About this course:
This module reviews the most common types of skin cancer, risk factors, evidence-based screening guidelines, treatment modalities, and recommendations for prevention and sun safety.
Skin Cancer: Diagnosis, Management, and Prevention
This module reviews the most common types of skin cancer, risk factors, evidence-based screening guidelines, treatment modalities, and recommendations for prevention and sun safety.
Upon completion of this module, learners should be able to:
- describe the epidemiology of skin cancer in the US and identify the three most common types of skin cancer (squamous cell carcinoma [SCC], basal cell carcinoma [BCC], and melanoma), along with their defining features and key differences
- define clinical ABCDE (asymmetry, border irregularity, color variation, diameter, and evolution) features of BCC, SCC, and melanoma that distinguish them from benign nevi and discuss evidence-based skin cancer screening guidelines
- describe the connection between ultraviolet (UV) radiation exposure and skin cancer and list the most common risk factors for skin cancer development
- review the diagnosis, treatment, and management of skin cancer, as well as melanoma staging guidelines
- discuss skin cancer prevention guidelines and recommendations for sun safety throughout the lifespan
According to the Centers for Disease Control and Prevention (CDC) and the American Cancer Society (ACS), skin cancer is the most common cancer diagnosed in the US. Non-melanoma skin cancers (NMSC) include two subtypes: basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). NMSC represents over 98% of all cases of skin cancer, is primarily curable when treated early, and rarely results in death or substantial morbidity (US Preventative Task Force [USPTF], 2016). Melanoma is the third type of skin cancer and is the most serious and fatal. Skin cancers are largely preventable, and if diagnosed early, they are usually curable. Therefore, all healthcare professionals (HCPs) must have a keen awareness and understanding of skin cancer prevention, screening, and early detection (ACS, 2022a; CDC, 2022b).
Approximately 9,500 people in the US are diagnosed with skin cancer each day. The incidence of skin cancer is higher than all other cancers combined, and incidence rates continue to climb, particularly in children and adolescents (Siegel et al., 2022).
Non-melanoma Skin Cancers
NMSCs are not reported to most cancer registries, making the exact incidence difficult to appraise. However, research studies estimate that approximately 5.4 million new NMSC cases are diagnosed in the US annually, and roughly 8 out of 10 are BCC. Treatment of NMSC increased by nearly 77% between 1994 and 2014, with an annual cost of $4.8 billion. It is estimated that approximately 1 in 5 Americans will develop skin cancer throughout their lifetime, and 40%-50% of Americans who live to age 65 will develop NMSC at least once. The increased incidence of skin cancer may be attributed to better detection, more sun exposure, and people living longer (ACS, 2022a; CDC, 2022b; Lim & Asgari, 2021a; Wu, 2022).
BCC is the most common skin cancer, accounting for approximately 80% of NMSC cases, whereas SCC comprises the remaining 20%. Both BCC and SCC have higher incidence rates in populations located within closer proximity to the equator. Epidemiology studies have demonstrated that higher UV radiation exposure at lower latitudes, in locations such as Hawaii, compared to higher latitudes, as in the Midwest, leads to an increased incidence of BCC. Despite the high incidence of NMSC, almost all cases of BCC and SCC can be cured, especially if detected early and treated adequately. NMSC is estimated to cause about 2,000 deaths annually. However, those numbers have been steadily declining over recent years. Most NMSC deaths are among the older adult population or those who did not seek treatment until the cancer was advanced (ACS, 2022b; Lim & Asgari, 2021a; Wu, 2022).
The National Cancer Institute (NCI) estimates there will be 99,780 new cases of melanoma diagnosed in 2022. The Surveillance, Epidemiology, and End Results (SEER) is a government-funded program that compiles information on cancer statistics among the US population. According to the most recent data, more than 1.3 million Americans are currently living with melanoma. SEER data examining melanoma rates from 1975 through 2019 revealed a tremendous rise in melanoma incidence. In 1975, the age-adjusted rate of new cases of melanoma was 8.8 per 100,000 people and 2.1 per 100,000 deaths. As of 2020, there were 21.5 (per 100,000) new cases with 2.0 (per 100,000) deaths. Melanoma is most commonly diagnosed in non-Hispanic Whites. Whites have an annual incidence rate of 27 per 100,000, whereas Hispanics have an annual rate of 5 per 100,000. In African Americans and Asians/Pacific Islanders, the incidence rate is only 1 per 100,000. Although melanoma can develop at any point during the lifespan, the risk increases with age. It is most frequently diagnosed among people aged 65 to 74 (25.8%), followed by those aged 55 to 64 (22.4%), with 65 as the median age at diagnosis. Before age 50, incidence rates are higher in females than males, but by age 65, rates in males are double those of females, and by age 80, they are triple (ACS, 2022a; Curiel-Lewandrowski, 2022; NCI, 2022).
