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skin cancerOncology A cutaneous malignancy Nonmelanoma SCs BCC, SCC–up to 106 new cases/yr, ±2700 deaths Melanoma ±34,000 new cases/yr, very aggressive–±7000 deaths Biology 1º SC may be indolent, as in BCC, or serious, as in melanoma–depth of invasion is a critical prognostic parameter; metastatic SCs–eg, from breast, GI tract, have a poor prognosis. See Basal cell carcinoma, Melanoma, Squamous cell carcinoma.
skin cancerOne of various malignant conditions of the skin such as MALIGNANT MELANOMA, BASAL CELL CARCINOMA, SQUAMOUS CELL CARCINOMA, PAGET'S DISEASE OF THE NIPPLE, MYCOSIS FUNGOIDES and KAPOSI'S SARCOMA.
|Mean LOS:||5.8 days|
|Description:||SURGICAL: Skin Graft and/or Débridement Except for Skin Ulcer or Cellulitis With CC|
|Mean LOS:||7.7 days|
|Description:||MEDICAL: Major Skin Disorders With Major CC|
|Mean LOS:||6 days|
|Description:||MEDICAL: Minor Skin Disorders With Major CC|
Skin cancer is the most common malignancy in the United States, accounting for over 50% of all diagnosed cancers. The majority of skin cancers (more than 90%) are classified as nonmelanoma skin cancers (NMSCs) of which there are two types: basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Approximately 75% of skin cancers are BCC; SCC is the next most common skin cancer, followed in frequency by melanoma. More than 2 million cases of NMSC are diagnosed annually. Other, less frequently occurring skin cancers include skin adnexal tumors, Kaposi’s sarcoma, various types of sarcomas, Merkel cell carcinoma, and cutaneous lymphoma, all of which together account for fewer than 1% of NMSCs.
BCC is a slow-growing, nonmetastasizing neoplasm of the nonkeratinizing cells of the basal layer of the epidermis, which extends wide and deep if left untreated. If distant metastasis does occur to the bone, brain, lung, and liver, the prognosis is grave. BCC is most frequently found on the head, neck, and on skin that has hair. There are two types of BCC. The nodular ulcerative BCC is a nodulocystic structure that begins as a small, flesh-colored, smooth nodule that enlarges over time. A central depression forms that progresses to an ulcer surrounded by a waxy border. The superficial BCC is often seen on the chest or back and begins as a flat, nonpalpable, erythematous plaque that enlarges and becomes red and scaly with nodular borders. Although BCC can be treated effectively, it is not uncommon for it to return after treatment. Of people diagnosed with one BCC, 35% to 50% will develop a new skin cancer within 5 years of the first diagnosis.
SCC leads to an invasive tumor that can metastasize to the lymph nodes and visceral organs. SCC, which constitutes 20% of all skin cancers, is characterized by lesions on the squamous epithelium of the skin and mucous membranes. SCC appears as a red, scaling, keratotic, slightly elevated lesion with an irregular border, usually with a shallow chronic ulcer. The risk of metastasis is associated with the size and penetration of the tumor, the tumor morphology, and the causative factors. Complications of NMSCs include disfigurement of facial structures and metastasis to other tissues and organs.
Because occurrence of NMSC is not reported, incidence can only be estimated. It is suspected that more than 1 million cases of BCC occur each year, and 1,000 to 2,000 deaths occur from BCC. The 5-year survival rate for patients with BCC is greater than 99%; although BCCs rarely spread to lymph nodes or other organs, those patients who do have metastasized BCC have a 5-year survival rate of only 10%. The overall 5-year survival rate for patients with SCC is more than 95%; for patients with spread of SCC to lymph nodes or other organs, the 5-year survival rate is 25%.
The cause of NMSCs may be environmental (ultraviolet [UV] radiation or UVB exposure), occupational (arsenic, mineral oils, or ionizing radiation exposure), viral (HIV or human papillomavirus [HPV]), related to medical conditions (immunosuppression or scars from removed SCC or BCC), or related to heredity (xeroderma pigmentosum, albinism). More than 90% of NMSCs are attributed to exposure to UV radiation from the sun. Indoor tanning beds are an avoidable risk factor to nonmelanoma skin cancer.
