Skin cancer has a higher incidence than breast, colon, prostate, and lung cancer combined. It accounts for 35% to 45% of all cancers in White Americans, 4% to 5% in Hispanics, and 1% to 2% in Black Americans. It's important for you to differentiate between basal cell carcinoma, squamous cell carcinoma, and malignant melanoma when you assess your patient's skin (see Characteristics of skin cancer). In this article, we'll focus on caring for a patient with malignant melanoma because this form of skin cancer has the highest probability of metastasizing to many parts of the body. But first, let's briefly review the types of skin cancer.
Types of skin cancer
The most common type of skin cancer is basal cell carcinoma (BCC), with 2.8 million Americans diagnosed each year. The lesions in BCC often present with a translucent, single nodule that contains an ulcer in the center. BCC may also look like a scar or an open sore that bleeds easily. People at the highest risk for BCC are those with fair skin, red or light-colored hair, and light-colored eyes. A history of frequent exposure to the sun and tanning beds is usually the main reason people develop BCC. Those with depressed immune systems from medications such as steroids or chemotherapy or from diseases such as HIV are more prone to develop BCC. BCC is rarely fatal, but can be disfiguring if allowed to grow.
The second most common form of skin cancer is squamous cell carcinoma (SCC), with more than 750,000 new cases diagnosed annually. SCC may metastasize to distant sites, and accounts for approximately 2,500 deaths annually. SCC generally manifests as a superficial lesion that grows from an indurated, rounded, and elevated base. SCC may also present as a cluster of warts; a scaly, irregularly shaped red patch; or an open sore that bleeds, crusts, and endures for weeks. Sometimes SCC may look like eczema, psoriasis, or discoid lupus erythematosus. Bowen disease (often referred to as SCC in situ) is a noninvasive stage of SCC, often presenting as a scaly, red-brown patch. Chronic exposure to sunlight and use of tanning beds increase the risk of SCC. Immunosuppression also predisposes a person to SCC.
Malignant melanoma is the most lethal type of skin cancer. The incidence for malignant melanoma more than doubled in 30 years, increasing from 7 cases per 100,000 people in 1973 to more than 18 cases per 100,000 people in 2003. Approximately 68,000 new cases of melanoma are diagnosed each year, resulting in over 8,000 deaths. Malignant melanoma usually begins as very small and innocent-looking lesions that can be treated successfully. The lesions have irregular borders and have a high probability of metastasis. A major risk factor for melanoma is high levels of exposure to sunlight. Other risk factors include an increased number of nevi (moles), freckling, family history of malignant melanoma, fair skin, red or light-colored hair, and light-colored eyes. Understanding the disease and patient assessment and teaching is important to prevent metastasis of lesions that may lead to disfigurement and death if not treated aggressively at an early stage. The prognosis of malignant melanoma is improved with early detection.
More about malignant melanoma
Melanocytes are cells found in the basal layer of the epidermis. These melanocytes contribute pigment to our skin and hair and protect deeper layers of the skin from the harmful effects of UV radiation by synthesizing a protein pigment called melanin. After DNA (or cell memory for proliferation) within the melanocytes is damaged from chronic exposure or hereditary factors, malignant melanoma or other forms of skin cancer can occur.
Malignant melanoma—a malignant proliferation of melanocytes—has a strong tendency for metastasis that's characterized by irregularly hyperpigmented asymmetric papules, nodules, or plaques with or without ulceration that can occur anywhere. Malignant melanoma is commonly found on the skin but can occur, less frequently, in other sites such as the eyes, ears, gastrointestinal (GI) tract, leptomeninges (a membrane covering of the brain and spinal cord), and oral and genital mucous membranes. Malignant melanoma cells generally continue to produce melanin that allows the lesions to have mixed shades of tan, brown, blue, or black color (see The many faces of malignant melanoma).
Some families are genetically inclined to have a proliferation of melanocytes, making them susceptible to malignant melanoma. Excessive exposure to the sun is often a trigger that causes a proliferation of melanocytes leading to malignant melanoma. The number of blistering sunburn episodes, time reportedly spent outdoors, use of artificial UV radiation devices (tanning beds), and numerous nevi contribute to the vulnerability of the skin for melanoma.
There are four basic types of malignant melanoma. Three of them begin in situ or occupy only the top layer of the skin and over years become invasive. The fourth begins invasive and penetrates into deeper layers of the skin, metastasizing to other areas of the body. Let's learn about the various forms of malignant melanoma.