While melanoma is highly curable when detected in its earliest stages, it is more likely than NMSC to spread to other body parts. Although only 1% of skin cancer cases are melanoma, it accounts for most deaths from skin cancer. Approximately 20 Americans die from melanoma every day, and the ACS estimates there will be 7,650 deaths from melanoma in 2022, 5,080 men and 2,570 women. The overall 5-year relative survival rate for melanoma is currently 93.7%; however, this percentage varies based on the stage at diagnosis. Eighty-two percent of melanoma cases are diagnosed at a localized stage (e.g., confined to the primary site), and the 5-year survival rate is 99.5%. For regional disease (e.g., spread to the nearby lymph nodes), the survival rate drops to 70.6%. For those with distant disease (e.g., stage IV) at the time of diagnosis, survival is further reduced to 31.9%. White males have the highest death rates from melanoma, along with those aged 65 to 74 (25.3%), followed by those aged 75 to 84 (24.7%). The median age at death is 72 (ACS, 2022c; NCI, 2022; Siegel et al., 2022).
Anatomy & Physiology
The skin is the largest organ in the human body and protects against sunlight, injury, heat, and infection. It also regulates body temperature, stores water and fat, and produces vitamin D. The skin comprises three main layers, the epidermis, dermis, and subcutaneous tissue. Each layer of skin contains different types of cells that serve specific functions (Hinkle & Cheever, 2018). Figure 1 provides a graphic depiction of the layers and components of the skin.
Structure of the Skin
(OpenStax College, 2013)
The epidermis is the outermost surface layer of the skin and protects against microorganisms by providing a barrier to intruders from the outside environment. The epidermis is divided into five layers, as outlined in Table 1, and is primarily made up of keratinocytes, which are flat, scale-like stratified squamous epithelial cells. Keratinocytes are responsible for synthesizing the protein keratin, which forms a protective barrier for the body. Underlying this layer of skin are spherical-shaped basal cells, followed by the lowest inner level of the epidermis, which contains melanocyte cells. Me
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Layers of Epidermis (In order from most superficial to deepest)
Composed of many dead skin cells that are shed into the environment, it functions to repel water.
Found on the palms of the hands, fingertips, and soles of the feet.
A portion of keratin production occurs in this area.
Composed of layers of keratinocytes, it contains Langerhans cell, which functions as a macrophage by engulfing bacteria, foreign particles, and damaged cells.
Composed of melanocytes, this is where keratinocytes are formed before they move to the surface of the epidermis and are shed into the environment as dead skin cells.
(Hinkle & Cheever, 2018)
The dermis is the layer beneath the epidermis and comprises collagen-producing fibroblasts, proteins responsible for giving skin its strength, durability, and flexibility. The dermis contains blood vessels, lymphatic vessels, glands, hair follicles, and nerves. Blood vessels nourish the skin with oxygen and nutrients, deliver immune system cells to the skin to fight infection, and carry away waste products. Some of the glands produce sweat, which helps regulate body temperature, whereas others produce sebum, an oily substance that helps keep the skin from drying out. Nerves communicate signals from the skin, including touch, pain, pressure, temperature, and itching (Hinkle & Cheever, 2018).
The deepest layer of the skin is the subcutaneous layer. Similar to the dermis, it contains blood vessels and nerves. It also includes a layer of fat that cushions and protects against physical trauma or impact on internal organs, muscles, and bones. This layer of fat also helps regulate body temperature (Hinkle & Cheever, 2018).
Basics of Cancer Biology
Cancer begins in the cells, the building blocks that make up all tissues within the human body, and tissues make up organs. In theory, any cell in the body can develop into cancer. Cells typically grow and divide through a system of checks and balances called the cell cycle. Through this process, as cells grow old, they die and are eliminated, and new cells take their place. Cancer develops when there is a disruption in the orderly process, and the cell cycle goes haywire. New cells form when the body does not need them, and old cells do not die when they should. These new cells grow uncontrollably, function abnormally, and develop into cancerous tumors (Yarbro et al., 2018).