There are several heritable syndromes that increase susceptibility to NMSC. These include xeroderma pigmentosum, nevoid basal cell carcinoma syndrome, albinism, and epidermodysplasia verruciformis, which produces multiple warts on the hands and feet and is linked to susceptibility to HPV.
Gender, ethnic/racial, and life span considerations
The incidence of skin cancer is more common between ages 30 and 60, with the majority of lesions occurring in patients over 50. However, younger people are now more likely to develop skin cancer, perhaps because of greater exposure to the sun. Children rarely have the disease, although the incidence increases with each decade of life. The ratio of European Americans to African Americans among people who develop skin cancer is 20:1. Males are more likely than women to develop BCC (2:1 ratio) and SCC (3:1 ratio). People with fair skin and freckles are at especially high risk.
Global health considerations
Rates are increasing worldwide. The World Health Organization reports that, globally, between 2 and 3 million nonmelanoma skin cancers occur each year and that 132,000 melanoma skin cancers occur each year.
Assess the patient for a personal or family history of skin cancer. Ask if the patient has an exposure to risk factors, including environmental or occupational exposure, at-risk medical conditions, or exposure to viruses. Note that outdoor employment and living in a sunny, warm climate such as the southeastern (Florida) or southwestern (New Mexico, Arizona, California) United States, Australia, or New Zealand place the patient at risk. Question the patient about any bleeding lesions or changes in skin color. Explore the history of nonhealing wounds or lesions that have been present for several years without any change. Question the patient about the presence of atypical moles, an unusual number of moles, or any noticeable change in a mole.
The most common symptoms are the appearance of a new skin lesion or a change in a mole or skin growth. Inspect the patient for additional risk factors, such as light skin and hair (red, blond, light brown), freckling, and light eye color (blue or green). Examine the patient’s skin for the presence of lesions. Use a bright white light and magnification during the skin examination. Stretch the skin throughout the examination to note any nodules or translucent lesions. Examine folds or wrinkles in the skin. Assess the skin for ulcerations, sites of poor healing, old scars, drainage, pain, and bleeding. Because more than 70% of NMSCs occur on the face, head, and neck, closely examine these areas. Complete the skin assessment, considering that in order of frequency, the remainder of NMSCs occurs on the trunk, upper extremities, lower extremities, and lastly, the genitals. Determine if the patient has precursor lesions of SCC, such as actinic keratoses (a hornlike projection on the skin from excessive sun exposure) and/or Bowen’s disease (intraepidermal carcinoma). No assessment of precursor lesions for BCC is necessary because no equivalent lesions exist.
Assess for the characteristic lesions of BCC, which tend to be asymptomatic, grow slowly, are 0.5 to 1 cm in size, and have overlying telangiectasis (vascular lesions formed by dilated blood vessels). BCCs are classified as nodular (the most common type), superficial, pigmented, morpheaform, and keratotic. Nodular BCC appears as a translucent, nodular growth. Superficial BCC, frequently appearing on the trunk, presents as a scaly lesion with a distinct, raised, pearly margin. Pigmented BCC has a characteristic dark or bluish color with a raised and pearly border. The morpheaform BCC lesion is poorly demarcated, is light in color, and has a plaquelike appearance. Keratotic BCC lesions appear similar to ulcerating nodular BCC.
Assess for the characteristic lesions of SCC, which are usually found on sun-damaged skin. The lesions tend to be scaly, 0.5 to 1.5 cm in size, and likely to metastasize; they also grow rapidly. SCC lesions are usually covered by a warty scale surrounded by erythema that bleeds easily with minimal trauma. The tumor appears nodular, plaquelike, and without a distinct margin. When SCC is invasive, the lesion appears firm, dome-shaped, erythematous, and with an ulcerating core.
