Hi, I'm Hung Doan, an associate professor of Dermatology
at MD Anderson Cancer Center.
I'm joined today by my colleague, Dr. Pamela Schlembach, a
professor of Radiation Oncology at MD Anderson Cancer
Center, and this is the Cancerwise Podcast.
Hi, Dr. Schlembach, thanks for joining me today.
Thank you, my pleasure.
Today we're here to talk about how cancer patients and
survivors can stay healthy during the summertime, as
they consider travel, as they consider being more outdoors,
and also issues of hydration.
What advice can you give cancer patients and survivors
about these issues?
So, one of the things that I like to talk to patients about
is dehydration.
Hydrating is very important even when you're healthy, but
when you have cancer, a lot of times you're not
as hydrated as you should be and it's for good reason.
Sometimes things don't taste well,
sometimes you're fatigued, you don't feel like eating.
You could have nausea so you're not drinking as much
as you could, or you could even have diarrhea,
and these are all based on the facts that patients are
having cancer treatments, and they affect them in different
ways. So, these are some of the concerns that I have when
I talk with my patients.
So, one of the first questions I ask them are,
'Tell me about what you're drinking.' And they
are usually quick to say, 'Well, I'm drinking coffee,
tea, soda, maybe alcohol.'
And then I explain to them, 'Well, do you realize that that
might be dehydrating?' And a lot of times they don't.
And so, I'll share with them about the importance of
water.
And I say, especially in the summer, you're gonna have
not only your normal needs, but then you've got all the
heat that we have in Texas, and
you might be outside more than you normally are.
So, I share with him about the importance of drinking
water. So, then I go into,
how about tell me your water intake?
And they usually say, which is surprising, 'I don't like
water.'
Right. I mean, we have to worry about what we call the
insensible losses too, as we sweat, work outdoors, like you
say, or even the compromised skin
barrier. Certainly, when patients are undergoing treatments
that may impact the skin, including chemotherapies
that can impact the palms and the soles, make swelling of
the skin, but also radiation therapy where your expertise
comes in, too.
Yeah, absolutely. And so, some of the ways that I
talk to the patients about that because, you know, they are
going to have more needs is, 'Let's
talk about how we can make water taste a little bit
better.' So, I'll say you can add
vegetables to water.
Oh, that's a great idea.
Either cucumber, fruits, a little bit of that.
You also get some electrolytes in there.
Absolutely, and we do talk about fruit and then
if they don't want to do that I'll say, 'Do you like
juice?' And most people like juice, and I say, 'How about
if you take a quarter cup of juice and add
it to a pitcher of water?'
Oh great idea.
And that's a good way to get hydration.
So, that's one of the key components, that I find and
a lot of people don't drink enough water as it is, cancer
and non-cancer patients, and then the symptoms from
that can just be something like a headache and fatigue.
So, that's one of the first questions I ask them when they
share those kind of symptoms with me.
And it's so important during the summer months.
I think raising that issue, especially in this podcast,
allows for patients to really reflect on that, even if they
may not explicitly discuss it with their provider, too.
So, thanks for bringing that up.
I think hydration is very important.
From our skin standpoint, I sometimes,
should patients come up or ask about that, if the issue
arises, I do recommend either
a moisturizer that contains ceramides.
That's a great product because it reinforces the skin and
kind of maintains that lipid barrier for sure.
Um, sometimes moisturizers or even cleansers that contain
hyaluronic acid can help to retain the moisture in the
skin, but we have to remember that, um, hydration systemic
wide, right? Body-wide too.
So, that includes maintaining blood pressure for the heart,
for the kidneys and so forth, but from a skin standpoint,
those two kind of additives or ingredients are, um at
least a good consideration.
Absolutely, and as a dermatologist,
I'm sure that people ask you, what do you think
about sunscreens? I know there's a lot of mixed information
out there today. Can you talk about that?
I'd be happy to. That's actually one of the areas that I'm
most interested and passionate about.
I work in the prevention side of things and so
we do know, for instance, that sunscreens,
especially at least SPF 30 or greater, are recommended by
the FDA, recommended by the American Academy of
Dermatology. They come in a variety of ingredients, and
they come into two broad classes.
So, there's the physical blockers which contain zinc
oxide or titanium dioxide.
And then there's the chemical blockers.
And they're the others.
They're kind of like the ones that contain avobenzone,
octocrylene, oxybenzone, those are few of the sunscreen
ingredients.
There was a study in 2019 and a
follow-up study in 2020 conducted by Food and Drug
Administration scientists that showed that some
sunscreen ingredients are actually found in the bloodstream
when used properly.