Actinic Keratosis (AK) is a pre-cancerous skin condition caused by too much sun exposure affecting more than 58 million Americans. Approximately 65% of all SCCs and 36% of all BCCs arise in lesions previously diagnosed as actinic keratoses. AKs typically occur on the face, hands, arms, and ears in individuals with fair skin and older than 40. They are often pink or flesh-colored scaly spots, and sometimes they can disappear on their own. Approximately 90% of NMSCs are associated with exposure to UV radiation from the sun (ACS, 2019b; Lim & Asgari, 2021a, 2021b; McDaniel et al., 2022; Wu, 2022). Among all types of skin cancer, risk factors associated with increased environmental or artificial UV exposure include:
- long term, intense sun exposure lacking adequate use of sunblock and other sun safety precautions
- Northern European ethnic origin
- people with fair skin, blonde or red hair, and light-colored eyes
- a tendency to burn rather than tan
- closer proximity to the equator
- history of blistering sunburns in childhood and adolescence
- use of indoor tanning beds
- a weakened immune system (immunocompromised state), including a history of organ transplantation
- exposure to therapeutic ionizing radiation
- HIV seropositive
- specific genetic syndromes: nevoid basal cell carcinoma and xeroderma pigmentosum (ACS, 2019b, 2022a; Gruber & Zito, 2021; Lim & Asgari, 2021a)
Risk Factors specific to increased risk for NMSC include:
- prior scars, burns, ulcers, or areas of inflammation of the skin
- basal cell nevus syndrome (Gorlin syndrome), which is an autosomal dominant mutation of the human patched gene
- chronic exposure to arsenic (ACS, 2022a; Lim & Asgari, 2021a; McDaniel et al., 2022)
The sun's UV rays can damage unprotected skin in as little as 15 minutes, yet it can take up to 12 hours for skin to show the full effect of sun exposure. Those who have already been diagnosed with skin cancer have an increased chance of developing it again, especially in the same sun-damaged area or in a nearby location. A tan is the body's attempt to protect itself from the sun's harmful rays, even without a sunburn. Sunburns and suntans are signs that skin has been damaged. The more damage the sun does to the skin, the more likely the individual is to have complications. These include early wrinkles, skin cancer, or other skin problems (Gruber & Zito, 2021; Lim & Asgari, 2021a; McDaniel et al., 2022).
For melanoma, major risk factors include a personal or family history of melanoma. Melanoma risk is greater if one or more first-degree relatives (parent, sibling, child) have been diagnosed with melanoma. Statistically, about 10% of all people with melanoma have family members with melanoma. Another risk factor is the presence of dysplastic nevi, a type of mole that looks different from an ordinary mole. A dysplastic nevus may be bigger than a common mole, and its color, surface, and border may differ. A dysplastic nevus is usually wider than a pea and longer than a peanut. A dysplastic nevus can display several colors, from pink to dark brown. Often, they are flat with a smooth, slightly scaly, or pebbly surface, and it has an irregular edge that may fade into the surrounding skin. A dysplastic nevus is more likely than a common mole to turn into melanoma (Curiel-Lewandrowski, 2022; Heistein et al., 2022; NCI, 2018).
An important risk factor for melanoma includes the presence of atypical, large, or numerous (more than 50) moles. Similar to NMSC lesions, melanoma is much more common in individuals of fair complexion and those exposed to natural or artificial sunlight (i.e., tanning beds). Using artificial tanning beds before 35 years of age increases the risk of melanoma by 75%. Heavy exposure to UV radiation from sunlight or indoor tanning use is a risk factor for all skin cancer; indoor tanning devices are classified as carcinogenic by the International Agency for Research on Cancer. One blistering sunburn during childhood doubles the risk of melanoma, whereas five or more blistering sunburns before age 20 increase the risk of melanoma by 80% (ACS, 2022a; Curiel-Lewandrowski, 2022; Heistein et al., 2022; NCI, 2022; Skin Cancer Foundation, 2022).
UV radiation is part of the natural energy produced by the sun's invisible rays but is also made from artificial sun lamps and tanning beds. UV radiation can damage the skin and lead to skin cancer. On the electromagnetic spectrum, UV light has shorter wavelengths than visible light, so it cannot be seen with the naked eye, but the skin can feel and be impacted by it. Two types of harmful UV radiation reach the Earth's surface and are found to contribute to the risk of skin cancer; long-wave ultraviolet A (UVA) and short-wave ultraviolet B (UVB) rays. While UVA and UVB rays differ in how they affect the skin, they both induce harm to the skin, and when combined, the risk for damage rises. Unprotected exposure to UVA and UVB rays damages the DNA in skin cells, producing genetic defects or mutations that can lead to premature aging, skin cancer, and immune system suppression. The more prolonged and intense the exposure, the higher the risk of harmful consequences to the skin (Curiel-Lewandrowski, 2022; Gruber & Zito, 2021; Wu, 2022). Table 2 outlines the differences between these two types of rays.
UVA Versus UVB Radiation Rays
It has a longer wavelength and is associated with skin aging.
It has a shorter wavelength and is associated with skin burning.
It damages the collagen and elastin in the skin, generates free radicals, and causes almost all forms of skin aging, including wrinkles (photoaging).
It plays a key role in the development of skin cancer by damaging cells and causing DNA mutations; it can eventually lead to melanoma and cause cataracts.
It can penetrate deep into the skin's dermis, resulting in a tan, and can penetrate through glass.
It does not penetrate as deep as UVA but is the primary source of sunburn. It usually burns the superficial layers of the skin.
It makes up 95% of all the UV rays that make it to the Earth's surface.
It makes up only 5% of the UV rays from the sun, but it is very high energy.
This is the primary radiation source used in tanning beds; UV rays produced by tanning units are 10 to 15 times more potent than UV rays produced by the midday sun.
UVB rays' intensity varies by season, geographic location, and time of day, with 10 AM to 4 PM considered the peak hours.
