrier films, moisturizers, topical corticosteroids, and antiperspirants. Water-based lotions, soaps, foams, and solutions with minimal impact on electrical impedance are preferred with TTFields use over petroleum-based ointments, which increase impedance. Conclusions: Early identification, prophylactic measures, and symptomatic skin AE management help patients maximize TTFields usage, while maintaining quality-of-life and optimizing therapeutic benefit. Implications for practice: TTFields confer a survival benefit in patients with glioblastoma that correlates positively with duration of daily use. Skin events (rash) are the primary treatment-related AE that can limit duration of use. The recommendations described here will help healthcare professionals to recognize, prevent, and manage dermatologic AEs associated with TTFields treatment. These recommendations may improve cutaneous health and support adherence to therapy, both of which would maximize treatment outcomes.

Copyright © 2020 Lacouture, Anadkat, Ballo, Iwamoto, Jeyapalan, La Rocca, Schwartz, Serventi and Glas.

In plain English

This review set out recommendations for preventing and managing skin side effects of Tumor Treating Fields (TTFields). TTFields is a device delivering alternating electric fields (200 kHz) through arrays attached to the shaved scalp of patients with glioblastoma, a brain tumor. The recommendations drew on clinical trial evidence and real-world clinical experience; no new study was reported. The authors described five types of skin problems under the arrays. They recommended shifting arrays about 2 cm at each change, topical corticosteroids for dermatitis, and topical antibiotics for erosions, ulcers or infections. Pausing array use for 2 to 7 days, alongside topical treatment, often let skin problems resolve; ulcerations needed a pause until symptoms reached grade 0 or 1, possibly up to 14 days. In preclinical studies the authors cited, water-based products had minimal effects on electrical impedance, while petroleum-based ointments raised it most, so the authors did not recommend them. The article is not about asbestos. It mentioned a separate trial (STELLAR) in malignant pleural mesothelioma where skin events were the main device-related side effect. The authors concluded their recommendations should help patients minimize skin side effects.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Review article presenting clinical practice recommendations, based on clinical trial evidence and real-world clinical experience; no new study was carried out
• Who was studied: No study population; the recommendations address patients with glioblastoma treated with TTFields
• Exposure: Tumor Treating Fields (TTFields): low-intensity alternating electric fields (200 kHz) delivered to the brain through transducer arrays on the shaved scalp. No asbestos exposure is discussed.
• Main results:
  • The authors described five types of skin adverse events with TTFields: hyperhidrosis (excessive sweating), xerosis or pruritus (dry or itchy skin), contact dermatitis, skin erosions or ulcers, and skin and soft tissue infections
  • As a preventive measure, the authors recommended shifting the array position by about 2 cm at each array change, moving pairs of arrays together
  • The primary treatments the authors recommended were topical corticosteroids for irritant or contact dermatitis and topical antibiotics for skin ulcers, erosions or infections
  • In preclinical studies cited by the authors, water-based products had minimal effects on electrical impedance
  • Petroleum-based ointments caused the highest increases in impedance, and the authors did not recommend them for use with TTFields
  • The authors stated that interrupting array use for 2 to 7 days, in addition to topical therapies, is often sufficient for skin adverse events to resolve
  • For skin ulcerations, which the authors described as infrequent, array contact should be interrupted until symptoms are grade 0/1, which may require up to 14 days of treatment interruption
  • Cited from a separate trial (STELLAR) of TTFields (150 kHz) with chemotherapy in unresectable malignant pleural mesothelioma, not from this article: dermatologic adverse events were the main TTFields-related adverse event, 68% in total, with 66% as grade 1/2
• The authors' conclusion: The authors concluded that healthcare professionals applying these recommendations should help patients minimize dermatologic adverse events, improve quality of life, support adherence and potentially improve treatment outcomes
• Limitations the authors state:
  • The authors stated that management strategies are likely to evolve as use of the therapy increases and more evidence accumulates
  • The authors stated that future studies are needed to establish which treatments best reduce skin adverse events

Topics

Medical terms in this study, explained in our Lexicon: Tumor Treating Fields (TTFields), Mesothelioma, Chemotherapy, Overall Survival, Clinical Trial.

Related studies

• Expert guidance on prophylaxis and treatment of dermatologic adverse events with Tumor Treating Fields (TTFields) therapy in the thoracic region — M.J. Anadkat, M. Lacouture, et al. (2022)
• Tumor Treating Fields: An Innovative Therapy for Glioblastoma and Other Solid Tumors — J.N. Serventi, H.B. Newton (2025)
• Tumor Treating Fields dually activate STING and AIM2 inflammasomes to induce adjuvant immunity in glioblastoma — D. Chen, S.B. Le, et al. (2022)
• The safety profile of Tumor Treating Fields (TTFields) therapy in glioblastoma patients with ventriculoperitoneal shunts — N.A. Oberheim-Bush, W. Shi, et al. (2022)
• Integration of Tumor-Treating Fields into the Multidisciplinary Management of Patients with Solid Malignancies — Y. Wang, M. Pandey, et al. (2019)
• Tumour treating fields therapy for glioblastoma: current advances and future directions — O. Rominiyi, A. Vanderlinden, et al. (2021)

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