Risk assessment and early detection of skin cancers

Seminars in Oncology Nursing, Vol 19, No 1 (February), 2003: pp 43-51

43

OBJECTIVES: To descr/be a sys[enmtic tnettmd for skh~ cancer assessment, appl3~ng current stmwlard practices Jbr integration into nursing practice. To provide the fimdamentals of pergbrming a skin cancer assessmenctbr rhe nonmelanoma skin cancers, basal cell carci~ugma. and squamous cell carcinomas, and melanoma. Inchtded in ~his discussion are risk profile calcndations, mechanics of skin cancer assessmena descriptions of

RISK ASSESSMENT AND EARLY DETECTION OF SKIN CANCERS

suspiciou.q lesio~s, patio~t nmnc~ement, coM Jbllo~-up. MARYELLEN MAGUIRE-EISEN

DATA SOURCES: Textbooks. rese/trch, r ~ e ~

of the

literature, and clinical experience.

CONCLUSIONS: Skill exmcer assessmo~r ~s a sk//l that nu:rses can learn and implement into practice.

[MPLICATIONS FOR NURSING PK),CTICE:

8

kin eaneers are visually apparent and can be diagnosed early, t h e r e b y preventing death and disfigurement. 1 Early deteetion of skin cancers requires good assessment skills. Overall, dermatologists are more skilled at recognizing skin e a n e e r than nurses and primary care practitioners.2, 3 However, there are not enough dermatologists to adequately screen the public for this disease_ 4 Nurse practitioners are able to acquire good c o m p e t e n c y in skin c a n c e r sereening after participating in a didactic and clinical training program. 5 Studies indicate that nurses can recognize skin cancers but need greater aeeuraey. 6,7 By improving their aeeuraey, nurses eould play a pivotal role in the skin c a n c e r epidemic by earefully monitoring patients to detect this ubiquitous disease early.

Kno~z,led~e and lyractice of good

SKIN CANCER RISK ASSESSMENT

skin cancer assessment skills enhances nurs~N competence and positively influomes patient outCoDles.

From the South Shore S k i n Center, Plymouth, ~g4.

Mal~'ellen Maguire-Eisen, MSN. RN, CS, OCN®: Nurse Praeti~ionvr, South Shore S k i n Center. P(vmoutk, MA. Address reprint reqaesfs to Mary¢llen Maguire-Eisen, MSN, tL~.r CS, 0C5,~ . South Shore Skin Center. 45 Remlik Road Suite 102, Plymoudk Jl~-'l 02360-4843.

C o p y r ~ h t 2003, Elsevier Science IUSA). All r(ghts reselx, ed. 0749-2081/03/1901-0004835.00/0 doi: l O.1053/sonu.2003.50003

ssessment requires a reliable health history, accurate objective findings, standards of care, and recognition of normal and abnormal findings. The ability to differentiate normal from abnormal requires theoretical and praetieal knowledge. The practical knowledge can only be acquired by observing lesions. Although the focus of this discussion is the recognition of primary skin cancer, the practitioner needs to be familiar with the appearance of other c o m m o n skin lesions. The managed care e n v i r o n m e n t dietates that nurses focus their assessment skills on those at greatest risk for a disease. Although a n y o n e can get skin cancer, determining who might benefit most from a skin examination is important_ This may be accomplished by calculating the individual's relative risk for skin cancer. Relative risk is the degree of increased risk for developing cancer that an individual with a risk faetor has c o m p a r e d with those without the risk factor, s Multiple risk faetors can e o m p o u n d a person's risk. Patients with significant relative risk m a y require frequent skin

A

44

MiARYELLENMAGUIRE-EISEN

T A B L E 1. Risk Factors for Developing Cutaneous Melanoma

Risk Factor New mole, pre-existing mole that has changed Dysplastic nevi, prior melanoma, and familial melanoma Dysplastic nevi, no prior melanoma, and familial melanoma Dysplastic nevi, no personal or family history of melanoma Congenital nevus 20 nevi -> 2 mm diameter (if ->50) 5 nevi --- 7 mm diameter (if >-12) Lentigo maligna White (v black) Prior cutaneous melanoma Cutaneous melanoma in first-degree blood relative Immunosuppression Sun-induced freckles by history Sun sensitivity, relative inability to tan Red hair, blond hair, or green or blue eyes Excessive sun exposure

s y n d r o m e are prime candidates for a baseline skin examination. 9 HEALTH HISTORY (SUBJECTIVE DATA)

Estimated Relative Risk* High (10 to 400)l-

Presenting Problem history of a new or changing pigmented lesion is the most important clue to the possibility of melanoma. 1° A r e c u r r e n t wound or bump or one that will not heal is an important clue to n o n m e l a n o m a skin cancer (NMSC). A r e c u r r e n t or persistent rough patch may be indicative of AK.

