LPN2008 l Volume 4, Number 4

36 LPN2008 l Volume 4, Number 4

2.0 CONTACT HOURS PAMELA R. JAKUBEK, RN, CWOCN, MSN Wound, Ostomy, Continence Clinical Nurse Specialist ROBIN NEWMILLER, RN, BA Clinical Nurse for Mohs Clinical Suite Fox Chase Cancer Center Philadelphia, Pa. The authors have disclosed that they have no significant relationship with or financial interest in any commercial companies that pertain to this educational activity. Skin cancer is on the rise, and it s now one of the most common forms of cancer in the United States. Because skin cancer can look like normal moles and lesions, it s often overlooked during assessment. In this article, we ll review what the different skin cancers look like and how you can help your patients recognize the dangers of sun exposure to protect their skin from harm. MANY AMERICANS THINK that having a tan is attractive and healthy, but sun exposure contributes to more than 90% of all skin cancers. Over 1 million people will be diagnosed with skin cancer in 2008; of them, about 10,850 won t survive. Although the general media provide a lot of information about the dangers of sun exposure, they don't place enough emphasis on screening, early detection, and treatment of skin cancer. Most skin cancers are curable if detected and treated early. Even the most serious type, melanoma, has a good survival rate when found and treated early. Before we start talking about how to identify skin cancers, let s take a look at the skin and how it s affected by sun damage. The structure of skin The skin is the largest organ in the body and has multiple functions. It protects the body from injury, infection, sunlight, and heat. It plays a role in thermoregulation: It perspires when you re hot and contracts and shivers when you re cold. Skin stores fat and water and produces vitamin D when it s exposed to ultraviolet (UV) light. July/August l LPN2008 37

The skin is made of two distinct layers: The epidermis, the top or outer layer, is the layer that tans when exposed to UV radiation (see Figure 1). The dermis, deeper and thicker, lies below the epidermis and contains hair follicles, glands, and blood vessels. Skin cancer and melanoma develop in the cells of the epidermis, which consists of three main cell types: squamous cells: thin, flat cells found in the top layer of the epidermis basal cells: round cells found under the squamous cells melanocytes: dendritic (tree-shaped) cells found in the lower portion of the epidermis. They produce melanin, a pigment that gives the skin color. When exposed to the sun, melanocytes produce more pigment, causing the skin to darken. A mole is a cluster of melanocytes. Cancer can develop in any of these cells. More than 90% of all skin cancers in the United States are basal cell carcinomas (BCCs). BCC is a slow-growing cancer that can be cured if detected early. Squamous cell carcinoma (SCC) also is a slowgrowing cancer that can be cured if detected early but has a greater tendency to spread to other parts of the body than BCC. Metastasis is rare for both types. Together, BCC and SCC are referred to as nonmelanoma skin cancers. Melanoma, the most serious type of skin cancer, can develop in the melanocytes on any skin surface. It can also occur, although rarely, in other areas of the body that contain melanocytes, such as the eye, digestive tract, lymph nodes, or meninges (the protective membranes around the brain and spine). Melanoma can also metastasize to other areas of the body. Skin is classified as six different types ranging from very pale to very dark. Type I includes people with Figure 1. The epidermis and dermis. pale skin, freckles, and red hair whose skin is very sensitive, burns easily, and never tans. On the other end of the spectrum, people with type VI skin are usually of African descent with very dark skin that never burns. Regardless of how pale, dark, or sensitive someone s skin is, however, anyone can develop skin cancer. Skin cancer basics According to the American Cancer Society, 40% to 50% of Americans who live to age 65 will develop skin cancer. People with fair skin that freckles easily, light-colored eyes, and red or blond hair are at greater risk. There s no one cause of skin cancer, but many defined risk factors may increase a person s chance of developing it. UV radiation is a main cause of skin cancer because people are exposed to it on a daily basis. Sources of UV radiation include the sun and artificial sources such as sunlamps or tanning booths. Many people aren t aware that UV radiation is present outdoors on cold and even cloudy days. The amount of exposure to UV radiation in a person s lifetime is an important factor in the development of skin cancer. People who live in states with high levels of UV radiation, such as Arizona and Florida, are more likely to develop skin cancer. The diagnosis is less likely in areas less exposed to UV radiation, like Alaska and Vermont. Globally, the highest rates of skin cancer occur in areas that are exposed to very high amounts of UV radiation: South Africa and Australia. UV radiation damages the skin as early as childhood, but most skin cancers don t appear until after age 60. Personal and family history and medical conditions or medications that suppress the immune system increase the risk of skin cancer. For example, organ transplant recipients require long-term use of immunosuppressant medications to prevent organ rejection; these medications impair the immune system s capacity to repair or destroy UV-damaged cells, letting them become cancerous. Skin damage from scars, burns, skin ulcers, or infection such as human papillomavirus can cause skin cancer. Assessment and diagnosis The most common sign of skin cancer is a change in the skin, which can be subtle and occur in various ways. Changes include new growths, old growths that look different, or 38 LPN2008 l Volume 4, Number 4