(Saric-Bosanac et al., 2019)
UV radiation can penetrate light clothing, windows, and windshields. It is also reflected by sand, water, snow, and concrete. It can reach swimmers at least 1 foot below the water's surface. Roughly 60% to 80% of the sun's rays transmit through clouds, so clouds and water do not offer protection (Saric-Bosanac et al., 2019).
Screening and Early Detection
The best way to detect skin cancer early is to be aware of new or changing skin growths, particularly those that look unusual. The ACS recommends that a clinician evaluate any new lesion or a progressive change in a lesion's appearance (size, shape, or color change) promptly (Geller & Swetter, 2021). While many researchers and clinicians argue that skin cancer screening with a total body skin examination (TBSE) is a safe and cost-effective screening test, there remains no national consensus regarding its benefit or implementation. The USPSTF (2016) recommendation statement concludes that the current evidence is "insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adults" (p. 479). This recommendation only applies to asymptomatic adults with no history of pre-cancerous or cancerous skin lesions. Therefore, TBSEs are not considered part of the general physical examination performed by primary care providers or other non-dermatology specialties. The USPSTF (2016) guideline is currently being updated with an anticipated release date in early 2023 (USPSTF, 2016; 2021).
While the USPSTF (2018) concluded that the current evidence is insufficient regarding self-examination to prevent skin cancer, many organizations, including the American Academy of Dermatology (AAD, n.d.), the ACS (2019a), and the Melanoma Research Alliance (n.d.), jointly emphasize the importance of monthly skin self-examinations for the detection of early skin cancer. Engaging in self-care activities contributes to the maintenance of health. These organizations recommend that HCPs counsel patients on the importance of performing skin self-examinations routinely in a well-lit room during daylight hours, preferably once a month. Patients will need a wall mirror, a hand mirror, and a chair footrest to perform an adequate self-assessment. Patients should also be given access to a body map diagram or encouraged to use a skin mole-tracking mobile device application to note any areas of suspicion. Patients should be counseled to bring the body map diagram to their clinician to evaluate any possible suspicious lesions (AAD, n.d.). The AAD (2022) started a SPOT Skin Cancer campaign, offering a free body map tool for patients to use. In addition, HCPs should teach patients the following steps for performing a skin self-exam:
- examine the body in a full-length mirror
- examine underarms, forearms, and palms
- examine legs, between toes, and soles of feet
- use a hand mirror to examine the scalp and neck
- use a hand mirror to examine the buttocks and back (AAD, n.d.)
Signs and Symptoms
Warning signs of all skin cancers include changes in the size, shape, or color of a mole or other skin lesion, new growth on the skin, or a sore that does not heal. Changes that progress over a month or more should always warrant evaluation by an HCP (Lim & Asgari, 2021b; Swetter & Geller, 2022; Wu, 2022).
The ABCDE Rule
Dermatologists routinely perform TBSE, assessing skin lesions utilizing the ABCDE rule. The ABCDE rule outlines specific characteristics to be aware of when evaluating suspicious abnormalities. This rule provides an easy way to recognize moles and growths that may be cancerous. Melanoma can disguise itself as a suspicious mole or lesion, so understanding the ABCDE rule can save lives. However, not all melanomas have these signs, so it is important to be alert for any new or changing skin growths or spots (Lim & Asgari, 2021b; Swetter & Geller, 2022; Wu, 2022). Table 3 provides an overview of the clinical use of the ABCDE rule, and Figure 2 demonstrates melanoma lesions compared to normal moles or benign nevi.
ABCDE Rule of Melanoma
(Lim & Asgari, 2021b; Swetter & Geller, 2022; Wu, 2022)
Melanoma Lesions (Left) Compared to Benign Nevi (Right)
AK most commonly appears on sun-exposed areas of the skin, such as the head, neck, forearms, and hands. They develop as dry, scaly patches or spots (see Figure 3). Although this skin condition is pre-cancerous, it can lead to SCC and BCC. Therefore, early identification and treatment remain important (Lim & Asgari, 2021b; Wu, 2022).
(Future FamDoc, 2014)
Basal Cell Carcinoma
BCCs arise from abnormal, uncontrolled growth of basal cells within the epidermis. BCC lesions are slow-growing and rarely fatal, as they uncommonly spread to other body parts. However, these lesions can be highly disfiguring if allowed to grow and can cause extensive invasion into surrounding tissues. BCC can grow into the nerves and bones, causing damage and disfigurement. BCC lesions often develop on regions of the body that receive regular sun exposure, such as the face and hands but can form anywhere on the body, including the chest, abdomen, and legs. They appear as flesh-colored, pearly bumps or a raised pink or red translucent, shiny area (see Figure 4). On dark skin, BCC can present in tan, black, or brown colors and can easily be mistaken for a normal mole. Alternatively, they may present as an open sore, scar, or growth with rolled edges or a central indentation. These lesions may develop tiny surface blood vessels over time. Lesions may crust, ooze, itch, and often bleed following minor injury. To avoid misdiagnosing a lesion, HCPs must understand that BCC lesions may appear quite different from one individual to another (McDaniel et al., 2022; Wu, 2022). The five most common warning signs of BCC include:
- an open sore that does not heal or may appear to heal but then reappears
- a reddish patch or irritated area
- a shiny bump or nodule
- a small pink growth
- a scar-like area that is flat white, yellow, or waxy in color; the skin may be shiny and taut with poorly defined borders, indicating invasive BCC (McDaniel et al., 2022; Wu, 2022)
Four common subtypes of BCCs are characterized by distinctive features, as listed in Table 4.
