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Medical-Surgical Nursing: Skin Cancer
SKIN CANCER
Introduction
Skin cancers are cancers that arise from the skin. They are due to the development
of abnormal cells that have the ability to invade or spread to other parts of the body.
There are three main types: basal-cell cancer (BCC), suamous-cell cancer (SCC)
and melanoma. The first t!o to"ether alon" !ith a number of less common skin cancers are
kno!n as non-melanoma skin cancer (#$SC). Basal-cell cancer "ro!s slo!ly and can
dama"e the tissue around it but is unlikely to spread to distant areas or result in death. %t
often appears as a painless raised area of skin, that may be shiny !ith small blood vessel
runnin" over it or may present as a raised area !ith an ulcer . Suamous-cell cancer is more
likely to spread. %t usually presents as a hard lump !ith a scaly top but may also form an
ulcer. $elanomas are the most a""ressive. Si"ns include a mole that has chan"ed in si&e,
shape, color, has irre"ular ed"es, has more than one color, is itchy or bleeds.
'reater than * of cases are caused by e+posure to ultraviolet radiation from
the Sun. This e+posure increases the risk of all three main types of skin cancer. +posure
has increased partly due to a thinner o&one layer . Tannin" beds are becomin" another
common source of ultraviolet radiation. or melanomas and basal-cell cancers e+posure
durin" childhood is particularly harmful. or suamous-cell cancers total e+posure,
irrespective of !hen it occurs, is more important. Bet!een * and /* of melanomas
develop from moles. 0eople !ith li"ht skin are at hi"her risk as are those !ith poor
immune function such as from medications or 1%234%5S. 5ia"nosis is by biopsy.
5ecreasin" e+posure to ultraviolet radiation and the use of sunscreen appears to be
effective methods of preventin" melanoma and suamous-cell cancer. %t is not clear if
sunscreen affects the risk of basal-cell cancer. #on-melanoma skin cancer is usually curable.
Treatment is "enerally by sur"ical removal but may less commonly involve radiation thera py or
topical medications such as fluorouracil. Treatment of melanoma may involve some
combination of sur"ery, chemotherapy, radiation therapy, and tar"eted therapy. %n those people
!hose disease has spread to other areas of their bodies, palliative care may be used to improve
uality of life. $elanoma has one of the hi"her survival rates amon" cancers, !ith over 67* of
people in the 89 and more than * in the 8nited States sur vivin" more than years.
Skin cancer is the most common form of cancer, "lobally accountin" for at least ;* of
cases. %t is especially common amon" people !ith li"ht skin. The most common type is non-
melanoma skin cancer, !hich occurs in at least -/ million people per year. This is a rou"h
estimate, ho!ever, as "ood statistics are not kept. <f non-melanoma skin cancers, about 6*
are basal-cell cancers and * suamous-cell cancers. Basal-cell and suamous-cell cancers
rarely result in death.
%n the 8nited States they !ere the cause of less than .=* of all cancer deaths.
'lobally in = melanoma occurred in /, people, and resulted in , deaths.
4ustralia and #e! >ealand have the hi"hest rates of melanoma in the !orld. The three main
types of skin cancer have become more common in the last to ; years, especially in those
areas !hich are mostly Caucasian.
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Medical-Surgical Nursing: Skin Cancer
Classification
There are three main types of skin cancer : basal-cell carcinoma (BCC), squamous-cell
carcinoma (SCC) and malignant melanoma.
Cancer Description Illustration
Basal-cell
carcinoma
#ote the pearly translucency to fleshy color, tiny
blood vessels on the surface, and sometime
ulceration !hich can be characteristics. The key
term is translucency.
Squamous-cell
carcinoma
Commonly presents as a red, crusted, or scaly patch
or bump. <ften a very rapid "ro!in" tumor.
Malignant melanoma
The common appearance is an asymmetrical area,
!ith an irre"ular border, color variation, and often"reater than 7 mm diameter.