Determine the patient’s willingness to follow primary prevention strategies and to institute changes that decrease the risk of skin cancer or its recurrence. Of particular concern are patients who are adolescents and young adults who place a high premium on physical appearance. If the patient has metastatic disease, assess the ability to cope with highly stressful situations. Determine if the patient has support systems and the ability to cope with major lifestyle changes.
General Comments: The initial diagnosis of skin cancer is made by clinical observation and is confirmed by histologic studies through biopsy.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Shave biopsy||No cancer cells present||Presence of cancer cells||Scraping off the top layers of skin; may not be thick enough to determine the degree of cancer invasion|
|Punch biopsy||No cancer cells present||Presence of cancer cells||Deep sample of skin is removed after numbing the site; cuts through all layers of skin|
|Incisional and excisional biopsy||No cancer cells present||Presence of cancer cells||Surgical knife is used to cut through full thickness of skin, and a wedge of skin is removed; incisional biopsy removes only a portion; excisional biopsy removes entire tumor|
|Fine-needle aspiration biopsy||No cancer cells present||Presence of cancer cells||Thin needle is used to remove very small tissue fragment; may be used to biopsy a lymph node near a melanoma to determine extent of disease|
Primary nursing diagnosis
DiagnosisImpaired skin integrity related to cutaneous lesions
OutcomesTissue integrity: Skin and mucous membranes; Wound healing: Primary intention; Knowledge: Treatment regimen; Nutritional status; Treatment behavior: Illness or injury
InterventionsIncision site care; Wound care; Skin surveillance; Medication administration; Infection control; Nutrition management
Planning and implementation
Treatment depends on the patient’s characteristics; whether the lesion is a primary or recurrent tumor; and its size, location, and histology. For some primary SCCs and BCCs, therapies may include electrosurgery, surgical excision, cryosurgery, and radiation therapy, which all have comparable cure rates of greater than 90%. Tumors best suited to such methods are generally small, superficial, well defined, and slow growing. Treatment is done on an outpatient basis unless the tumor involves deep anatomic sites and surgery cannot be performed under local anesthesia. Mohs’ micrographic surgery is the preferred procedure for invasive SCCs, incomplete excisions, and recurrences. The procedure is also preferred for BCCs that are greater than 2 cm, are located in high-risk areas, have aggressive morphology, or have ill-defined borders. This time-consuming procedure involves removing a layer of skin, immediately checking the removed tissue for cancer cells, and continuing this process until the removed skin samples are cancer free. Reconstructive surgery may be necessary after Mohs’ surgery or extensive excision.
Topical fluorouracil may be used to manage some SCC skin lesions. During treatment, the patient’s skin is more sensitive than usual to the sun. Healing generally occurs in 1 to 2 months. With metastatic SCC, radiation, chemotherapy, and surgery may be combined. The chemotherapeutic agent commonly used is cisplatin or doxorubicin, or both. External beam radiation therapy may be used in cases where a tumor is difficult to remove surgically because of its size or location and in situations in which the patient’s health precludes surgery. As an adjuvant therapy after surgery, radiation can be used to kill small deposits of cancer cells that were not visible during surgery. Radiation may also be used when NMSC has spread to other organs or to lymph nodes. If the patient undergoes radiation therapy, prepare the patient for common side effects such as nausea, vomiting, diarrhea, hair loss, and malaise.
|Medication or Drug Class||Dosage||Description||Rationale|
|Chemotherapeutic agents||Topical application||Fluorouracil (5-FU)||Manage premalignant conditions such as actinic keratosis|
|Biological response modifier||Topical application||Imiquimod||Causes the body to react and destroy the lesion|
Nursing care focuses on wound management, threats to body image and self-esteem, and prevention. Teach the patient how to care for the wound aseptically. Coordinate a consistent, standard plan so that the patient can begin to assume care for the wound. If the wound is large and infected, keep it dry and clean. If it has an odor, control the odor with odor-masking substances such as oil of cloves or balsam of Peru in the room.