Four Common Types of BCC and their Associated Characteristics
Nodular basal cell carcinoma
Pigmented basal cell carcinoma
Morpheaform or sclerotic basal cell carcinoma
Superficial basal cell carcinoma
(McDaniel et al., 2022; Wu, 2022)
Superficial Basal Cell Carcinoma
Squamous Cell Carcinoma
SCCs arise from the keratinocyte cells within the epidermis, and while these lesions are less common than BCC, they are more likely to spread. SCC are round to irregular shapes with a plaque-like or nodular character (see Figure 5). The appearance of SCCs can vary from an ulcerated, infiltrating mass to an elevated erythematous nodular mass. Additionally, SCC lesions may feel rough, scaly, or lumpy, and blood vessels may appear at the edge, causing them to bleed easily. SCC most commonly occurs on parts of the body that experience increased levels of sun exposure, such as the face, lips, and back (Howell & Ramsey, 2022; Lim & Asgari, 2021b).
Bowen's disease is an intraepithelial form of SCC and is also referred to as squamous cell carcinoma in situ. Bowen's disease is associated with human papillomavirus (HPV) and is confined to the epidermis. It does not infiltrate the dermis and often presents as a rough, scaly, erythematous plaque with irregular borders (see Figure 6). Most cases are present on the lower legs and sun-exposed skin and are primarily found in women (Howell & Ramsey, 2022; Lim & Asgari, 2021b).
Squamous Cell Carcinoma
Melanoma arises from the melanocyte cells and is characterized by radial and vertical growth (see Figure 7). While most melanoma is referred to as cutaneous melanoma, which appears in the skin, melanoma may also occur in the eye, known as ocular melanoma. There are rare instances where melanoma arises in other areas, such as the lymph nodes or digestive tract. Melanoma can develop on any skin surface but is most commonly found on the trunk, head, and neck in males and on the lower legs and feet in females. The classification of cutaneous melanoma lesions is outlined below in Table 5 and includes four major subtypes: superficial spreading melanoma, nodular melanoma, lentigo maligna melanoma, and acral-lentiginous melanoma (Heistein et al., 2022; Swetter & Geller, 2022).
Classification of Malignant Melanoma
Superficial spreading melanoma
Nodular melanoma (NM)
Lentigo maligna melanoma
(Heistein et al., 2022; Swetter & Geller, 2022)
Melanoma is rare in those with naturally dark-skinned complexion, although when it does occur, it usually develops beneath the fingernails and toenails or on the palms or soles. Ultimately, melanoma can metastasize (spread) throughout the whole body but most commonly spreads to the liver, lungs, and brain. Upon arrival at these locations, the cancerous cells replicate and develop into malignant tumors, leading to death if left untreated (Heistein et al., 2022; Swetter & Geller, 2022).
Early skin cancer diagnosis and treatment are vital, as nearly all NMSC lesions can be cured by excision (surgical removal). Early identification and treatment of melanoma can significantly reduce the risk of spread to other tissues through the lymphatic system and blood vessels. Since the most crucial risk factor for skin cancer is chronic UV exposure, obtaining a detailed history from the patient is vital. Diagnosis is usually suspected in older, fair-skinned patients who present with scaly, indurated lesions on sun-exposed areas of the head and neck. The accuracy of clinical diagnosis of abnormal skin lesions is enhanced by adequate room lighting and a dermatoscope. A dermatoscope is a handheld tool that offers a built-in illuminating system and magnifying optics to improve the visualization of subsurface skin structures not easily detected by the unaided eye. Applying an immersion fluid such as mineral oil, ultrasound gel, or liquid paraffin to the skin can enhance translucency, improving the visibility of the skin structures of the lesion under investigation (Sonthalia et al., 2022).
In addition to information acquired from a thorough history and physical examination, most early skin cancers are diagnosed and treated by removal (excision), followed by microscopic examination of the cells. Histopathology is the gold standard for the definitive diagnosis of skin cancer. A biopsy should be performed on any lesion suspicious of melanoma. Several types of skin biopsies may be performed, such as a punch biopsy, shave biopsy, and excisional biopsy. For the diagnosis of melanoma, a full-thickness biopsy is required because management and prognosis depend on the depth of the lesion (Lim & Asgari, 2021b; McDaniel et al., 2022; Wu, 2022).
