Multidisciplinary Strategies to Manage Treatment-Related Dermatologic Toxicity and Improve Quality of Life in Cancer Patients: A Narrative Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The topic is clinically relevant because dermatologic toxicities from chemotherapy, targeted therapy, radiotherapy, and immunotherapy affect quality of life, body image, treatment adherence, and treatment continuity. The manuscript addresses an important supportive-care issue in oncology. However, substantial revision is needed before the paper is suitable for publication. The manuscript states that the initial objective was to synthesize pharmaceutical interventions, but the Discussion later explains that the scope was broadened because few studies specifically evaluated pharmaceutical interventions. This creates a mismatch between the title, objective, methods, results, and conclusions. The authors should  revise the title and aim to reflect a broader review of dermatologic toxicity management.

Title

Comment 1
The title emphasizes “Pharmaceutical Strategies,” but many included studies appear to concern general dermatologic, oncologic, or multidisciplinary management rather than pharmacist-led or pharmaceutical-care interventions. The title should be revised to accurately reflect the final scope of the review.

Abstract

Comment 1
The abstract is generally informative, but it should more clearly distinguish between evidence on incidence, supportive dermatologic care, pharmaceutical care, and multidisciplinary management. At present, the conclusions about pharmaceutical care appear stronger than the evidence base described.

Comment 2
Please correct grammatical and stylistic issues in the abstract, for example subject–verb agreement, punctuation, and overly long sentences.

Introduction

Comment 1
The Introduction provides a relevant background on cancer-related dermatologic toxicities and their impact on quality of life, body image, psychological distress, and adherence. However, the specific evidence gap should be stated more sharply: Is the gap about incidence, management strategies, pharmacist-led interventions, multidisciplinary care models, or patient-reported outcomes?

Comment 2
The role of pharmacists is introduced, but the manuscript should better explain why pharmaceutical care is central to this review and how it differs from broader dermatologic or oncology supportive care.

Methods

Comment 1
The eligibility criteria are too broad because they include randomized trials, observational studies, systematic reviews, narrative reviews, and clinical practice guidelines in the same evidence synthesis. Mixing primary studies with reviews and guidelines risks double-counting evidence and weakens the scientific interpretation. The authors should either restrict the review to primary studies or clearly separate primary evidence, reviews, and guidelines.

Comment 2
The authors report using PubMed, ScienceDirect, and Cochrane. The rationale for selecting these databases should be strengthened. For a systematic review in oncology/dermatology/pharmacy, the authors should consider or justify the absence of Web of Science, CINAHL, and clinical trial registries.

Comment 3
The manuscript states that MeSH and Emtree terms were used, Entree terms are currently used in Emboss but Embase does not appear to have been searched. The authors should clarify whether Emtree was actually used and, if not, remove this statement.

Comment 4
The full search strategy is said to be available in supplementary materials, but the main manuscript should still provide enough information for reproducibility, including exact last search date, full search strings (in a table), database-specific filters, and any manual-search procedures.

Comment 5
The risk-of-bias and quality-assessment approach needs clarification. The manuscript states that RoB 2, ROBINS-I, observational checklists, and GRADE were used, but Table 1 also refers to tools such as AMSTAR and ROBIS. The authors should specify which tool was used for each included study type and ensure that the tools are appropriate.

Comment 6
The authors should clarify how GRADE was applied.

Results

Comment 1
The Results section is too brief and relies heavily on dense tables. The authors should provide a clearer narrative synthesis organized by major dermatologic toxicity, anticancer therapy class, intervention type, and outcome.

Comment 2
For each major outcome, the Results should report how many studies contributed evidence, their study designs, sample sizes, direction of effect, and certainty of evidence. At present, it is difficult to understand which conclusions are supported by randomized evidence and which are based on observational or narrative evidence. The way results are reported is not appropriate.

Comment 3
Table 1 contains useful information but is difficult to read because of excessive abbreviations and compressed wording. It should be simplified, split into smaller tables, and written in full terms wherever possible.

Comment 4
The PRISMA flow diagram is useful, but the manuscript should more clearly explain the reasons for exclusion at the full-text stage and how the final 17 studies were derived.

Comment 5
Table 2 is clinically useful, but it should include references for each prevention or treatment strategy and indicate the strength of evidence supporting each recommendation.

