Mitigating Melanoma Early Detection and Intervention Is Key for Higher Survival Rates

Mitigating melanoma Early detection and intervention is key for higher survival rates.

By Kathileen Boozer, DNP, APRN, FNPC

SKIN CANCER is the most commonly diag- form annual skin exams have an opportunity nosed cancer in the United States and around to identify, detect, and biopsy suspicious skin the world. According to the American Acade- lesions; collaborate in care; and make timely my of Dermatology, approximately one in five referrals. Melanoma is easily treated when it’s Americans will develop a basal cell carcinoma identified at an early stage, making early diag- (BCC), squamous cell carcinoma (SCC), or a nosis key to increased survival rates. melanoma skin cancer in their lifetime. Mela- noma, which was once thought to be uncom- Skin mon, is the most serious type of skin cancer. The skin is the largest organ in the body. It It accounts for 75% of deaths associated with protects internal structures from the environ- cutaneous cancers. (See Melanoma facts.) The ment (including ultraviolet [UV] radiation) and skin cancer burden in the United States con- harmful pathogens, and it helps the body reg- tinues to rise, creating a substantial annual ulate moisture, control temperature, and pro- cost for treatment and management. mote vitamin D synthesis. Prevention strategies and early recogni- The skin consists of three main layers: the tion, diagnosis, and treatment of melanoma epidermis (top layer), the dermis (middle lay- can lower the disease incidence. Nurses’ role er), and the hypodermis (fat layer). Skin can- in primary and secondary prevention meas- cer is categorized as nonmelanoma (for exam- ures—including assessments, risk screenings, ple, BCC and SCC) and melanoma. When skin and patient education—can improve patient cancer occurs, it initially affects one of three outcomes and help reduce healthcare costs. types of cells (squamous, basal, and mela - In addition, advanced practice RNs who per- nocytes) within the epidermis. In a patient with melanoma, cancer cells form in the melanocytes. Melanoma can arise from a cur- rent skin lesion or nevus that progressively CNE changes or as a new lesion (de novo). 1.5 contact hours Skin cancer risk factors LEARNING O BJECTIVES According to the American Cancer Society, pa- 1. Describe patient assessment for melanoma. tient factors that influence the risk for skin 2. Compare the subtypes of melanoma. cancer, including melanoma, are UV radiation exposure from natural (excessive sun expo- 3. Discuss strategies for skin cancer prevention. sure) and artificial (tanning bed) sources, per- The author and planners of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity. See the last page of the article to sonal history of blistering sunburns, family or learn how to earn CNE credit. personal history of skin cancer, genetic pre- Expiration: 4/1/24 disposition, and other hereditary factors in- cluding light skin and red or blonde hair.

6 American Nurse Journal Volume 16, Number 4 MyAmericanNurse.com Melanoma facts

Melanoma has been identified as a global health burden. • Americans have experienced a 200% increase in melanoma diag- Skin cancer signs noses since the 1970s. The most common sign of skin cancer is • New melanoma cases are estimated to grow by 2% annually, and an change, including changes to a current ne- estimated 100,000 Americans received the diagnosis in 2020. vus; a skin lesion that’s bleeding, ulcerated, • Lifetime risk of melanoma is 1:40 for Whites, 1:200 for Hispanics, and or won’t heal; a satellite mole; a new skin le- 1:1,000 for Blacks. sion that stands out on inspection of the skin; • The estimated annual cost of treating cutaneous cancers in the Unit- ed States is roughly $8 billion. or a growth that meets the ABCDE mnemon- • ic criteria, which describes clinical signs of 10% of individuals diagnosed with melanoma have a positive family melanoma: Asymmetry, Border irregularity, history of the disease. • Individuals who use a tanning bed before age 35 years have a 75% Color variation, Diameter, and Evolving. (See higher risk for melanoma. ABCDE mnemonic.) • Among women, melanoma is more common in those who are The mnemonic can be combined with the younger than 50; among men, it’s more common in those who are ugly duckling sign, which refers to a spot older than 50. that’s different from other cutaneous lesions • The National Cancer Institute ranks melanoma as the fourth most and should prompt suspicion of melanoma. commonly diagnosed cancer among the general US population Nurses can use these indicators to improve (63 is the average age at time of diagnosis). early melanoma detection and teach them to • In the United States, melanoma ranks #1 in cancer diagnosis for in- patients to increase awareness and identifica- dividuals 25 to 29 years of age. tion of potential melanomas. Nurses also need • The estimated U.S. death rate from melanoma is 4,600 for men and to know the difference between nevi and the 2,200 for women. various subtypes of melanoma. Source: Melanoma Research Alliance