Figure 2. Basal cell carcinoma (left) and squamous cell carcinoma (right). Reprinted by permission from the New England Journal of Medicine, 326, 169-170, 1992. sores that won t heal. Skin cancers can present as shiny, waxy, crusty, flat, raised, itchy, red, tender, pink, brown, pale, or firm. They may bleed and scab regularly (see Figure 2). A common misconception is that skin cancer is painful most of the time it s painless. If skin cancer is suspected, immediate action should be taken. Currently, the only way to make a diagnosis is by biopsy using one of three techniques: A shave biopsy is performed with a thin razor in which the lesion or part of the lesion is shaved off. A punch biopsy uses a trephine (a punch-like tool) to remove the lesion and a small amount of skin around the area. An excisional biopsy is a surgical procedure during which the practitioner uses a scalpel to remove the growth or lesion and a small amount of surrounding skin. A pathologic examination is performed on the biopsy tissue to confirm a diagnosis. Once the diagnosis is final, the patient is given several treatment options, depending on the type of cancer found. Treating nonmelanoma skin cancer The results of a skin cancer biopsy may show that the cancerous lesion was completely removed during the biopsy procedure. If the cancer wasn t completely removed and more cancer is present in the area, numerous options for treatment are available. Surgical removal is the most common option for BCC and SCC using one of the following techniques: Surgical excision is usually performed on areas such as the trunk, arms, and legs. After the excision, the site is sutured and the specimen is sent to pathology again. If tumor tissue still exists along the margins of the excision, another excision will be done to remove it. Mohs micrographic surgery is used on cosmetically sensitive areas like the face to remove skin cancers. The Mohs surgeon removes the lesion, and a pathologist examines the tissue under a microscope to see if all of the cancer was removed. If all of the cancer wasn t eliminated, the surgeon must remove more tissue. The site is closed with sutures. The benefit of Mohs surgery is that little noncancerous tissue is removed, and less scarring occurs. Electrodessication and curettage is used to treat smaller sites of BCC. The area is numbed and the cancerous lesion is scraped with an instrument called a curette (curettage) and burned with an electric current (electrodessication) to kill any remaining cancer cells. The current also helps stop the bleeding at the site. Cryotherapy is used for early and thin, superficial skin cancers. It uses extreme cold to freeze the area of cancer; the cancer will then scab and be destroyed. Nonsurgical options for treating nonmelanoma skin cancer include the following: Topical chemotherapy, such as fluorouracil (5-FU), is used on BCCs and SCCs located in the epidermis. The benefit of 5-FU is that scarring after healing is minimal. Photodynamic therapy requires injecting a chemical into the body then activating it with a beam of light to destroy the cancer cells. This method is useful for BCC and SCC located only at the surface of the skin. Radiation therapy targets an external beam of radiation to destroy the affected cells. Radiation therapy is usually reserved for skin cancers that are difficult to treat surgically. After treatment for nonmelanoma Follow-up skin assessment recommendations BCC SCC Skin exam every 6 months for 5 years Skin exam every 3 months for 3 years After 5 years, yearly skin exam After 3 years with no evidence of recurrence, skin exam every 6 months July/August l LPN2008 39