Discussion

Comment 1
The Discussion is relevant and clinically oriented, but several statements are stronger than the underlying evidence allows. The authors should consistently distinguish between evidence from randomized trials, observational studies, case series, narrative reviews, and expert consensus.

Comment 2
The role of pharmacists and pharmaceutical care should be discussed more concretely. The manuscript should specify which interventions can realistically be pharmacist-led, such as patient education, adherence monitoring, skin-care counselling, early toxicity screening, referral pathways, drug–drug interaction review, and follow-up protocols.

Comment 3
The discussion of psychosocial burden, body image, and quality of life is important but should be linked more directly to the included studies and patient-reported outcome measures.

Limitations

Comment 1
The limitations section appropriately mentions heterogeneity, small sample sizes, retrospective designs, and lack of patient-reported outcomes. However, it should also explicitly acknowledge the inclusion of secondary sources, possible double-counting of evidence, database limitations, language restrictions, and the limited number of pharmacist-specific interventions.

Conclusions

Comment 1
The conclusion should be more cautious. The need for standardized, evidence-based guidelines is well supported, but the statement that a pharmaceutical-intervention protocol can be developed and managed effectively should be softened unless the review provides direct evidence for this claim.

Tables/Figures

Comment 1
Table 1 should be reformatted for readability. The current table is too dense and abbreviation-heavy for most readers.

 

Language: 
The English language requires editing for grammar, clarity, punctuation, and scientific style. Examples include inconsistent terminology, overly long sentences, compressed table language, and grammatical errors in the abstract, discussion, declarations, and conclusions.

Author Response

 

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript presents a systematic review of pharmaceutical and multidisciplinary strategies for the management of treatment-related dermatologic toxicity in cancer patients, with attention to incidence, severity, supportive care, quality of life and treatment adherence. However, the manuscript does not meet the minimum organisational and structural standards expected for a systematic review article. The text is filled with bullet points, lists and inappropriate formatting that should have been incorporated into coherent narrative paragraphs. The Results section consist of a single figure without an adequate title, figure legend or meaningful integration into the text, while the manuscript refers to “Appendix A.3” in a way that makes the structure impossible to follow. The tables are excessively long and not presented in a reader-friendly manner. In addition, the Discussion is divided into subsections with generic textbook-style headings which further contributes to the impression that the manuscript has not been prepared as a properly structured review article. Given these major organisational problems, the manuscript is not reviewable at the level expected for a journal submission. I therefore recommend rejection.

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

This manuscript presents a systematic review evaluating treatment-related dermatologic toxicities in cancer patients and the role of pharmaceutical and multidisciplinary strategies in their prevention and management. The topic is clinically important because dermatologic adverse events are frequent complications of anticancer therapies and may significantly affect patients’ quality of life, body image, psychological well-being, and treatment adherence. It has a relevant objective and addresses an area that is increasingly important in supportive oncology care. The main strength and novelty of this work is its attempt to integrate dermatology, oncology, and pharmaceutical care perspectives, highlighting the potential contribution of pharmacists in patient education, early detection, prevention, and management of skin-related toxicities. However, the novelty of the review should be explained more clearly.The authors should better describe how this review differs from previous systematic reviews and clinical guidelines, especially because several aspects of dermatologic toxicity management have already been discussed in the literature. It initially focuses on pharmaceutical interventions but later expands its scope to general dermatologic toxicity management due to the limited available evidence. This change in focus should be explained more carefully, including whether it was planned and how it relates to the registered protocol.

It includes only a limited number of studies, and many included studies have observational designs, small sample sizes, or single-center approaches. Although the authors acknowledge these limitations, some conclusions appear stronger than the available evidence supports. The findings should be interpreted with caution, particularly regarding the effectiveness of multidisciplinary care and preventive strategies. The review would benefit from a clearer discussion of the certainty of the evidence, the risk of bias, and the distinction between well-supported interventions and expert recommendations.

 The heterogeneity of included studies is also a major concern because the review combines different cancer therapies, toxicity types, and management approaches. Chemotherapy-related toxicities, targeted therapy-associated reactions, and immune checkpoint inhibitor-related adverse events have different mechanisms and clinical characteristics, and separating these groups would improve the scientific value and clinical interpretation of the review.

The tables contain useful information, particularly the summary of dermatologic adverse events and management strategies. However, Table 1 is very dense and difficult to read because it combines study findings, limitations, risk of bias, and GRADE evaluation in a single format. Simplifying the table structure would improve readability.