A punch biopsy excises small lesions ranging from 2 mm to 10 mm. This is not a sterile procedure and is usually performed in the office. The site is prepared with isopropyl alcohol, povidone-iodine, or chlorhexidine and anesthetized with 1% to 2% lidocaine. A disposable round knife punch tool is often used, and the biopsy is generally taken to the depth of the subcutaneous tissue. For more extensive punch biopsies (those 8mm to 10 mm), one or two sutures may be used for cosmetic results. Patients should be advised to keep the area clean and dry and to apply an antibiotic ointment (such as bacitracin [Neosporin]) twice daily (Lim & Asgari, 2021b; McDaniel et al., 2022; Wu, 2022).
A shave biopsy is also performed in the office and is not a sterile procedure. The site is prepped in the same manner as the punch biopsy, but a wheal of anesthesia may be injected to raise the lesion to assist in the biopsy. The shave biopsy is performed with a 15-blade scalpel or double-edged razor tool. It is the recommended choice of biopsy for lesions confined to the epidermis. It should not be performed for pigmented lesions or those suspicious of melanoma because the depth of the lesion is vital for melanoma staging. Sutures are typically unnecessary, and the patient should be counseled on keeping the area clean and dry and applying bacitracin (Neosporin) twice daily (Lim & Asgari, 2021b; McDaniel et al., 2022; Wu, 2022).
An excisional biopsy is a sterile procedure ideal for large lesions known to be malignant or suspicious of malignant melanoma. An excisional biopsy includes the removal of the entire lesion with 1-mm to 3-mm margins of healthy skin (called negative margins) and part of the subcutaneous fat whenever possible. Depending on the size and extent of the lesion in question, this procedure may be performed in an outpatient surgical center, operating room, or a dedicated surgical office with the proper equipment to ensure the sterility of the procedure. Excisional biopsies are usually performed using a scalpel, and the biopsy is taken to at least the depth of the subcutaneous tissue or the extent of the visible lesion. Sutures are usually necessary, and postoperative care generally includes keeping the wound clean and dry and applying bacitracin (Neosporin) with dressing changes (Lim & Asgari, 2021b; McDaniel et al., 2022; Wu, 2022).
Contraindications to skin biopsies may include infection at the site, history of a bleeding disorder, or current use of blood thinners. Patients generally do not need to be taken off therapeutic or prophylactic blood thinners for a skin biopsy. Patients presenting with suspicious lesions on the face, eyelids, or lips may need to be referred to a dermatologist or plastic surgeon due to the cosmetic aspect of removing one of these lesions (Lim & Asgari, 2021b; McDaniel et al., 2022; Wu, 2022).
Treatment for skin cancer depends on several factors, such as the type of cancer, location, identifying features, and depth of invasion (if it has spread to other areas). Most cases of NMSC are cured by removing the lesion through surgical excision, laser therapy, or deep cryosurgery (e.g., destruction of the cancerous lesion by freezing). Radiation therapy and certain topical medications may also be used. Since Bowen's disease is confined to the epidermis, effective treatment can be seen with cryotherapy, cauterization, and topical 5-fluorouracil (Efudex, Carac). It is important to note that NMSCs can recur, even after complete removal. Some cancer cells may remain undetectable after surgery, and others can form roots that extend beyond what is visible. BCCs on the nose, ears, and lips are more likely to recur within the first two years after surgery. Therefore, appropriate follow-up and surveillance are crucial (Aasi, 2022; Aasi & Hong, 2021; Howell & Ramsey, 2022; McDaniel et al., 2022).
Curettage and electrodesiccation are treatment options for managing superficial NMSCs. In this treatment, the cancerous lesion is removed by scraping it with a curette, a long, thin instrument with a sharp looped edge on one end. The area is then treated with an electrode to destroy any remaining cancer cells. Mohs surgery is considered the most effective technique for treating many BCC and SCC lesions, with up to 99% cure rate for a skin cancer lesion that has not been treated before and up to 94% for skin cancer that has recurred after prior treatment. Mohs surgery is performed in specific stages that occur in one visit. First, the surgeon removes a layer of tissue and then examines it under the microscope. If any cancer cells remain, the surgeon knows the precise location and removes another layer of tissue while sparing as much healthy tissue as possible. This process is repeated until no cancer cells remain. It removes all cancerous cells for the highest cure rate while sparing healthy tissue and leaving the smallest possible scar (Aasi, 2022; Aasi & Hong, 2021; Howell & Ramsey, 2022; McDaniel et al., 2022).
Melanoma Staging and Treatment
Once a diagnosis of melanoma has been made by biopsy of the lesion, pathologic staging must be completed to determine prognosis and treatment. The American Joint Committee on Cancer (AJCC) staging system is used to stage melanoma skin cancer. In addition, the National Comprehensive Cancer Network (NCCN) offers evidence-based treatment guidelines correlating with each stage (Coit et al., 2019). This system has five melanoma stages, outlined below in Table 6.