skin cancers, follow-up skin assessments are recommended. Because SCC can spread more quickly than BCC, follow-up assessment should be more frequent (see Follow-up skin assessment recommendations). What s different about melanoma The cause of melanoma isn t fully understood, but many of the same risk factors exist for melanoma as for other skin cancers (see Risk factors for malignant melanoma). People with very dark skin rarely develop melanoma; when they do, it generally occurs under the fingernails or on the soles of the feet or palms of the hands. Exposure to UV radiation plays a role in the risk for melanoma. A history of one or more severe, blistering sunburns as a child or teenager significantly increases a person s risk of developing melanoma. Other factors include a family history of melanoma, a weakened immune system, and prior history of melanoma. Moles, although common, play a role in the risk for melanoma. Moles can be present at birth or develop as we age, usually by age 40. They tend to fade with aging. Having a large number of moles increases the chances of developing melanoma. Dysplastic nevi (large, atypical moles that appear different than other moles on a person s body) are more likely to develop into melanoma than an ordinary mole. They re usually irregularly shaped and colored, and have irregular or nondistinct borders. Reducing exposure to UV rays, both natural and artificial, is critical to reducing melanoma risk. Sunscreen with an SPF of 15 or higher is important, as is protection for the eyes. Wraparound sunglasses that block UVA and UVB rays are best (most sunglasses sold in the United States meet these standards). What melanoma looks like The most common presentation of melanoma is a change in appearance of a mole, or development of a new mole. Changes in size, shape, color, border, or the actual feel of a mole when palpated are signs of melanoma. The center of a melanoma may change to a blue or black color. In men, the most common sites for melanoma are the trunk, head, and neck. Women with melanoma more commonly have lesions on the extremities, usually the legs. When assessing a patient s mole, the ABCDE method is helpful but not foolproof (see The ABCDE method of examining a mole for melanoma). Some moles exhibit only one change and are melanoma. When a lesion or mole looks suspicious for melanoma, shave July/August l LPN2008 41

Risk factors for malignant melanoma Fair-skinned or freckled, blue-eyed, light-haired people of eastern European descent People who burn and don t tan or who have a significant history of severe sunburn Environmental exposure to intense sunlight (older Americans retiring to the southwestern United States appear to have a higher incidence) History of melanoma (personal or family) Skin with giant congenital nevi biopsy or cauterization should never be used. An experienced dermatologist or surgeon should thoroughly examine it and perform an excisional biopsy. After biopsy, a pathologic examination can confirm melanoma. Research has identified genetic predisposition to melanoma in some families. The absence of a gene that resides on chromosome 9p increases the likelihood that potentially mutagenic DNA damage will escape repair before cell division to cause melanoma. Treating melanoma Melanoma can be cured if treatment is started early. When a melanoma lesion is superficial, it can be fully removed without spreading to deep tissues and other organs. Surgery is usually the first and best treatment for melanoma. The goal of surgery is to remove all the melanoma cells. The extent of the surgical excision depends on the width and depth of the lesion. Wide excisions may require reconstruction and/or skin grafting. Sentinel lymph node biopsy or lymph node dissection is usually performed if the lesion is deep. Adjuvant therapy (therapy in addition to surgery) is recommended for patients whose disease has spread beyond the original lesion. Chemotherapy and biological therapy can help kill any cancerous cells remaining in the body. Studies have shown that with more advanced melanoma, some adjuvant therapy has increased the time of disease recurrence but not overall survival time. The best survival rates are found in patients who have diagnosis of melanoma in the early stages and have had full surgical removal. Radiation therapy usually isn t effective to treat melanoma. Palliative radiation is sometimes used to reduce the symptoms of advanced disease. Patients with metastasis to the brain, spinal cord, and bone may have some pain relief when they receive radiation to those areas. Teaching your patient When it comes to skin cancer, prevention is a key concept to emphasize to your patients. The biggest risk factor for both nonmelanoma skin cancer and melanoma is UV radiation: the sun and its harmful rays. Avoidance of the sun is nearly impossible, but patients can develop many habits to avoid the sun s damage. The sun s rays are strongest in the middle of the day: 10 a.m. to 2 p.m. (11 a.m. to 3 p.m. during daylight savings time). Advise patients to perform outdoor activities during this time in the shade, such as under a porch. Encourage them to wear protective clothing such as hats, long sleeves, and long pants. Teach them to use sunscreen lotion whenever they re going outdoors. Sunscreen rated at an SPF of 15 to 30 will block most of the sun s harmful rays. Advise parents to develop the habit of using sunscreen on their children whenever they re outdoors. Encourage your patients to do The ABCDE method of examining a mole for melanoma A: Asymmetry The lesion doesn t appear balanced on both sides; the two halves don t look alike. The lesion has an irregular surface with uneven elevations (either palpable or visible). A change in the surface may be noted, from smooth to scaly. Some nodular melanomas have a smooth surface. B: Border The edges are often ragged, notched, blurred, or irregular. The border is fuzzy or indistinct, as if rubbed with an eraser. C: Color Normal moles are usually a uniform light to medium brown. Darker color indicates that the melanocytes have penetrated the dermis. Colors that may indicate malignancy if found together within a single lesion are shades of red, white, and blue. Shades of blue are ominous. White areas within a pigmented lesion are suspicious. Some malignant melanomas, however, aren t variegated but are uniformly colored (bluish black, bluish gray, bluish red). D: Diameter There s a size change, usually an increase. A diameter exceeding 6 mm (about the size of a pencil eraser) is considered more suspicious, although this finding without other signs isn t significant. E: Elevated Although some melanomas are flat, most are raised above the skin surface. 42 LPN2008 l Volume 4, Number 4

