Identifying Skin Cancer and Knowing What To Do Next
Basal Cell Carcinoma
Skin cancer is the most common cancer diagnosed in the United States.³ The most common skin cancers are basal cell
and squamous cell carcinomas (BCC and SCC). Known as nonmelanoma skin cancers (NMSC), BCC and SCC are curable, but can be disfiguring and costly to treat. Melanoma is the third most common skin cancer. It is treatable if detected early, however, melanoma can be deadly if left undiagnosed or untreated.
Causes of Skin Cancer
The incidence of skin cancer can be mainly attributed to unprotected exposure to Ultraviolet (UV) rays–both from the sun and from artificial light sources such as tanning beds. ²
UV exposure can occur in a variety of ways, including spending time outside without applying adequate sunscreen or not wearing protective clothing. Blistering sunburns can drastically increase a person’s likelihood of developing skin cancer, especially if the burns occur before the age of 20.4 Tanning beds also contribute significantly to high skin cancer rates; using indoor tanning beds before age 35 can increase your risk of melanoma, the deadliest form of skin cancer, by 59 percent; the risk increases with each use.6
Incidence Among the U.S. Population
Melanoma
It is estimated that one in five Americans will develop skin cancer in their lifetime.³ Approximately 9,500 people are diagnosed with skin cancer every day.7 The incidence of BCC increased by 145 percent between 1976-1984 and 2000-2010. SCC incidence increased 263 percent in the same time period.8Furthermore, the rates of NMSC are increasing in Americans younger than 40.8 According to estimates, more than 1 million Americans are living with melanoma.³ Melanoma rates doubled between 1982 and 2011 and have continued to increase.³ It is further estimated there will be over 100,000 new cases of melanoma and approximately 6,800 people will die of the disease in 2020.4
The Role of NPs in Skin Cancer Screening and Detection
Primary care NPs are often the first to screen and detect potential skin cancers. A comprehensive clinical skin examination (CSE) consists of a skin cancer risk assessment, a head-to-toe skin examination, and a skin lesion assessment.8 Evaluations should also include family and personal history of skin cancer, personal risk factors (i.e. fair skin, excessive sun, and UV light exposure, history of sunburns or precancerous lesions), and counseling on safe sun exposure.
How to Detect Skin Cancer
Squamous Cell Carcinoma
Detecting skin cancer requires direct skin observation. The most commonly used approach for screening skin cancer is the use of ABCDE criteria.8 The acronym is further described below:
A – Asymmetry. If a lesion is cut in half, it should be a mirror image of itself.
B – Border. Irregular, scalloped borders are concerning.
C – Coloration. Different shades of brown, blue, red, white, or black are concerning.
D – Diameter. The diameter of a mole or pigmented spot should be less than 6mm.
E – Evolution. Assess for changes in color, size, or shape over time.
For a thorough assessment, NPs should evaluate the palmar surface of the hands and the soles of the feet where acral lentiginous melanoma (ALM) can occur. These areas should be examined closely for flat patches of discolored skin. Fingernails and toenails should also be examined for suspicious brown or black streaks.
Performing a Biopsy
If an NP believes their patient has a suspicious mole or lesion, a biopsy is performed to remove skin tissue for testing.
Prior to the procedure, the NP will numb the patient’s skin with a local anesthetic and then perform one of the following types of biopsies:
Shave biopsy. During a shave biopsy, a scalpel, a curette, scissors, or electrosurgery is used to remove cells at the level of the deep dermis. This technique is best for raised or pedunculated lesions, and often leaves little to no cosmetic damage. If a patient has pigmented skin lesions that may be related to melanoma, this will not allow for adequate measurement of the depth of invasion and may interfere with treatment.13
Punch biopsy. A punch biopsy is often the best technique to obtain diagnostic, full-thickness skin specimens. Using a circular blade or trephine with a handle, an NP should rotate the tool through the epidermis and dermis, down into the subcutaneous fat. After the sample is retrieved, the site can be closed with a single suture and minimal scarring.12
When to Refer to a Dermatologist?
NPs should refer patients to a dermatologist if moles or skin lesions are suspicious or presumed to be precancerous or cancerous. Anyone who is considered high-risk or who has a history of skin cancer should be referred to dermatology for management.
Patient Education on Skin Cancer Prevention
Avoiding harmful UV light in the form of direct sunlight or tanning beds is the most preventable risk factor for all skin cancers. As summer approaches, more people will be looking to enjoy outdoor activities. NPs should encourage patients to protect the skin by wearing protective clothing, hats, seeking shade, using a broad-spectrum, water-resistant sunscreen (SPF of 30 or higher), and scheduling activities before or after midday. Education on safe sun exposure and skin cancer prevention is key to reducing mortality as it relates to this health issue.
Guy, G. P. Jr., Thomas, C. C., Thompson, T., Watson, M., Massetti, G. M., & Richardson, L. C., Centers for Disease Control and Prevention (2015). Vital signs: Melanoma incidence and mortality trends and projections— United States, 1982–2030. Morbidity and Mortality Weekly Report, 64(21), 591–596.
Global Burden of Disease Cancer Collaboration. (2019). Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 29 cancer groups, 1990–2017. Journal of the American Medical Association Oncology, 5(12), 1749–1768.