The Five Stages of Melanoma
(Coit, 2019; Melanoma Research Alliance, n.d.)
Treatment of Advanced and Metastatic Melanoma
As outlined above in Table 6, surgical intervention with wide local excision is often curative if the primary growth and surrounding healthy tissue are removed (negative margins) for localized melanoma. These patients require close follow-up and surveillance with TBSE by a skilled HCP every three months and are counseled to perform monthly skin self-examinations. They generally do not require additional treatment. For some patients, a sentinel lymph node is biopsied to determine the stage of the disease, and more extensive lymph node surgery may be necessary if the sentinel lymph node contains cancer. Treatment for advanced disease and metastatic melanoma can be more complex. Melanomas with deep invasion or those that have spread to lymph nodes may be treated with surgery, immunotherapy, or radiation therapy. The treatment for advanced melanoma has changed dramatically in recent years with the US Food & Drug Administration (FDA) approval of several new immunotherapy agents and targeted drugs. Chemotherapy may rarely be used but is generally considered much less effective than immunotherapy and targeted treatments (Coit, 2019; Sosman, 2022).
Treatment options for melanoma beyond surgery may include one or more of the following modalities:
- radiation therapy: high-energy rays like x-rays shrink or kill the cancerous cells
- immunotherapy and vaccine therapy: systemic treatments injected into the body using substances produced by living organisms made in the body or a laboratory; these treatments boost and alter the immune system's normal functioning to help the body attack cancer cells
- targeted therapy: systemic treatment administered in a pill form or injected into the veins designed to target specific mutations or weak areas in the cancer cells
- chemotherapy: nonspecific systemic treatments administered in pill form or injected into the veins and devised to shrink or kill cancer
- clinical trial participation (Coit, 2019; Melanoma Research Alliance, n.d.; Sosman, 2022)
Skin Cancer Follow-up Care
Patients with NMSC or melanoma skin cancer who completed treatment still require follow-up surveillance at regular intervals. Follow-up is often recommended for patients with BCC every 6 to 12 months. For those with SCC, monitoring is usually more frequent than BCC, such as every 3 to 6 months for the first few years. If the patient remains without evidence of recurrent cancerous lesions, follow-up intervals can be extended. Surveillance for melanoma is much more complicated. Surveillance depends on the cancer stage at diagnosis, treatment response, residual disease following treatment, and the need for ongoing treatment. Melanoma-in-situ treated with wide local excision with negative margins is considered cured. According to the NCCN guidelines, patients with stages 0, I, and IIA should undergo complete skin examinations every 6 to 12 months for the first two years, then annually. For patients with stage IIB-IV, the NCCN recommended follow-up every 3 to 6 months for the first two years, then every 6 to 12 months from years 3 to 5. In patients with a history of brain metastases and those at high risk for brain metastases (e.g., those with stage IIIC-IV), the NCCN advises more frequent brain imaging with magnetic resonance imaging (MRI). For all patients with a prior history of melanoma, the NCCN guidelines recommend at least annual skin exams for life (Coit, 2019; Pathak & Zito, 2022).
Skin Cancer Prevention and Sun Safety
Minimizing sun exposure is the key to preventing skin cancer. According to ACS researchers, most melanoma cases and deaths are potentially preventable by reducing exposure to intense and damaging UV radiation. The USPSTF (2018) found moderate-grade evidence to recommend counseling young adults, adolescents, children, and patients of young children to minimize exposure to UV radiation for persons aged six months through 24 years with fair skin to reduce their risk of skin cancer. Further, the USPSTF recommends that HCPs selectively offer counseling to adults older than 24 years with fair skin about minimizing their exposure to UV radiation. However, evidence indicates that the net benefit of counseling adults older than 24 years is small. In determining whether this service is appropriate in individual cases, patients and HCPs should consider the presence of other risk factors for skin cancer (USPSTF, 2018). The following is a compilation of evidence-based interventions to educate patients on how to reduce the risk of skin cancer induced by UV radiation:
- avoid sunbathing or indoor tanning
- seek shade when outdoors; however, understand that while the shade is an effective mode of reducing UV radiation, it does not eliminate the exposure completely
- avoid exposures to midday sun when the sun's UV rays are strongest and can do the most damage to the skin (from 10 AM through 4 PM)
- Wear protective clothing made of tightly woven fabric (e.g., long sleeves, a wide-brimmed hat, long pants, etc.) when outside. A hat with at least a 6-inch brim around the entire circumference is recommended, as it protects the face, neck, and ears. Baseball caps do not protect the back of the neck or the tops of the ears;
- wear sunglasses with UV-absorbing lenses to block UV rays; seek sunglasses that protect the sides of the eyes and lenses that offer protection against both UVA and UVB rays; sun exposure increases the risk of cataracts
- apply a broad-spectrum sunscreen with a sun protection factor (SPF) of at least 30 to unprotected skin every day, regardless of anticipated sun exposure and even on cloudy days
- adequate sun protection should be ensured while driving or sitting near windows due to exposure to UVA and UVB rays through the glass, especially to the hands, arms, neck, and face
- be mindful of medications, as some over-the-counter (OTC) and prescription medications can increase photosensitivity (sensitivity to harmful sun rays); A few of the most common include:
- antihistamines such as diphenhydramine (Benadryl)
- ibuprofen (Motrin)
- certain antibiotics such as tetracyclines (doxycycline [Monodox] and minocycline [Minocin])
- certain antidepressant medications such as selective serotonin reuptake inhibitors (fluoxetine [Prozac] or citalopram [Celexa])
- several types of chemotherapeutic agents, such as capecitabine (Xeloda), doxorubicin (Adriamycin), or fluorouracil (5-FU; Guerra et al., 2021; Young & Tewari, 2022)
HCPs should educate patients to use broad-spectrum sunscreen, which protects against UVA and UVB rays. Sunscreens are rated in strength according to SPF. The higher the SPF, the more sunburn protection is provided. Sunscreen should be SPF 30 or higher and water-resistant. HCPs should caution patients that sunscreen does not offer 100% protection against the sun's harmful UV rays, so the above precautions must be taken to ensure safety (Guerra et al., 2021; Young & Tewari, 2022). Additional patient teaching points include (Guerra et al., 2021; Young & Tewari, 2022):
- Use sunscreen every day, even on cloudy days. Up to 80% of the sun's harmful UV rays can penetrate the skin through clouds.