Superficial spreading melanoma (SSM) is the most frequently diagnosed malignant melanoma, accounting for approximately 70% of cases in White patients. Typically SSM is seen in individuals in the fourth and fifth decade of life, but SSM may occur at any age. Common sites of SSM in women are the backs of the legs; in men, the trunk; and in both genders, the back. These lesions are commonly found on sun-exposed skin, particularly areas of intermittent sun exposure. SSM appears as slow growing initially, a discolored flat or slightly raised patch with irregular borders. It may be pigmented tan, brown, black, red, blue, or white. There's an apparent association with nevi in SSM.
Nodular melanoma (NM) accounts for 10% to 15% of diagnosed malignant melanoma cases and has an invasive and penetrating growth pattern. It's seen in individuals in the fifth or sixth decade of life, with men affected twice as often as women. It occurs primarily on sun-exposed areas of the head, neck, and trunk. A bump or papule arises that may be black, but may also be blue, gray, white, brown, tan, red, or skin tone. This bump often becomes ulcerated and nonhealing. Bleeding is a late sign of invasive melanoma. Amelanotic melanoma is a nonpigment-producing variant of NM that's distinct for being pink, erythematous, or flesh-colored, most commonly seen in albino individuals.
Acral lentiginous melanoma (ALM) is the most common form of malignant melanoma in dark-skinned and Asian populations. The median age of occurrence is 50 years, and it's seen equally in men and women. Areas of the skin that are hairless (glaborous), such as the fingers, palms, feet, and soles of the feet, are commonly affected sites. ALM manifests as black or brown discoloration under the nails, soles of the feet, or palms of the hands. ALM has a spreading nature, but over time a vertical growth phase develops. Metastasis often occurs due to delay in diagnosis.
Lentigo melanoma (LM) is diagnosed in 4% to 15% of those with advanced age. It correlates highly with long-term sun damage, age, and living in sunny climates. It appears as a macular area that's flat or mildly elevated, with a mottled tan, brown, or dark brown discoloration. LM is slow growing such that the patient pays little attention to the lesion. The invasive and penetrating form of this melanoma is known as lentigo malignant melanoma.
Ace skin assessment
It's important that you collaborate with other members of the healthcare team, including a dermatologist, as you assess your patient's skin. A thorough assessment of the skin is to be done annually on any individual with fair skin, frequent sun exposure, nevi, blemishes, freckles, skin discolorations, or those who have a history of malignant melanoma or other forms of skin cancer. The nurse and other healthcare providers must take time when examining the patient's skin, ensuring that all areas have been assessed.
A quick "overview" isn't sufficient. Make sure your patient has removed all clothing and keep him covered with a lightweight gown that will make inspection of the skin easier. Expose only the area you're assessing. Make sure you have enough light as you assess your patient. A gooseneck lamp is often helpful. A magnifying glass or monocle may be helpful to assess very small and innocent-looking lesions. Don't forget to consider your patient's overall health status that might contribute to lesion development. For example, a patient who has a weakened immune system from disease processes or immunosuppressant medications may develop malignant melanoma or other forms of skin cancer. Remember, the skin often tells us what's happening in other parts of the body.
It's imperative to listen to your patient or a family member regarding changes to the lesion or the appearance of a new pigmented lesion. An exam of the skin should include a numbering of moles, with documentation of their location, size, and appearance. Ask your patient whether moles or other lesions are painful or itch. Obtaining a thorough history from your patient regarding the number of incidences of sunburn, the frequency of sun exposure (such as job or lifestyle related), use of tanning beds, and a family history of melanoma (especially first-degree relatives) is another aspect of completing an assessment for skin cancer.
Use of digital photography may be warranted to objectively track suspicious lesions. Assistive optical devices that are becoming a part of routine clinical practice include high-resolution optical handheld devices called dermascopes, dermatoscopes, or epiluminescent microscopes. The handheld dermascope magnifies polarized light, enabling a dermatologist to see the depth and pattern of skin pigmentation so malignant lesions can be detected. In addition, portable scanning units using visible, infrared, and UV sources create images or spectroscopic outputs that can be electronically captured, archived, retrieved, and analyzed.
Let's take a closer look at the defining characteristics of malignant melanoma lesions using the ABCDE method of assessment.
The ABCDEs of melanoma assessment
The most important warning sign of malignant melanoma is a new or changing pigmented lesion. Often, a noticeable increase in size over a period of weeks to months or the development of changing pigment (black or hues of brown, red, blue, or white) requires biopsy. A guideline for evaluation of suspicious moles is the ABCDEs. However, NM often doesn't follow this rule.