Patients are often upset about the changes in their appearance. Listen to the patient’s fears and anxieties and accept the patient’s perception of her or his appearance. Assist the patient and significant others to have realistic expectations. Help the patient present a pleasant appearance by assisting with hair care and clothing. Some patients experience increased self-esteem when they wear their own clothing rather than hospital-issued clothing, if hospitalization is needed. If hair loss occurs during radiation, encourage the patient to wear any type of head covering that improves body image, such as baseball caps, wigs, scarves, or bandanas. If it is appropriate, arrange for the patient to interact with others who have a similar problem. If the patient has end-stage disease, listen to the patient’s and significant others’ fears and concerns. Identify the needs of the family, and investigate mechanisms for support from the chaplain, the American Cancer Society, or a local hospice.
If the patient cannot continue with his or her present occupation, arrange for job counseling to evaluate possible occupational alternatives. Encourage the patient to avoid excessive sun exposure by using sunscreen and wearing protective clothing. Explain the necessity of examining the skin weekly or monthly for precancerous lesions and to obtain health care when any unusual skin changes occur.
Evidence-Based Practice and Health Policy
Long, M.D., Herfarth, H.H., Pipkin, C., Porter, C.Q., Sandler, R.S., & Kappelman, M. (2010). Increased risk for non-melanoma skin cancer in patients with inflammatory bowel disease. Clinical Gastroenterology and Hepatology, 8(3), 268–274.
- A retrospective study in which 53,377 patients with inflammatory bowel disease (IBD) were compared with 160,037 control participants revealed an increased risk of NMSC among IBD patients over median follow-up periods ranging from 700 to 1,004 days (IQR range, 456 to 1,217 days).
- Patients with Crohn’s disease (49.5% of IBD patients) were 1.84 times more likely to develop NMSC (95% CI, 1.63 to 2.06), and patients with ulcerative colitis (50.5% of IBD patients) were 1.47 times more likely to develop NMSC than control participants (95% CI, 1.31 to 1.65).
- Compared to control participants, Crohn’s disease patients being treated with an immunomodulator were 3.71 times more likely to develop NMSC (95% CI, 2.74 to 5.02; p < 0.001), and those being treated with a biologic were 2.47 times more likely to develop NMSC (95% CI, 1.29 to 4.73; p = 0.006).
- Physical findings related to skin cancer: Location and description of lesions, degree of healing, appearance and healing of surgical wound
- Patient’s history related to skin cancer and associated risk factors
- Psychological response: Psychosocial state related to diagnosis of skin cancer, self-esteem, body image, level of anxiety and fear about prognosis, coping ability
- Response to diagnostic and treatment interventions: Surgery, chemotherapy, radiation
Discharge and home healthcare guidelines
Teach the patient primary prevention strategies:
- Perform self-skin assessments, including the use of a buddy or a mirror during the self-assessment.
- Use sunscreens and lip balms with a sun protection factor of 15; to apply sunscreens 15 to 30 minutes before every exposure to the sun; and to follow the reapplication guidelines.
- Use wraparound sunglasses with 99% to 100% UV absorption to protect the eyes and the skin area around the eyes.
- Avoid sun exposure, particularly between 10 a.m. and 3 p.m.
- Use available shade, avoid artificial tanning, and wear protective clothing.
- Be aware of photosensitivity because certain medications and cosmetics can enhance UV ray exposure.
- Encourage members of the family to follow all prevention strategies.
Patient discussion about skin cancer
Q. How can you know if a mole is a skin cancer or not? I'm only 15, but I’ve had this small thing on my right shoulder for a reeeeaaaally long time. It's the same color as my skin. It’s smaller than the head of a pencil eraser, perfectly round, and its smooth. I've never worried about it seriously, until about a week ago, when I read an article in a magazine about skin cancer. Even then I wouldn't have worried about it, because It didn't really match any of the symptoms, except one. It did bleed once about 2 1/2 years ago. And it said bleeding was a big sign I don't know, what do you think? And please try and say something other than," go have it checked out". Because I currently have no insurance. Thanks :]
look for one near your home.
Q. is it dangerouse to stay in the sun even if you don't get burned? how bad is it if you only get a little tan? does it matter what is your skin type in the first place? is only getting burned dangerouse, or being in the sun alltogether?