However, to contrast with that, zinc and
titanium-containing products do not get absorbed or have
not found in the bloodstream in any large detectable
amounts from these studies,
it goes to show that the Food and Drug Administration does
recognize that zinc and titanium containing sunscreens
are actually called GRACE,
which stands for Generally Regarded as Safe and Effective.
I would like to also say that we have to balance the
benefit of sunscreen use with the unknown risk
or unknown harms.
And so, while these FDA scientists did find
that there was some sunscreen products that were found
in the bloodstream, we don't have long-term harm data
or safety data to suggest that there is harm.
We do have about 40-or 50-years' worth of really good
data to support that sunscreen, consistent sunscreen use,
whether physical chemical blockers, actually do prevent
and slow down the progression and the
attainment or the accumulation of pre-cancerous
lesions called actinic keratosis.
So, I still recommend sunscreen to all my patients.
If there is a concern, the zinc and titanium
routes are just as equally effective and,
like I said, are generally regarded as safe and effective
by the FDA.
Thank you so much for clarifying that.
I think there's a lot of discussion about should
we or shouldn't we, so thank you for that.
Yeah.
My question is, so how often should you apply
sunscreen?
There's actually a lot of interest in that.
The American Academy of Dermatology, as well as the FDA
recommends at least every two hours is a sufficient
amount, especially when you're out in the sun for extended
periods of time.
Good rule of thumb also is to avoid the peak hours
between 10 and two.
In Texas, maybe that kind of window would probably be
eight and four, but that's just my personal
preference for that too.
But there's also some interest in waterproof and
water-resistant sunscreens. Some may think it's a marketing
ploy. From the few
bits of literature that I've reviewed, there is some
credence for some of the water- resistant products.
But I don't think any of the commercially available
products have a grading of every two hours.
I think some of the products say water resistant to 80
minutes or so.
Some interesting studies a few years
back showed that the sunscreen can be effective almost
virtually immediately, but the recommendation is to wait
for about 15 to 30 minutes, especially when you're going
into the water, to let the products dry.
Also, if you're coming from a wet area, let's say you go in
the pool, it's been about two hours and you wanna reapply,
towel off. Dry a little bit, because sunscreen can very
slippery and slick.
How much sunscreen should you use?
And the FDA again recommends
an application of two grams per square centimeter.
Well, what does that mean?
Basically, I use the the teaspoon rule or the
rule of nines from the British Association of
Dermatologists, and basically, it's a teaspoon for your
head and neck, scalp area as well.
An Approximate teaspoon for each arm.
So, that's two teaspoons for the upper extremities.
One teaspoon for the front.
One teaspoon for back, and two teaspoons for
each leg. So, that amounts to about nine teaspoons total
or about the size of a golf ball, and that's every
two hours. So, I also recommend to my patients that if you
buy a whole tube of sunscreen and you plan on going to the
beach and all that, that's pretty much for yourself for the
whole day. Which is a lot.
Which is a lot.
That's a lot. I wouldn't think that.
But that's actually how sunscreens are measured by
the FDA because you measure sunscreen efficacy based on
naked skin, that means unapplied skin, and
then SPF applied or the sunscreen product applied
skin, and then they shine a UV light on you, and
then they measure how long it takes to get red.
It's sort of qualitative, sort of reproducible.
I've never actually witnessed a sunscreen test, but that's
my understanding. And even some private agencies and, you
know like, companies also ensure or
validate those products too.
So, it's very interesting how sunscreen is measured and
recommended how to use.
With that being said, there are spray
sunscreens.
Oh, yes, the spray sunscreens.
That would be hard to measure with what you just shared.
So, what do you do there?
Absolutely. So, technically speaking, I love
talking about this, by the way, I'm very excited talking
about this. But sunscreen spray sunscreens, I feel,
and this is sort of personal here, but I don't think you
get the the same quality of application because
it's variable based on how far you spray from your,
from yourself and the spray can.
Also, the proper application for spray sunscreens is you
spray it on your skin and then you massage it in.
There's no homing mechanism, no nanoparticles
that could find the skin.
Also, if you think about it, it's a cone of spray.
So, on the areas where you don't feel the spray on your
skin or that it's just not hitting, you're likely not
getting sunscreen. So, you spray the top part of your
forearm, but not necessarily the bottom part.
The other risk is that you're also breathing in some of
these aerosolized products. And there was a recent,
kind of finding some articles that got published that some
of the propellants were contaminated with benzene or had
benzene byproducts that were found in the propellants,
and there were some voluntary recalls about that.