Basal-cell carcinomas are present on sun-e+posed areas of the skin, especially the face. They
rarely metastasi&e and rarely cause death. They are easily treated !ith sur"ery or
radiation. Suamous-cell carcinomas (SCC) are common, but much less common than basal-
cell cancers. They metastasi&e more freuently than BCCs. ven then, the metastasis rate is
uite lo!, !ith the e+ception of SCC of the lip, ear, and in people !ho are
immunosuppressed. $elanomas are the least freuent of the / common skin cancers. They
freuently metastasi&e, and could potentially cause death once they spread.
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Medical-Surgical Nursing: Skin Cancer
Signs and Symptoms
There are a variety of different skin cancer symptoms. These include chan"es in the skin that do
not heal, ulcer in the skin, discolored skin, and chan"es in e+istin" moles, such as ?a""ed ed"es to the
mole and enlar"ement of the mole.
Basal-cell carcinoma
Basal-cell carcinoma usually presents as a raised, smooth, pearly bump on the sun-e+posed skin
of the head, neck or shoulders. Sometimes small blood vessels (called telan"iectasia) can be seen !ithin
the tumor. Crustin" and bleedin" in the center of the tumor freuently develops. %t is often mistaken for
a sore that does not heal. This form of skin cancer is the least deadly and !ith proper treatment can be
completely eliminated, often !ithout scarrin".
Squamous-cell carcinoma
Suamous-cell carcinoma is commonly a red, scalin", thickened patch on sun-e+posed skin.
Some are firm hard nodules and dome shaped like keratoacanthomas. 8lceration and bleedin" may
occur. @hen SCC is not treated, it may develop into a lar"e mass. Suamous-cell is the second most
common skin cancer. %t is dan"erous, but not nearly as dan"erous as a melanoma.
Melanoma
$ost melanomas consist of various colors from shades of bro!n to black. 4 small amount of
melanomas are pink, red or fleshy in colorA these are called amelanotic melanomas !hich tend to be
more a""ressive. @arnin" si"ns of mali"nant melanoma include chan"e in the si&e, shape, color or
elevation of a mole. <ther si"ns are the appearance of a ne! mole durin" adulthood or pain, itchin",
ulceration, redness around the site, or bleedin" at the site. 4n often-used mnemonic is 4BC5, !here
4 is for asymmetrical, B for borders (irre"ular: Coast of $aine si"n), C for color (varie"ated),
5 for diameter (lar"er than 7 mmthe si&e of a pencil eraser) and for evolvin".
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Medical-Surgical Nursing: Skin Cancer
Ris !actors
• air-skinned, fair-haired, blue-eyed people, particularly those of Celtic ori"in, !ith
insufficient skin pi"mentation to protect underlyin" tissues
• 0eople !ho sustain sunburn and !ho do not tan
• Don"-time sun e+posure (farmers, fishermen, construction !orkers)
• +posure to chemical pollutants (industrial !orkers in arsenic, nitrates, and coal.
• Sun-dama"ed skin (elderly people)
• Scars from severe burns
• Chronic skin irritations
• @eak immune system.
"at#op#ysiology
4 mali"nant epithelial tumor that primarily ori"inates in the epidermis, in suamous
mucosa or in areas of suamous metaplasia is referred to as a suamous-cell carcinoma.
$acroscopically, the tumor is often elevated, or may be ulcerated !ith irre"ular borders.
$icroscopically, tumor cells destroy the basement membrane and form sheets or compact masses
!hich invade the sub?acent connective tissue (dermis). %n !ell differentiated carcinomas, tumor
cells are pleomorphic3atypical, but resemblin" normal keratinocytes from prickle layer (lar"e,
poly"onal, !ith abundant eosinophilic (pink) cytoplasm and central nucleus).