Nevi A nevus (also referred to as a common mole) should be biopsied, and the patient should be is a skin lesion made up of melanocyte clus- referred to a dermatology specialist for removal. ters. These noncancerous lesions can range from pink to dark brown and can be either Melanoma flat or raised. Incidences of melanoma continue to increase among all age groups. Genetic predisposition Dysplastic nevus can play a role in its development but ac- counts for only 15% of cases. UV radiation ex- posure continues to be the primary risk factor. According to the Centers for Disease Control and Prevention, when melanoma is recog- nized early and appropriately treated, the 5- year survival rate is 98% to 99%. Melanoma subtypes include superficial spread ing melanoma (SSM), nodular, len- tigo maligna (LM), LM melanoma (LMM), Dysplastic nevi have a 5% to 20% chance of de- acral lentiginous melanoma, and amelanot- veloping into melanoma. They’re typically larger ic melanoma. than 6 mm and have irregular or ill-defined fad- ing borders. They can be pink, tan, brown, or Superficial spreading melanoma black. Dysplastic nevi occur most frequently in sun-exposed areas, including the trunk and up- per extremities; however, they also can develop in protected areas such as the scalp, breasts, but- tocks, genitalia, palms, and soles of the feet. The lesions can occur throughout a person’s life, and their history frequently includes a first- or sec- ond-degree relative with a melanoma diagnosis. Individuals with a dysplastic nevus should have yearly skin exams that include baseline SSM accounts for 70% of melanoma diagnoses photography and updates. Lesions that change and can affect adults of all ages. It has a peak

MyAmericanNurse.com April 2021 American Nurse Journal 7 ABCDE mnemonic Nurses, providers, and patients can use this mnemonic to identify skin cancer.

Asymmetrical (irregular shape) Border (irregular or jagged border) growing, and invasive, thus having a higher chance of metastasis at the time of diagnosis. Nodular melanoma lesions are uniformly blue–black, blue–red, or pink–red; 5% lack pigment (amelanotic). The most common lo- cations for these lesions are the trunk, head, and neck. They frequently occur de novo.

Lentigo maligna Color (more than one color Diameter (>6 mm or roughly the LM is the most common melanoma subtype identified or uneven coloring) size of a pencil eraser) and is defined as in situ (confined to the epi- dermis). It’s frequently seen in adults over age 40 (with a peak in the seventh and eight decades of life [median age 65]) with fair, chronically sun-damaged skin. The most com- mon lesion locations are the cheek, head, and neck, but they also can occur on the extremi- ties (most commonly in women) and the back (most commonly in men). LM typically appears as smooth, nonpalpa- Evolving (change that occurs over ble skin lesions with irregular light brown or weeks or months) tan color. When peripheral growth occurs, LM will have multiple brown and tan variations. LM lesions also may appear patchy and have incidence during the fourth and fifth decade a noncontiguous pattern. The slow progres- of life, but most commonly occurs in adults sion of LM can range from 5 to 15 years be- between 25 and 29 years old and among fore it becomes invasive. Most patients are those with fair skin. asymptomatic, but advancing LM can cause In men, the most common SSM location is pain, burning, itching, or bleeding. the upper back; in women it’s the lower legs. In the early stages, SSM (which can arise from Lentigo maligna melanoma a current mole) appears flat or slightly raised with irregular color distribution and an asym- metric border. Late-stage SSM slowly expands peripherally, and color changes include tan, brown, black, red, pink, and white. Invasive SSM typically occurs on the trunk, head, or neck with vertical growth in the dermis. SSM can take several years to become invasive.

