Saving cancer patients' skin

Becky Sasaki has the quick laugh and easy smile of a woman who continues to thrive despite her four-year wrestling match with lung cancer.

She still works every day in the family business, heads out for Thai food with her husband and baby sits for her energetic grandchildren.

This winter when the cancer, which had metastasized, appeared in her brain for the third time, her oncologist prescribed a new breed of targeted cancer drugs to shrink the tumor. But before she could even fill the prescription, her doctor dispatched her to the Cancer Skin Care Program at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.

The goal: save her skin so she can continue to enjoy her active life.

The targeted cancer drug she was about to take can have such disfiguring dermatologic side effects, some patients are embarrassed to be seen in public and hide at home. Others can't bear the extreme skin problems, such as severe acne, and toss their pills.

Mario Lacouture, M.D., founder and director of the pioneering Cancer Skin Care Program, waited patiently for Sasaki until 6:30 p.m., the soonest she could arrive from her appointment with the oncologist. Lacouture wanted to arm her with an arsenal of specially formulated lotions and drugs to head off potentially devastating skin problems. He launched the skin cancer program – the first in the country – about a year ago to parry the painful skin conditions caused by these drugs.

"We are trying to help people keep their dignity and quality of life," said Lacouture, an assistant professor of dermatology at Northwestern's Feinberg School of Medicine and a dermatologist at Northwestern Memorial Hospital. He often sees patients the same day they call for an appointment, an intentionally lightning-fast response. Generally, patients need to wait weeks or longer for an appointment with a dermatologist.

"These people don't have that luxury of time," explained Lacouture. "If the side effects become severe, they are taken off the anticancer medicines." He keeps half of his weekly schedule open so he is always available for urgent, last minute appointments. And the clinic phone number is actually a pager to a nurse coordinator, so cancer patients receive a swift return call.

When Lacouture met with Sasaki, he prescribed four specially formulated creams including sunscreen, a body moisturizing cream to ward off the severely dry and itchy “alligator” skin, a topical steroid ointment for her face and medicated shampoo. He also recommended an ophthalmologist for dry eyes -- another unpleasant side effect.

“This has made a huge difference,” said Sasaki, 57, a Chicago resident. “I can't even imagine what I would look like at this point without these medications. You don't want to go out and get stared at.”

As new skin problems erupt – like the recent painful, split skin on her fingers – Sasaki visits Lacouture for new potions.

Cancer patients' skin problems erupted in 2004 with the emergence of a powerful new class of chemotherapy agents. These agents attack specific proteins in cancer cells rather than the “spray gun approach” of conventional chemotherapy that "basically shoots at everything and kills all kinds of cells,” Lacouture said. The new agents minimize the side effects of traditional chemotherapy so patients lose less hair and don't suffer from plummeting white blood cell counts, which leave them vulnerable to infections.

The new drugs work by destroying a protein called the EGFR, which naturally occurs in the skin, but also helps cancer cells thrive. In the top four deadliest cancers – lung, breast, colorectal and pancreatic -- cancer cells start churning out huge amounts of EGFR to feed themselves and self propagate. The drugs that attack EGFR are prescribed for patients – about 100,00 so far -- whose cancer has not responded to conventional chemotherapy.

But EGFR, which the drugs so handily wipe out, also is critical for the normal function of skin. Thus, about 90 percent of patients who take it have skin problems so serious that they feel embarrassed by their appearance.

"They get a rash that looks like acne that covers their entire face and chest and back. And it's itchy and tender," said Lacouture. "Acne in a 15 year old is not surprising, but when you're talking about severe acne in a 50 year old, that's not normal. So friends and acquaintances ask them, 'Hey, what's wrong with your face"'

"So that person has to say, ' I have cancer.' Not everyone who has cancer likes to go out and tell everyone. And every time they look in the mirror they are reminded they have cancer. It heaps more misery on an already difficult situation."

Lacouture said most physicians are not yet aware of how to treat these dermatologic side effects. He receives e-mails with questions from patients as far away as Australia, Europe and South Africa.

Each patient responds differently to dermatological treatments. Lacouture is analyzing the outcomes of 150 of his patients to determine the most effective interventions for the acne rash. He also is testing the effectiveness of newer drugs against the acne rash in a new study.

The Northwestern University program is a unique collaboration between oncologists, dermatologists and ophthalmologists in which there is a seamless treatment of these patients. The clinic is now being modeled in other places around the country.

As for Becky Sasaki, she just hosted two of her grandchildren for a sleepover. “My skin looks good and my grandchildren still want to be near me. That means everything to me.”