So, probably another reason to at least consider just the
cream and the topical sunscreens versus
the spray sunscreens.
Thank you for that.
That was, that's really, really interesting.
And you're right, you just spray it usually in the wrong.
Mm-hmm.
Not probably good enough.
Oh, and then one other thing is don't spray your face,
okay? Um, you, um, technically if you read the instructions
on the spray cans, you spray your hands and then you apply
it to the face. So, it's no different in my opinion than
just getting a lotion or cream sunscreen and just using on
your face.
Very good. Well, you know, a lot of times we see people now
in swimming pools and they're all
covered up and that's a lot different than when I was
growing up. So-
Yeah, from me too.
So, the question I have is how effective
are these, these new clothing that people are using and
is there one sort of clothing that's better than another?
Do you have any recommendations on that?
I do advocate for the sun protective clothing.
I do notice in my patients who tend to fish or be on
the- anglers and out in the water because you
can also get reflected UV up from the water as well,
that they prefer that clothing.
They sweat a lot; they're not in a place where they could
easily get sunscreen in the shirt or reapply for
that matter. And the shirts and the clothing provide
adequate sun protection.
I would not go so far as to say that I'm aware of any
particular studies, but I do like that there are
sun protective shirts.
The grading for protective factors is
UPF, which is UV protective factor.
It's just a broad term.
I don't think there's any industry-wide consensus
about what that means, unfortunately.
However, from my understanding, they come in different
grades. There's UPF 30, 50, and 70, and it's
about the density of the weave.
So, if you were to wash the clothing, you would still
maintain that UV protective factor
actually.
Does it work year after year, or do you have to buy a
new piece of clothing?
I think there's no rigorous or
consistent understanding or suggestions that
you lose that quality as it goes on.
But I would expect that if there's tatters or if there is
like, you could visibly see some
stains or visibly see that the weave is
just not intact, I think that would be a good time to
buy some new clothing, the UV protective
clothing. The other thing is they come in sleeves as
well. So, if you're just wearing your regular clothing,
which may already have UPF, you could still put on
some of the sun protective sleeves, go out.
I recommend that for my patients who enjoy golf or
long bike rides, for instance.
I haven't cracked the nut yet on cyclists because when
they're going on their long rides, which is at least two
hours or more, there's no good way to reapply because
they're in the middle of riding.
Hopefully the clothing that they wear does provide some sun
protection But that has to be balanced also with the
hydration issues and everything because they are literally
just riding for hours on open road
but wherever they're covered, that's where they'll get the
UV protection
There's a lot of things online about alternatives to
sunscreen. Do you have any thoughts on that?
Why, yes, I do actually.
So, there's kind of like two things that have crossed my
radar when it came to oral or alternatives
to sunscreen. One is we just talked about the clothing
which I completely advocate for, by the way.
The other thing is actually oral sunscreen or
oral SPF supporting products.
There is actually no good prospective data to suggest
or support that these oral products can replace
sunscreen. There's just no rigorous way to prove that
because it's about the comparison between non-UV
exposed skin and protected skin, like we talked about how
the FDA measures it.
And then more importantly, I think that there are some
products on the market that actually grades SPF or says
orally, you take this and somehow it has
SPF protection. That's not true.
That is absolutely not true, and I can't support that.
There may be some products on the market that would, say,
protect DNA, but even then, there's laboratory testing
and then there is FDA testing for human
consumption and the data just are not there to
this point. So, at this time, I can only recommend topical
sunscreen products as well as clothing.
Wear your hat.
And wear your hat, too, as well.
And sunglasses.
Wonderful.
Now, going for, you know, radiation treatment patients
and radiation oncology patients, when it comes to just
staying safe in summertime, what are your concerns about
heat stroke, heat exhaustion for your patients and what
have you encountered?
Well, heat stroke and heat exhaustion
are two very different things, but they do have some
similar side effects.
So, in a heat exhaustion, patients can have
headaches, dizziness, nausea, muscle cramping,
extreme sweating, but their skin is actually clammy.
They are still alert, but they might feel
weak. So, the most important thing is to get that patient
out of the heat.
And you can do that by putting them in the shade if there's
nowhere for them to go, or if you can get them in an
air-conditioned area, get a fan on them
and get them drinking, because it is from salt depletion
and it's generally a short-term effect of
overheating.
Now, heat stroke is something very serious and different,
and you could have things like elevated
temperature of 104, your skin is red.