* Asymmetry. Moles may have one half different from the other. The mole may be higher, a different texture, or different color.
* Border irregularity and bleeding. Moles should have smooth, round borders. A tiny bit of notching is allowed, but jagged edges or tails are suspicious. Bleeding or ulceration requires attention.
* Color. If a mole has two or three colors or a variation that includes blue, black, or red, it's a warning sign.
* Diameter. Generally, moles are 0.6 mm or less than half an inch across, or the size of a pencil eraser. Melanomas may be larger.
* Evolving or changing. Any change in the mole over a period of weeks to months is suspicious.
Individuals with suspicious moles that undergo any of the above signs should receive immediate evaluation by a dermatologist.
Don't be an ugly duckling
The "ugly duckling" approach is an additional technique to use in conjunction with the ABCDEs of early detection. It refers to an individual's moles having a similarity in general appearance. If the outlier lesion, at a given moment in time, looks or feels different than the other moles or over time it changes differently, there may be a problem (see The ugly duckling sign). This approach is especially helpful in detecting NM, which doesn't follow the ABCDE signs.
Diagnosis and staging
A biopsy is the only certain way of diagnosing malignant melanoma. The type of biopsy depends on the size of the lesion and its location on the body. There are several types of biopsy that may be performed:
* Excisional biopsy excises, or cuts away, the entire growth with a margin of normal surrounding skin.
* Incisional biopsy, or core biopsy, removes only a sample of the lesion; the resulting wound is closed with stitches.
* Punch biopsy removes a small, cylindrical-shaped sample of skin, including the epidermis and dermis. This procedure is performed with a surgical tool that looks like a round hollow tube with sharp edges.
* Saucerization biopsy removes the entire lesion by cutting under the lesion in a scoop-like manner. This leaves a deep depression in the skin, but it can be performed immediately and provides the healthcare provider with a complete specimen to analyze.
* Fine-needle aspiration biopsy removes a very small sample of tissue. This type of biopsy isn't done on a suspicious mole or skin growth, but rather on other deeper tissue, such a nearby lymph node or an internal organ, to see whether malignant melanoma has metastasized.
Staging is the process used to determine the size of the tumor and where and how far it has spread. According to the American Joint Committee on Cancer (AJCC) staging, there are five stages of melanoma (see Staging melanoma and treatment approaches). The Clark method is another way to stage melanoma lesions, using a 1-to-5 scale to describe which layers of the skin are involved. The higher the number, the deeper the tumor.
Treatment approaches will depend on the stage and location of the malignant melanoma and your patient's overall health. The primary treatment for melanoma is surgical excision. Excision of the cancerous lesion with a 2- to 5-cm margin is recommended when feasible. The width of the surrounding margin should be wider for larger primary lesions. When the malignant melanoma is on a finger or toe, surgical treatment may include amputating as much of the finger or toe as is necessary. Lymph nodes near the tumor may be removed because cancer can metastasize through the lymphatic system.
Metastatic malignant melanoma is difficult to treat. Treatment usually includes radiation therapy, immunotherapy, and chemotherapy. Radiation therapy uses high doses of radiation to destroy or shrink advanced or metastatic malignant melanoma with little harm to nearby healthy tissue. However, radiation usually doesn't cure malignant melanoma, but it does relieve pain and other symptoms caused by metastases to body organs such as the bones, brain, and liver.
Immunotherapy with interferon or interleukin-2 is a treatment that uses the patient's immune system to fight melanoma. Although not currently FDA approved, one of the most promising treatments for metastatic malignant melanoma is the use of ipilimumab (sometimes called MDX-101), a monoclonal antibody that activates the body's immune system to fight malignant melanoma by inhibiting the cytotoxic T-lymphocyte associated antigen 4 (CTLA-4). CTLA-4 is a molecule on T-cells, a type of white blood cell (WBC) that plays a critical role in regulating natural immune responses. The presence of CTLA-4 suppresses the immune system's response to disease, so blocking its activity stimulates the immune system to fight the melanoma. Patients in clinical trials tolerated infusions of ipilimumab fairly well, with the most common adverse reactions being GI symptoms and skin rashes.
Patients with advanced disease may be treated with chemotherapeutic agents such as temozolomide, cisplatin, and tamoxifen. Immunotherapy and chemotherapy are beneficial for patients with metastatic disease; however, these agents also make the patient prone to infection due to immunosuppression. It's important for you to teach your patient to report signs and symptoms of infection, such as sore throat, sinus drainage, fever, or feelings of fatigue and malaise. It's also important for you to monitor lab indicators of infection, such as elevated WBC count, agranulocytosis, erythrocyte sedimentation rate, and C-reactive protein.