- Snow, sand, and water increase the need for sunscreen as they reflect the sun's rays.
- Apply enough sunscreen to cover all exposed skin. Most adults need about 1 ounce to cover their body entirely.
- Rub sunscreen in well to dry skin.
- Reapply at least every 2 hours when outside and more frequently after swimming, sweating, or toweling off.
- Ensure the sunscreen has not expired, as some ingredients in sunscreen break down over time.
- Sunscreen should be applied at least 15 minutes before exposure to all areas that the sun's rays may reach. Special attention to the areas most commonly omitted when applying sunscreen, including the tips of the ears, the back of the neck, and bald spots on the top of the head.
- Apply protective lip treatment with an SPF of at least 15 to protect the lips from sun exposure.
- Type of sunscreen:
- Products that include zinc oxide offer the safest sun protection.
- Available sunscreen options include lotions, creams, gels, ointments, wax sticks, and sprays.
- Creams are best for dry skin and the face.
- Gels are ideal for hairy areas like the scalp or male chest.
- Sunscreen sticks are good to use around the eyes.
- Patients sometimes prefer sprays since they are easy to apply. However, current FDA regulations on testing and standardization do not pertain to spray sunscreens; many organizations advise against their use.
Vitamin D is essential for healthy bones, muscles, and teeth. The human body makes vitamin D when exposed to sunlight (specifically UVB, which is processed through the skin). While sunlight is important for vitamin D, patients must be counseled on the importance of being careful about how much sunlight they are getting. In general, the lighter the skin tone, the less sunlight is needed on the skin to make vitamin D. The body only needs about 15 minutes of unimpeded sun exposure, 2 to 3 times a week, to fulfill the body's vitamin D needs. This small amount of sun exposure generates all the vitamin D the body requires. After that, the body starts to dispose of vitamin D to avoid an overload. At this point, sun exposure provides patients with risks without any presumed benefits. In addition to sunlight, vitamin D can be acquired through diet. Diets that include egg yolks, oily fish (i.e., salmon, tuna, sardines, eel), or fortified milk and cereal can satisfy vitamin D needs without sun exposure. Alternatively, patients can be advised to take vitamin D supplements (Guerra et al., 2021; Young & Tewari, 2022).
Special Considerations for Children and Adolescents
As described earlier, sunburns in childhood significantly increase the risk of melanoma later in life. Children with fair skin, red or blonde hair, freckles, and light-colored eyes are most vulnerable to harmful UV effects. Sun avoidance/limiting exposure to sunlight and sun protection measures can be used to reduce the risk of toxic overexposure. Parents should be taught to generously apply sunscreen with an SPF of at least 30 to their child's body, cover exposed skin with about 1 ounce of sunscreen 15 to 20 minutes prior to going outside, and reapply every 2 hours, even on cloudy days, and after swimming or sweating. Infants younger than six months should never be out in direct sunlight and should be dressed in tightly woven long-sleeved shirts, long pants, and brimmed hats that offer the best protection. Traditionally, it was advised to avoid applying sunblock to infants under six months, but the American Academy of Pediatrics (AAP) has now published new guidelines, as research has shown that the risk of sunburn is greater than the risk of chemical exposure. When adequate clothing and shade are unavailable, parents are advised to apply minimal sunscreen with at least 15 SPF on infants under six months. Clothing, especially swimsuits, can be manufactured with SPF fabric. Some small tents and umbrellas are designed with SPF 50 fabric to simultaneously protect the entire family when seated underneath it with no chemical exposure (AAP, 2021).
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