Their disposal tends to be similar to that of normal epidermis: immature3basal cells at the
periphery, becomin" more mature to the centre of the tumor masses. Tumor cells transform
into keratini&ed suamous cells and form round nodules !ith concentric, laminated layers, called
cell nests or epithelial3keratinous pearls. The surroundin" stroma is reduced and contains
inflammatory infiltrate (lymphocytes). 0oorly differentiated suamous carcinomas contain more
pleomorphic cells and no keratini&ation.
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Medical-Surgical Nursing: Skin Cancer
Melanoma
4 mali"nant melanoma is a cancerous neoplasm in !hich atypical melanocytes (ie, pi"ment
cells) are present in the epidermis and the dermis (and sometimes the subcutaneous cells). %t is
the most lethal of all the skin cancers and is responsible for about * of all cancer deaths
(<dom et al., ). The cause of mali"nant melanoma is unkno!n. %t can occur in one of
several forms: lenti"o-mali"na melanoma, nodular melanoma, and acral-lenti"inous melanoma.
a$ %EN&I'(-MA%I'NA ME%AN(MAS
Denti"o-mali"na melanomas are slo!ly evolvin", pi"mented lesions that occur on e+posed
skin areas, especially the dorsum of the hand, the head, and the neck in elderly people. <ften,
the lesions are present for many years before they are e+amined by a physician. They first
appear as tan, flat lesions, but in time, they under"o chan"es in si&e and color.
)$ N(D*%AR ME%AN(MA
#odular melanoma is a spherical, blueberry-like nodule !ith a relatively smooth surface
and a relatively uniform, blue-black color. %t may be dome shaped !ith a smooth surface. %t may
have other shadin"s of red, "ray, or purple. Sometimes, nodular melanomas appear as
irre"ularly shaped plaues.
c$ ACRA%-%EN&I'IN(*S ME%AN(MA
4cral-lenti"inous melanoma occurs in areas not e+cessively e+posed to sunli"ht and !here
hair follicles are absent. %t is found on the palms of the hands, on the soles, in the nail beds, and
in the mucous membranes in dark-skinned people. These melanomas appear as irre"ular,
pi"mented macules that develop nodules. They may become invasive early.
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Medical-Surgical Nursing: Skin Cancer
MANA'EMEN&
The "oal of treatment is to eradicate the tumor. The treatment method depends on the tumor
locationA the cell type, location, and depthA the cosmetic desires of the patientA the history of previous
treatmentA !hether the tumor is invasive, and !hether metastatic nodes are present. The mana"ement
of BCC and SCC includes sur"ical e+cision, $ohsE micro"raphic sur"ery, electrosur"ery,
cryosur"ery, and radiation therapy.
a$ Surgical
The primary "oal is to remove the tumor entirely. The best !ay to maintain cosmetic appearance
is to place the incision properly alon" natural skin tension lines and natural anatomic body lines. %n
this !ay, scars are less noticeable. The si&e of the incision depends on the tumor si&e and location but
usually involves a len"th-to-!idth ratio of /:=.
The adeuacy of the sur"ical e+cision is verified by microscopic evaluation of sections of the
specimen. @hen the tumor is lar"e, reconstructive sur"ery !ith use of a skin flap or skin "raftin"
may be reuired. The incision is closed in layers to enhance cosmetic effect. 4 pressure dressin"
applied over the !ound provides support. %nfection after a simple e+cision is uncommon if proper
sur"ical asepsis is maintained.
!igure +$ Mo#s, Micrograp#ic Surgery
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Medical-Surgical Nursing: Skin Cancer
!igure +$ Cryosurgery
Cryosurgery$ Cryosur"ery destroys the tumor by deep free&in" the tissue. 4
thermocouple needle apparatus is inserted into the skin, and liuid nitro"en is directed to the
center of the tumor until the tumor base is H; C to H7 C. Diuid nitro"en has the lo!est
boilin" point of all cryo"ens tried, is ine+pensive, and is easy to obtain. The tumor tissue is
fro&en, allo!ed to tha!, and then refro&en. The site tha!s naturally and then becomes "elatinous
and heals spontaneously. S!ellin" and edema follo! the free&in". The appearance of the lesion
varies. #ormal healin", !hich may take ; to 7 !eeks, occurs faster in areas !ith a "ood blood
supply.