Caring for your patient
Surgical removal of the melanoma is the most common form of treatment. It's essential that you inspect the incision for signs of infection or bleeding and monitor the amount, odor, and consistency of drainage on the wound dressing. Antibiotic therapy is often prescribed to prevent post-op infection.
If a large area of the skin is affected, the surgeon will perform a graft from another part of the body (donor site) to replace the skin that was removed with the melanoma. Be sure to assess the donor site for bleeding and infection. Carefully clean the skin with antimicrobial soap and water using sterile gauze. Be sure not to get the skin graft or donor site wet. Protect the skin graft and donor site from overexposure to light sources, including the sun, to prevent burning or blistering. Don't forget to manage the patient's pain due to wide and deep excision of the melanoma.
Radiation therapy may be used in some people with melanoma. Assess the skin over the treatment area for redness, irritation, or signs of infection. Avoid using creams or lotions and protect the skin from light sources. Conserve your patient's energy as much as possible because radiation therapy tends to cause fatigue. Don't forget to assess your patient for signs and symptoms of infection secondary to immunotherapy or chemotherapy. Trend the WBC count and differential for any indications of infection.
Be sure to provide emotional support for your patient. Reactions to skin disfigurement may alter the patient's perception of his body image. A diagnosis of cancer may be distressing, especially when there may be a poor prognosis in some cases. Encourage your patient to become involved in support groups or counseling.
Teaching your patient about early detection
The majority of malignant melanoma lesions would be almost 100% curable if they were found and treated early. Teach your patient that regular skin self-exam and assessments by the healthcare provider are especially important for people who have a higher than normal risk for malignant melanoma. It's important to teach your patient to assess the skin thoroughly, especially if there's a family history of malignant melanoma.
The best time to perform a skin self-exam is after a shower or bath. The skin should be checked in a well-lit room using a full-length mirror and handheld mirror while being completely naked. Tell your patient to check all areas of the skin, including but not limited to the back, face, scalp, between the buttocks, under the breasts, the soles of the feet, and the genital area. Explain to your patient that he's looking for a new mole; a mole that looks abnormal; a change in the size, shape, color, or texture of a mole or birthmark; or a sore that doesn't heal. Don't forget to teach your patient's spouse or partner about melanoma and other forms of skin cancer. Changes in the skin are sometimes initially identified by a patient's spouse during intimacy or daily activities.
Changes in the skin must be promptly reported to the healthcare provider. Teach your patient about the ABCDEs of melanoma lesions, stress the importance of minimizing exposure to the sun, and encourage your patient and family members to learn more about melanoma.
It's better to be early than late
Early detection is the most important patient teaching you can do to decrease morbidity and mortality from melanoma. That's why regular skin self-examination, limiting exposure to the sun, and yearly skin examination by a dermatologist is vital.
Follow the ABCDE guideline for evaluation of suspicious moles.
Border irregularity and bleeding
Evolving or changing
Patient teaching: Minimizing harm from the sun
* Avoid exposure to the midday sun (from 10 a.m. to 4 p.m.) whenever possible. The sun becomes less harmful whenever your shadow is as long as you are tall.
* Avoid exposure to artificial sources of UV radiation, such as sunlamps and tanning booths.
* If you must be outside, wear long sleeves, long pants, and a hat with a wide brim.
* Protect yourself from the glare of UV rays reflected by sand, water, snow, and ice. UV rays are sometimes even stronger at higher elevations such as the mountains. Make sure you wear protective clothing.
* Help protect your skin by using a lotion, cream, or gel that contains sunscreen. Use sunscreens that reflect, absorb, or scatter UV rays. These sunscreen products will be labeled as having "broad-spectrum coverage." Use a sunscreen with an SPF of 30 or greater. Don't forget to apply sunscreen every 4 hours while exposed.
* Wear sunglasses to protect your eyes and the skin surrounding the eyes.
* Special clothing is commercially available that shields much of the harmful radiation from the sun and other light sources.
On the web
These online resources may be helpful to your patients and their families:
American Cancer Society: http://www.cancer.org/Cancer/SkinCancer-Melanoma/index
Melanoma International Foundation: http://www.melanomaintl.org
Melanoma Research Foundation: http://www.melanoma.org
National Cancer Institute: http://www.cancer.gov/cancertopics/types/melanoma.
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