They're generally not sweating at that point.
You can have seizures, collapse, and even
death. So, it's really important for people to
differentiate the two and you wanna call 911 if somebody
has heat exhaustion.
Wow, those are actually very concerning.
And sometimes, as our patients go on long
trips and go into the beach and all that, they may not be
aware.
Right.
Or also just the proximity to help and safety too.
So, that's very important.
Absolutely, and it comes back again how you need to
hydrate hydrate, hydrate.
I mean it's just so important particularly in the summer
and living here in the South.
Absolutely, I think it's so important that hydration,
one, it helps us all.
It's proper nourishment and all that, but it's so
key to our patients.
So key to just fundamentals and so simple, so
simple.
Absolutely.
I love it. So, Dr. Schlembach, here in Houston, when we
think about summertime, it also brings up hurricane season.
What are your recommendations for your patients?
Yeah, absolutely. So, you want to, of course, follow all
the normal things having to do with your safety and your
home, but as a cancer patient in particular, you want make
sure that you have your medications all
filled and you want them in an accessible place
where if you need to leave suddenly, you know where they
all are, and then you want to make sure you're
communicating with your medical team.
I know here at MD Anderson we have a really great way of
communicating with our patients through MyChart, they get
text messages.
And they let us know if we're gonna be open or not.
You wanna make sure that, I tell patients, just open up
your phone and you can have a section, there's a section
called notes.
And I say, write in there your medical problems,
who your doctors are, what their phone numbers are, and
then another page, add all your medications so they're
listed. I know I have my medicines all listed on
my phone.
Absolutely.
And that way, your phone is with you all the time.
And make sure that you have a charger for your phone and
you can get portable chargers and make sure your phones
are charged up.
But those are the ways that I tell patients, you know, you
wanna certainly do the regular things that they tell us on
the news when a hurricane is coming, but your
situation is in addition as a cancer
patient, these are the things that I would like you to make
sure that you have ready.
I appreciate that. Yeah, hurricane preparedness is very
important.
Absolutely. So, my question to you is, speaking on
hurricanes, when we have really bad weather in Houston,
a lot of times we'll have rain and
then the bugs come out. So, as a dermatologist,
can you tell me, how can we tell our patients what
insect repellents are safe for them
to use?
Oh this is a great question.
Actually, I did a little bit of research on this, and
most if not all insect repellents and pesticides are
actually registered with the EPA first, and so I used
the CDC and the EPA website for my references.
And the key products that you know our
patients should be aware of one is DEET, D-E-E-T.
I think it's a long chemical name. I didn't write that down, but
that's a well-known insect repellent.
And so, any percentage, actually, has been shown to be
safe for human use.
They come in a variety of percentages from one to almost
100%. The key part is, apparently
the higher the number, it's more associated with the
duration or the durability of that product at repelling
insects. And while not mechanistic,
it's been suggested that insect repellents, including DEET
either, quote-unquote, repel insects or rather make the
human host undetectable to the insects.
That's the key part.
I think, for instance, at least abroad
in Europe, the recommendation is at least 50%
can have a good two-hour duration of
repelling mosquitoes, which is very important here in
Texas. West Nile has been detected already, so
that's also certainly a good thing.
It's also, DEET is also safe for use in all ages,
including young children as well.
Sprays are available, but especially in radiation patients,
I think the consideration is that the sprays may have some
alcohol in them, which can be very traumatic or
irritating for the skin.
So, the key part is they also come in a variety of other
products like lotions and creams and so forth.
So, we could use that as well.
Another product that I like to talk to my patients about is
picaridin, which is a pyrethroid.
It's similar to, I think chemically, it's related
to chrysanthemums, for whatever reason, but they have
been EPA registered and also CDC recognized to be
efficacious for insect repellents and that's used as
a cream typically but there are sprays available.
So, that's like an alternative.
An alternative to DEET.
OK.
A natural product that is actually a plant-derived product,
excuse me, that is actually approved or
registered by the EPA is a product called lemon
oil of eucalyptus.
And this product, it may sound nice, but apparently
it doesn't smell that nice. But it's also allowed and safe
for use on humans as
an insect repellent. It's more plant based too.
Surprisingly, citronella as a topical like some of the
sprays have not been registered by the EPA.
So, that's something to take into consideration.
And yet there are still other chemicals.
There's one called KR3535,
which is related to picaridin, actually, and is
available in some preparations, and that's also safe for
human use as well.