The manuscript would also benefit from an additional graphical summary showing the relationship between anticancer treatment, dermatologic toxicity, pharmaceutical management, and patient outcomes.

The discussion provides a good overview of the clinical burden of dermatologic toxicities and emphasizes their impact beyond physical symptoms. However, some scientific statements require more careful interpretation, particularly regarding the association between certain toxicities and treatment efficacy. Skin toxicity may sometimes correlate with therapeutic response, but this relationship depends on the treatment type and cancer setting and should not be generalized. The discussion could also be expanded by addressing patient-reported outcomes, access to dermatology services, economic burden, and the practical implementation of pharmacist-led supportive care.

Substantial revision is needed to clarify the novelty, improve methodological transparency, better organize the evidence, and align the conclusions with the strength of available data. 

 

Author Response

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Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

The review addresses an important supportive-care topic and follows PRISMA guidance, yet its added value is moderate because earlier guidelines already summarise oncodermatology management and the paper does not offer a quantitative synthesis or new conceptual model
• The search strategy is restricted to three databases and four languages, and grey literature is omitted, which raises the risk of publication bias; the authors should justify these limits and provide the full PubMed string in the main text rather than the appendix
• Only seventeen heterogeneous studies are included, most of low or very low certainty; despite this, the manuscript sometimes draws practice recommendations without clearly linking them to GRADE ratings or acknowledging imprecision in effect estimates
• Tables 1 and 2 are informative, but methods for risk-of-bias appraisal vary across studies and the process for resolving disagreements is briefly described; consolidating to one validated tool and presenting domain-level judgements would make the evidence profile more transparent
• The discussion reiterates known mechanisms and psychosocial impacts yet under-reports key gaps such as the lack of dermatology-validated outcome measures and patient-reported endpoints; future-research directions should be prioritised and mapped to specific study designs
• Writing is generally clear, though sections 4.1 and 4.2 overlap; minor issues include several typographical errors and inconsistent abbreviation definitions in the extensive acronym list

Author Response

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Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the careful and comprehensive revision of the manuscript. The authors have satisfactorily addressed my previous comments and have substantially improved the methodological transparency, structure, and overall clarity of the review. I have no further substantive comments and consider the manuscript suitable for publication, subject only to routine editorial and language proofreading

Author Response

Thank you for your comments that subtantially improved our work

Reviewer 2 Report

Comments and Suggestions for Authors

Please see comments to the editors.

Author Response

No comments were added. Thank you.

Reviewer 3 Report

Comments and Suggestions for Authors

The revised version is much improved, and most of the previous comments have been addressed. The paper is easier to follow, the evidence is better organized, and the discussion is more balanced. However, a few issues still need attention before publication.

The novelty is still not fully clear. Although the review now explains that its scope was expanded because there were very few studies on pharmaceutical care, it is still not obvious how this review adds to the existing systematic reviews and clinical guidelines. A brief comparison with previous reviews would help readers understand its unique contribution.

The inclusion criteria still combine primary studies with narrative reviews, systematic reviews, and clinical guidelines. While it is mentioned that primary studies were given more weight during the synthesis, the reason for including these different types of evidence together should be explained more clearly.

The quality assessment section should also clearly state which tool was used to assess observational studies. It currently mentions that appropriate checklists were used, but it does not specify which one, making the methods less clear.

The use of GRADE also needs clarification. GRADE is usually applied to the overall body of evidence for an outcome rather than to individual studies. Since the tables present GRADE ratings for each study, this approach should either be explained or revised.

The discussion is more balanced than before, but a few conclusions are still stronger than the available evidence supports. Because most of the included studies are observational and the certainty of the evidence is generally low to moderate, the conclusions should consistently reflect these limitations.

The practical management table is useful, but some recommendations seem to come from clinical guidelines or expert opinion rather than from the included studies. It would be helpful to make this distinction clear so readers know which recommendations are directly supported by the reviewed evidence.

A few methodological details are still missing. For example, it would be helpful to mention the software used for study selection and duplicate removal, whether the data extraction form was tested before use, and how consistency between reviewers was ensured.

There are also a few minor language and formatting issues throughout the paper. Some sentences are still longer than necessary, and a careful language edit would improve the overall readability.

 

Author Response

Please see the attached file

Author Response File: Author Response.pdf