Sun safety Remember to use sunscreen when you plan to spend time outdoors. Your sunscreen should be a broad-spectrum sunscreen that protects from both UVA and UVB rays and have an SPF of 15 to 30 or more. Apply two generous coats (like paint) of sunscreen to all exposed skin before going outdoors. Reapply every 2 hours, especially after swimming or perspiring. Wear protective clothing such as long-sleeved shirts, pants, a wide-brimmed hat, and sunglasses when possible. Seek shade when appropriate, remembering that the sun s rays are strongest between 10 a.m. and 2 p.m. Umbrellas offer shade, but the sun s harmful rays can still bounce off of nearby water sources, sand, and porch decks. Use extra caution near water, snow, and sand because they reflect the damaging rays of the sun, which can increase your chance of sunburn. Avoid tanning beds at all times. Their UV light causes skin cancer and wrinkling. If you want to get a sun-kissed look, consider using a self-tanning product that doesn t expose you to UV light. Every year on your birthday, take a good look at your birthday suit. If you notice anything on your skin that s changing, growing, or bleeding, see a dermatologist. Skin cancer is very treatable when caught early. self-skin assessments periodically; provide them with a handout that instructs them how to assess their skin and what to look for. Remind them that early detection and treatment (which is usually only surgery if detected early enough) is the key to staying healthy. (See Sun safety for a list of tips to share with your patients.) Prevention is key About 20% of Americans will develop some form of skin cancer in On the Web American Academy of Dermatology: www.aad.org National Cancer Institute: www.cancer.gov The Skin Cancer Foundation: www.skincancer.org their lifetime. If left untreated, it can spread and result in serious, if not fatal, consequences. Teaching your patients how to lessen their risk of getting skin cancer can help them avoid potential problems. LPN Selected references American Cancer Society: Cancer facts and figures 2007. http://www.cancer.org/downloads/ STT/CAFF2007PWSecured.pdf. Accessed February 29, 2008. Masso M. Policy and practice for preventing skin cancer in children. Public Health Nurse. 23(4):361-365, July/August 2006. Prager R, Khachemoune A. Basal cell carcinoma. Dermatology Nurse. 8(6):584-585, December 2006. Reynolds PL, Strayer SM. Treatment of skin malignancies. Journal of Family Practice. 52(6):456-464, June 2003. Smeltzer SC, et al. Brunner & Suddarth s Textbook of Medical-Surgical Nursing, 11th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2008. Vargo N. Cutaneous malignancies: BCC, SCC, and MM. Dermatology Nurse. 18(2):183, 200, April 2006. Weber J, Kelley J. Health Assessment in Nursing, 3rd edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2007.. July/August l LPN2008 43