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Lung Cancer

Expert Consensus on the Management of Erlotinib-Associated Cutaneous Toxicity in the U.K.

^aChristie CRC Hospital NHS Foundation Trust, Department of Medical Oncology, Manchester, United Kingdom; ^bAberdeen Royal Infirmary, Foresterhill, Aberdeen, United Kingdom; ^cGuy's Hospital, London, United Kingdom; ^dSt. Bartholomew's Hospital, London, United Kingdom; ^eUniversity of Pennsylvania, Philadelphia, Pennsylvania, USA; ^fThe Roy Castle Lung Cancer Foundation, Liverpool, United Kingdom; ^gHairmyres Hospital, Lanarkshire, United Kingdom; ^hChurch End Medical Centre, London, United Kingdom

Key Words. Cutaneous toxicity • Endothelial growth factor receptor inhibitors • Erlotinib • Non-small cell lung cancer • Rash

Correspondence: Nicholas Thatcher, M.B., B.Chir., Ph.D., Christie CRC Hospital NHS Foundation Trust, Department of Medical Oncology, Wilmslow Road, Manchester, M20 4BX, United Kingdom. Telephone: 44-161-446-3745; Fax: 44-161-446-3977; e-mail: nick.thatcher{at}christie-tr.nwest.nhs.uk

Received March 18, 2009; accepted for publication May 31, 2009; first published online in THE ONCOLOGIST Express on August 13, 2009.

Disclosures: Nicholas Thatcher: Honoraria: Roche, AstraZeneca, Lilly, SanofiAventis, Marianne Nicolson: Consultant/advisory role: Roche; Honoraria: Roche; Richard W. Groves: None; Jeremy Steele: Honoraria: Roche; paid member of the Consensus Group; Beth Eaby: Consultant/advisory role: Roche; Honoraria: Genentech; Joyce Dunlop: None; John McPhelim: Honoraria: Roche; Rajinder Nijjar: None; Ijeoma Ukachukwu: None.

The article discusses erlotinib (Tarceva®; Genentech, OSI Pharmaceuticals, and Roche) used to treat non-small cell lung cancer, pancreatic cancer, and several other types of cancer.

The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the independent peer reviewers.

Rash has been reported in up to 76% of patients with lung cancer who have received the epidermal growth factor receptor inhibitor (EGFRI) erlotinib. It has also been observed in patients treated with other agents that have a similar mode of action.

Erlotinib-associated skin toxicity typically presents as a papulopustular, follicular, acneiform rash. In most cases, it is mild, transient, and well tolerated, but in 8%–12% of patients, it may be sufficiently severe and persistent to necessitate intervention. Increasingly strong data suggest that the incidence and severity of skin toxicity may be predictive of response and survival in patients treated with erlotinib. This has prompted some clinicians to consider "treatment to rash" (i.e., increasing the dosage until a rash appears) as a rational management strategy.

In 2007, an international consensus was developed for the management of EGFRI-associated skin toxicity. Subsequently, a multidisciplinary group (the U.K. Erlotinib Skin Toxicity Management Consensus Group) met to validate and modify the international recommendations for U.K. use, with specific reference to erlotinib. Although many aspects of the international consensus were approved by the group as being relevant for the U.K., certain parts were modified. The resulting expert opinion is a practical and workable version of the international proposal that considers all applicable national issues regarding the management of erlotinib-associated skin toxicity.