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Medical-Surgical Nursing: Skin Cancer
!igure +$ Cryosurgery
Iadiation therapy is freuently performed for cancer of the eyelid, the tip of the nose, and
areas in or near vital structures (e", facial nerve). %t is reserved for older patients, because +-ray
chan"es may be seen after to = years, and mali"nant chan"es in scars may be induced by
irradiation = to / years later. The patient should be informed that the skin may become red
and blistered. 4 bland skin ointment prescribed by the physician may be applied to relieve
discomfort. The patient should also be cautioned to avoid e+posure to the sun.
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Medical-Surgical Nursing: Skin Cancer
Nursing Management
• The !ound is usually covered !ith a dressin" to protect the site from physical trauma,
e+ternal irritants, and contaminants.
• The patient is advised !hen to report for a dressin" chan"e or is "iven !ritten and verbal
information on ho! to chan"e dressin"s, includin" the type of dressin" to purchase, ho! to
remove dressin"s and the importance of hand !ashin" before and after the procedure.
• #ursin" $ana"ement cont..
• The patient is advised to !atch for e+cessive bleedin" and ti"ht dressin"s that compromise
circulation.
• %f the lesion is in the 0erioral area, the patient is instructed to drink liuids throu"h a stra!
and limit talkin" and facial movement.
• 5ental !ork should be avoided until the area is completely healed.
• 4fter the sutures are removed, an emollient cream may be used to help reduce dryness.
• 4pplyin" a sunscreen over the !ound is advised to prevent postoperative hyper
pi"mentation if the patient spends time outdoors.
• Studies sho! that re"ular daily use of a sunscreen !ith a solar protection factor (S0) of at
least = can reduce the recurrence of skin cancer by as much as ;*.
• The sunscreen should be applied to head, neck, arms, and hands every mornin" at least /
minutes before leavin" the house and reapplied every ; hours if the skin perspires.
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Medical-Surgical Nursing: Skin Cancer
RE!ERENCE
• 'rossman 5, Deffell 5J (=). Suamous cell carcinoma. %n D4 'oldman et al., eds.,
it&patrickKs 5ermatolo"y in 'eneral $edicine, 6th ed., vol. =, pp. =6/L=;. #e! Mork:
$c'ra!-1ill.
• Carucci J4, et al. (=). Basal cell carcinoma. %n D4 'oldman et al., eds., it&patrickKs
5ermatolo"y in 'eneral $edicine, 6th ed., vol. =, pp. =;L=//. #e! Mork: $c'ra!-
1ill.
• Brunner and SuddarthEs Te+tbook of $edical Sur"ical #ursin"
• 5efinin" Cancer. #ational Cancer %nstitute. Ietrieved July N, =
•
Skin Cancer Treatment. #C%. =/-=-. Ietrieved July N, =
• Cakir, BOA 4damson, 0A Cin"i, C (#ovember =). pidemiolo"y and economic burden
of nonmelanoma skin cancer.G acial plastic sur"ery clinics of #orth 4merica.
Ietrieved July N, =
• $arsden, edited by Sa??ad Ia?par, Jerry (6). 4BC of skin cancer . $alden, $ass.
Ietrieved July N, =
• Dynne $ 5unphy (==). 0rimary Care: The 4rt and Science of 4dvanced 0ractice
#ursin". Ietrieved July N, =
• 'eneral %nformation 4bout $elanoma #C%. Ietrieved July N, =
• 'alla"her, I0A Dee, T9A Ba?dik, C5A Boru"ian, $ (=). 8ltraviolet radiation.G Chronic
diseases in Canada. Ietrieved July N, =