Nodular melanoma Nodular melanoma ranks as the second most LMM (invasive LM) is rare (4% to 15% of common melanoma subtype, accounting for melanoma cases) and occurs almost exclu- 10% to 15% of diagnoses. It’s aggressive, fast- sively on sun-exposed skin (head, neck, nose,

8 American Nurse Journal Volume 16, Number 4 MyAmericanNurse.com Protection for prevention

Skin protection measures can help reduce the risk of skin cancer, in- cluding melanoma. Advise patients to take these precautions to re- cheeks). The median age for diagnosis is 65 duce their exposure to ultraviolet radiation when outdoors. years. The average LMM lesion size is 3 to 6 • Avoid sun exposure at peak times (10 AM to 4 PM). cm, but they can grow larger and typically • Decrease the amount of time spent in the sun. have a 1 mm to 2 cm nodular component. The • Seek shade while outdoors. lesions are flat and irregular with mottled or • Wear sunscreen (at least 30 SPF). variegated pigment patterns. • Reapply sunscreen every 2 hours with heavy sweating or swimming. Chronic UV exposure causes high mutation • Wear protective clothing, including hat, sunglasses, long sleeve rates in LMM, which leads to an estimated 30% shirts, and pants. life-time risk of progression from LM to LMM. • Avoid tanning beds. The rate of LMM progression to invasive mela - noma is 5%. reasons for these changes aren’t well under- Acral lentiginous stood, but amelanotic melanoma cells lack melanoma pigments seen in other types of melanoma. In the United States, acral Lack of pigmentation occurs when cells can’t lentiginous mela no ma is produce mature melanin clusters. Risks for the most common type of amelanotic melanoma include light skin, melanoma in Black, His- chronic photodamage from sun-exposed skin, panic, Native American, and increased age; however, it also occurs in and Japanese populations. young children. Median age for occurrence Amelanotic melanoma lesions appear as en- is 65 years, and it affects larging pink to red macules, papules, or nodules men and women at the with well- or ill-defined borders. Any subtype same rate. Sun exposure and UV radiation of melanoma can become amelanotic. aren’t believed to be a factor for developing acral lentiginous melanoma. Melanoma staging Lesions appear as black or brown discol- Melanoma staging is based on the American orations on the soles of the feet (the most Joint Committee on Cancer staging system, common site), palms of the hands, and under which includes tumor size, lymph node in- the fingernails and toenails; 60% of patients volvement, and metastasis. In 2016, the guide- have subungual (under the fingernail) or plan- lines incorporated evidence-based prognostic tar lesions. The lesions spread peripherally be- factors, including the Breslow Depth and the fore deep-tissue invasion occurs. Because acral Clark Level. lentiginous melanoma diagnosis isn’t common, The Breslow Depth measures how far mela - it’s frequently discovered in the late stages. noma has invaded the cutaneous tissue. It also A variant of acral lentiginous melanoma is directly correlates with the risk of death asso- subungual melanoma, which involves the ciated with the melanoma tumor. It’s vertically great toe or thumb. It arises from the nail ma- measured in millimeters from the top of the trix and has a positive Hutchinson’s sign (pig- superficial ulceration (granular layer) to the mentation on the proximal nail fold and nail deepest point of tumor involvement. This plate). measurement is a strong predictor of patient outcome; thicker melanomas have a higher Amelanotic melanoma chance of metastasizing. The Clark Level describes the melanoma depth and can help predict the outcome for thin tumors. The levels range from 1 to 5 (in situ, in- vading the papillary dermis, filling the papillary dermis, invading the reticular dermis, and in- vading the subcutaneous tissue). The higher the level, the greater the risk of metastasis.