Actually, of interest is that I wanted to bring up that
there's also products that contain insecticides,
and that includes permethrin, which on the one hand is
FDA approved as a cream to use to treat scabies
and some forms of lice, but actually as a spray that's
commercially available without a prescription.
Do not use this on the skin, however.
This actually goes as a spray onto clothing and tactical
gear and tents.
And it actually could basically kill mosquitoes
and ticks. And people should use this if they're going
hiking, they're tucking in their clothing into their
boots and so forth, but they could spray their clothing.
What's great is at least for the clothing, it's good for a
few washes. So, it's actually durable even after
laundry as well, so.
Nice.
Yeah
I have another question about what
if you get a sunburn?
What's a good way to take care of a sunburn?
Well, sunburns already, it basically is the body's
response to sun damage that damaged the keratinocytes.
So, honestly, it's almost like a real burn.
In that case, we just use aloe and
just moisturizers to help support the skin.
Also because of a compromised skin barrier, hydration's
very important too.
Do you ever recommend things like Silvadine or
Mepilex?
For severe cases, if the patient presents to
me in a timely fashion, I would actually prescribe
Silvadine. Now, when we get to the higher sunburns that do
blister, that do cause skin peeling because of the
compromised barrier, I do use some prescription
Silvadene to help support and soothe the skin, and
that's always a great topical.
It's used in burn patients, so we know that it helps to
reduce the bacterial burden should patients suffer that
because there is a compromised skin barrier, and it helps
support the skin barrier as it heals itself too.
And then patient needs to get themselves out of the sun,
right?
Right, absolutely.
Do they cover up when you put on
Silvadine? Do you use some sort of a barrier over that?
We can, yeah, absolutely, and that could be the
non-adhesive gauze,
or yeah, non-adhesive gauze, sometimes bandages and all
that, but we have to take into consideration that because
of the compromised skin barrier, any adhesives can actually
be a little more irritating to the skin as well.
Yes, and speaking of barriers to the skin,
that's one of the problems that we run into with radiation
is everybody wants to get in a swimming pool.
Oh, yeah.
Or with the water, let's say.
And so, we have conversations with our patients about that
as well. And I treat a lot of breast cancer
patients, and I generally say, it's fine to get the water
but you have to get it in the water from your belly button
down. So, we just don't want you to
be sitting, soaking in chlorinated water in
your breast area because sometimes you can get some skin
reaction from radiation and and
then we, they say, 'Well can I do other things like
can I go tubing in the river or in a pond or
a lake?' And I'll say we generally
recommend that you don't do that because there's bacteria,
microorganisms and who knows what else,
so I say we want to keep your skin protected in
the barrier, again it's
a barrier for your body. So, we want to make sure that's safe.
I absolutely agree. I support that fully.
We discourage brackish waters, certainly after radiation
treatment, but also, you know, in other cases, for
instance, when we do skin surgeries for skin cancers and
skin excisions for other various lesions, we recommend
avoiding brackish water because we just don't know what's
in there. For instance, even amoeba has been
detected in some fresh waters, especially around here in
the Gulf Coast region. So, that's certainly a concern.
No effective treatments for that that we're aware of
easily. Although you know get yourself to a tertiary
hospital for that.
And then also just even though we may think
that spring waters are clean, we also have to remember
that other people are in there so there's also other
sources of bacteria as well as even just nature,
the dirt, the brox and so forth.
Yeah, so it's probably just as better to go get your
sprinkler head and sprinkle yourself with cold water.
Absolutely, absolutely.
The American Academy of Dermatology and us dermatologists
also recommend the best way to reduce your risk
of UV exposure and all that is seeking sunshades, so any
shade structures, public parks,
recreational areas, but also just staying in your house
when you can and avoiding those peak hours I talked about.
I agree, my patients are like, 'But it's summer, I
wanna do things. I wanna be outside.
Can I be outside?' And I'm like, 'Absolutely, but I'm gonna
recommend that you do what I do.' I usually get up in the
morning and walk early, get my nature fill,
or you can do it in the evening.
Those are some good times, particularly living in the South
where it's so hot here and the sun shines
pretty long. So, those are my recommendations as
well.
Right, and the clothing is always quite convenient.
You don't have to worry about overheating in your car and
you just have like an extra set of clothes in there as
well. Dr. Schlembach, thank you so much for
joining me today. I thought this was a wonderful discussion
for our patients.
Thank you, Dr. Doan. It was my pleasure, and I just want
you to know I learned a lot today as well, so I appreciate
everything that you shared.
Thanks for listening to the Cancerwise Podcast from MD
Anderson Cancer Center.
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