Fewkes JL, Sober AJ. Skin biopsy: the four types and how best to do them. Prim Care Cancer. 1993;13:36–39.
Muzic, J. G., Schmitt, A. R., Wright, A. C., Alniemi, D. T., Zubair, A. S., Olazagasti Lourido, J. M., Sosa Seda, I. M., Weaver, A. L., & Baum, C. L. (2017). Incidence and trends of basal cell carcinoma and cutaneous squamous cell carcinoma: A population-based study in Olmsted County, Minnesota, 2000 to 2010. Mayo Clinic Proceedings, 92(6), 890–898.https://doi.org/10.1016/j.mayocp.2017.02.015
Siegel, R. L., Miller, K. D., & Jemal, A. (2019). Cancer statistics, 2019. CA: A Cancer Journal for Clinicians, 69(1), 7–34.https://doi.org/10.3322/caac.21551
Stratton, D. B., & Loescher, L. J. (2020). Educational interventions for primary care providers to improve clinical skin examination for skin cancer. Journal of the American Association of Nurse Practitioners, 32(5), 369–379. doi: 10.1097/JXX.0000000000000235
Identifying Skin Cancer and Knowing What To Do Next
Basal Cell Carcinoma
Skin cancer is the most common cancer diagnosed in the United States.³ The most common skin cancers are basal cell
and squamous cell carcinomas (BCC and SCC). Known as nonmelanoma skin cancers (NMSC), BCC and SCC are curable, but can be disfiguring and costly to treat. Melanoma is the third most common skin cancer. It is treatable if detected early, however, melanoma can be deadly if left undiagnosed or untreated.
Causes of Skin Cancer
The incidence of skin cancer can be mainly attributed to unprotected exposure to Ultraviolet (UV) rays–both from the sun and from artificial light sources such as tanning beds. ²
UV exposure can occur in a variety of ways, including spending time outside without applying adequate sunscreen or not wearing protective clothing. Blistering sunburns can drastically increase a person’s likelihood of developing skin cancer, especially if the burns occur before the age of 20.4 Tanning beds also contribute significantly to high skin cancer rates; using indoor tanning beds before age 35 can increase your risk of melanoma, the deadliest form of skin cancer, by 59 percent; the risk increases with each use. 6
Incidence Among the U.S. Population
Melanoma
It is estimated that one in five Americans will develop skin cancer in their lifetime.³ Approximately 9,500 people are diagnosed with skin cancer every day.7 The incidence of BCC increased by 145 percent between 1976-1984 and 2000-2010. SCC incidence increased 263 percent in the same time period.8 Furthermore, the rates of NMSC are increasing in Americans younger than 40.8 According to estimates, more than 1 million Americans are living with melanoma.³ Melanoma rates doubled between 1982 and 2011 and have continued to increase.³ It is further estimated there will be over 100,000 new cases of melanoma and approximately 6,800 people will die of the disease in 2020.4
The Role of NPs in Skin Cancer Screening and Detection
Primary care NPs are often the first to screen and detect potential skin cancers. A comprehensive clinical skin examination (CSE) consists of a skin cancer risk assessment, a head-to-toe skin examination, and a skin lesion assessment.8 Evaluations should also include family and personal history of skin cancer, personal risk factors (i.e. fair skin, excessive sun, and UV light exposure, history of sunburns or precancerous lesions), and counseling on safe sun exposure.
How to Detect Skin Cancer
Squamous Cell Carcinoma
Detecting skin cancer requires direct skin observation. The most commonly used approach for screening skin cancer is the use of ABCDE criteria.8 The acronym is further described below:
A – Asymmetry. If a lesion is cut in half, it should be a mirror image of itself.
B – Border. Irregular, scalloped borders are concerning.
C – Coloration. Different shades of brown, blue, red, white, or black are concerning.
D – Diameter. The diameter of a mole or pigmented spot should be less than 6mm.
E – Evolution. Assess for changes in color, size, or shape over time.
For a thorough assessment, NPs should evaluate the palmar surface of the hands and the soles of the feet where acral lentiginous melanoma (ALM) can occur. These areas should be examined closely for flat patches of discolored skin. Fingernails and toenails should also be examined for suspicious brown or black streaks.
Performing a Biopsy
If an NP believes their patient has a suspicious mole or lesion, a biopsy is performed to remove skin tissue for testing.
Prior to the procedure, the NP will numb the patient’s skin with a local anesthetic and then perform one of the following types of biopsies:
When to Refer to a Dermatologist?
NPs should refer patients to a dermatologist if moles or skin lesions are suspicious or presumed to be precancerous or cancerous. Anyone who is considered high-risk or who has a history of skin cancer should be referred to dermatology for management.
Patient Education on Skin Cancer Prevention
Avoiding harmful UV light in the form of direct sunlight or tanning beds is the most preventable risk factor for all skin cancers. As summer approaches, more people will be looking to enjoy outdoor activities. NPs should encourage patients to protect the skin by wearing protective clothing, hats, seeking shade, using a broad-spectrum, water-resistant sunscreen (SPF of 30 or higher), and scheduling activities before or after midday. Education on safe sun exposure and skin cancer prevention is key to reducing mortality as it relates to this health issue.
For more information and an opportunity to earn CE credit, sign up for our course, Cutaneous Carcinoma: Identifying Skin Cancer and Treatments, on the new NPACE Learning Center!
References
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