Amelanotic melanoma (1% to 8% of mela no - Nursing implications ma diagnoses) occurs from genetic changes in Nurses play a key role in preventing and de- DNA that form malignant melanocytes. The tecting melanoma and other types of skin can-

MyAmericanNurse.com April 2021 American Nurse Journal 9 Skin self-exam: Step-by-step

Because skin cancer comes in many shapes and sizes, patients should learn to recognize skin changes and new spots and to contact their provider about any concerns. Instruct patients in skin self-exam best Your exam of a patient who’s been diagnosed practices, and explain that examining their skin regularly will help in with skin cancer should include a full health his- early cancer identification. tory, focusing on risk and detection, and a com- • The best time to perform a skin self-exam is after a bath or shower. plete skin exam. Document all lesions (including • Check for moles, blemishes, or birthmarks from the top of the head their location, color, size, and pattern), photo- to the toes. graph them, and note local landmarks. In ad-

dition, palpate the patient’s lymph nodes. Step 1: Do the following while standing and facing a mirror. Providers will order a punch biopsy (ex- • Check face, ears, neck, chest, and belly (women should lift their breasts to check underneath). tending into subcutaneous tissue) of suspicious lesions. A Breslow Depth >1 mm requires an • Check underarm areas, both sides of the arms, tops and palms of hands, in between fingers, and under fingernails. immediate referral to a dermatologic, plastic, or general surgeon for large margin dissection and Step 2: Do the following while sitting down. lymph node biopsy. • Check the front of thighs, shins, tops of feet, in between toes, and under toenails. Patient role and barriers • Use a hand mirror to look at the bottoms of the feet, calves, and Patients play a role in their own healthcare backs of thighs (first checking one leg and then the other). outcomes, and nurses can directly impact a • Use a hand mirror to check buttocks, genital area, lower and upper patient’s knowledge and influence their be- back, and the back of neck and ears (it may be easier to look at the havior. Patient-related skin cancer treatment back in a wall mirror using a hand mirror). delays include patient behavior; an inability • Use a comb or hair dryer to part hair and check the scalp. to see lesions; inadequate knowledge of mela noma signs, symptoms, and risks; and not performing skin self-exams. According to cer, as well as in caring for patients who’ve Avilés-Izquierdo and colleagues, patients been diagnosed with the condition. without adequate education about skin can- cer risk factors and prevention measures who Prevention self-detected melanoma were found to seek Counseling patients can help them understand care with late-stage disease. The relative 5- the steps they can take to keep themselves safe year survival rate for melanoma found in ear- and increase adherence to skin cancer pre - ly, local stages is 98%, but for melanoma vention practices. (See Protection for preven- that’s metastasized, survival rates drop to tion.) The education you provide about sun roughly 25%. Education that targets primary protection and skin self-exams can help reduce and secondary prevention measures (sun a patient’s risk of skin cancer and increases the protection, ABCDE mnemonic, ugly duckling chances of early detection. sign, and skin self-exams) can improve early Epidemiologic data suggest that using sun detection of melanoma. protection and reducing sun exposure have the greatest impact on reducing the incidence Influence change of melanoma. Nurses, patients, and communities must sup- Advise patients to perform monthly skin port initiatives to inform the public about mela - self-exams, especially if they’re at risk for skin noma and other skin cancers to increase aware- cancer (for example, if they have a compro- ness and positively influence changes in sun mised immune system, family history of skin protective behaviors. Healthcare interventions cancer, excessive tanning, or repeated sun- that reduce patient barriers will improve early burns). All they need is a well-lit room and a detection and treatment, reduce morbidity, and mirror. (See Skin self-exam: Step-by-step.) increase survival rates of patients diagnosed with melanoma. AN Patient care An estimated 5% to 10% of patients who’ve Editor’s note: All photography is courtesy of the been diagnosed with melanoma will develop National Cancer Institute. a second invasive melanoma in their lifetime. Access references at myamericannurse.com/?p=74425. For that reason, nursing care focuses on edu- cation, regular follow-up appointments, and Kathileen Boozer is an assistant clinical professor at Louise Her- collaboration with a dermatology specialist. rington School of Nursing at Baylor University in Waco, Texas.

