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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, =