10 American Nurse Journal Volume 16, Number 4 MyAmericanNurse.com

POST-TEST • Mitigating melanoma CNE: 1.5 contact hours CNE Earn contact hour credit online at myamericannurse.com/mitigating-melanoma

Provider accreditation Contact hours: 1.5 The American Nurses Association is accredited as a provider ANA is approved by the California Board of Registered Nurs- of nursing continuing professional development by the ing, Provider Number CEP17219. American Nurses Credentialing Center’s Commission on Post-test passing score is 80%. Accreditation. Expiration: 4/1/24

Please mark the correct answer 6. Lentigo maligna 11. Which statement about Breslow online. a. most commonly occurs on the Depth is correct? 1. In a patient with melanoma, can- cheek, head, and neck. a. It assesses the dermis as a degree cer cells form in b. most commonly occurs on the of invasiveness. a. nevuscytes. extremities (for women). b. It is a weak predictor of patient outcomes. b. basal cells. c. usually appears as rough skin le- sions. c. It’s measured vertically in mil- c. melanocytes. d. usually appears as palpable skin limeters from the top of the su- d. squamous cells. lesions. perficial ulceration to the deep- est point of tumor involvement. 2. Among women, melanoma is more 7. In the United States, the most common in those who are d. It’s measured horizontally be- common subtype of melanoma in tween the widest areas of the a. younger than 40. Black, Hispanic, Native American, and margins of tumor involvement. b. younger than 50. Japanese populations is c. older than 50. a. lentigo maligna melanoma. 12. Describe the ABCDE mnemonic for d. older than 60. b. acral lentiginous melanoma. evaluating a skin lesion. c. amelanotic melanoma. ______3. Which statement about dysplastic d. nodular melanoma. ______nevi is correct? ______a. They are usually yellow. 8. Your skin assessment of a 66-year- b. They are usually red. old patient reveals pigmentation on 13. Your patient’s mother had melanoma. c. They occur most frequently in the proximal nail fold and nail plate. It was successfully treated, but your sun-exposed areas, including the You realize that this finding patient is worried about developing it, trunk and upper extremities. a. indicates superficial spreading too. What prevention information re- melanoma. lated to protection from ultraviolet d. They occur most frequently in radiation would you provide? the lower extremities and in the b. indicates amelanotic melanoma. ______scalp and palms of the hand. c. is a negative Hutchinson’s sign. ______d. is a positive Hutchinson’s sign. 4. In women, the most common loca- ______tion of a superficial spreading 9. Which statement about amelanot- melanoma is ic melanoma is correct? 14. Think about how you would ex- a. the lower legs. plain to the same patient how to per- a. The lesions lack pigments that form a skin self-exam. b. the upper arms. are seen with other subtypes. ______c. the lower back. b. The lesions have more pigments d. the upper back. than those seen with other sub- ______types. ______5. Which statement about nodular c. Risk factors include dark skin. melanoma is correct? d. Risk factors include age of 40 to a. It is the most common 50 years. melanoma subtype. b. It rarely occurs de novo. 10. Your patient’s Clark Level staging c. The lesions most commonly oc- results come back as 2, which means cur on the lower limbs. a. invading the papillary dermis. d. The lesions are uniformly blue– b. filling the papillary dermis. black, blue–red, or pink–red. c. invading the reticular dermis. d. filling the subcutaneous tissue.

MyAmericanNurse.com April 2021 American Nurse Journal 11