A 500 148 7 to 27 2 to 21 6 (then 17) 10 (then 41) 10 12 9 8 4 2 to 4 2 to 3 1 to 2 1 to 2

*Degree of increased risk for people with the risk factor, compared with people without the risk factor. A relative risk of 1,0 implies no increased risk. ]Risk estimated roughly to be increased 10-fold to 400-fold. Reprinted with permission,a

cancer examinations and a photographic medical record. Table 1 shows the risk factors for developing cutaneous melanoma.

Risk Factors for Developing Skin Cancer Factors increasing relative risk for developing skin cancer include (1) history of a primary skin cancer or precancerous lesion such as atypical/ dysplastic moles, actinic keratosis (AK), multiple c o m m o n nevi, congenital nevi, and nevus sebaceous; (2) a history of blistering sunburns, occupational ultraviolet radiation (UVR) exposure; evidence of dermatoheliosis (clinical findings seen in severely sun-damaged skin, such as dryness, marked freckling, small hypopigmented maeules, telangieetases, and elastosis); and (3) nonmodifiable risk factors such as fair skin, light eyes, and advanced age. Patients with any of these risk factors would benefit from regular skin examinations. Additionally, patients with a family history of skin c a n c e r or atypical mole/dysplastic nevus

Dermatology History A personal history of a premalignant lesion or a prior skin c a n c e r is important in that melanoma and NMSC impart a 6% and 44% chance of developing a second malignancy, respectively, al-a3 Actinic keratoses, atypical moles, congenital nevi, and nevus sebaceous are considered premalignant lesions, each with a variable risk of malignant transformation. 9,14 Actinic keratoses may be an i n d e p e n d e n t risk factor for squamous cell skin cancer because they indicate excessive sun exposure.15,16 The number, size, and location of nevi may be important risk factors for melanoma. 17-19 Congenital nevi are associated with an increased risk of melanoma: the malignant transformation potential is related to the size of the congenital nevus. 2° For example, small congenital nevi (less than 1.5 cm) impart a small (albeit, not well d o c u m e n t e d ) increased risk of melanoma. Giant congenital nevi (more than 20 cm) impart a higher risk for melanoma. One study reported that 4.5% to 10% of subjects with large congenital nevi developed melanoma31 Nevus sebaceous appears in infancy as a hairless plaque on the face, scalp, trunk, or extremities. At puberty it becomes rough, yellow, and hypertrophic. Nevus sebaceous has an estimated 20% c h a n c e of malignant transformation to basal cell carcinoma. An increased risk of skin c a n c e r has been found in patients treated with UVR for psoriasis and acne. There m a y be as m u c h as an S-fold risk of m e l a n o m a for some psoriasis patients. 22 Medical History Patients who are post-organ transplant may develop AKs and a virulent form of squamous cell carcinoma (SCC), which has an aggressive nature and high risk of metastasis. Unlike typical occur-

RISK ASSESSMENT

rence of NMSC in the general population, the incidence of SCCs in post-transplant patients far outweighs the incidence of basal cell carcinoma.23, 2 4

Family History A family history of either melanoma or NMSC may suggest both a genetie and environmental risk for skin eaneer. Two rare inherited skin disorders that predispose a patient to skin cancer are xeroderma pigmentosum and basal cell nevus syndrome. 25 Briefly, xeroderma pigmentosum, an autosomal recessive photosensitive disorder, imparts an extremely high risk (more than 1,000fold inerease) of both melanoma and NMSCs beeause of underlying impaired ability to repair UV-induced DNA damage. Affected individuals often develop hundreds of skin cancers, initially oeeurring in childhood. 26 Basal cell nevus syndrome (also referred to as Gorlin's syndrome) is an autosomal dominant disorder that affects the repair mechanisms of the keratinoeyte. Individuals with the disorder may develop multiple basal cell eareinomas, palmar pits, various skeletal anomalies, medulloblastomas, and other tumors. 27 Atypical mole (dysplastie nevus) syndrome may be sporadic or familial. Both forms convey an increased risk for melanoma, but of a significantly lower magnitude compared with the risk seen in the setting of familial melanoma and dysplastie nevi. The risk for familial atypical multiple mole and melanoma syndrome is higher if two or more first- or second-degree relatives have atypical moles and melanoma. Familial atypical multiple mole and melanoma syndrome is associated with multiple melanomas that may appear as early as the first decade of life. 17,1s Inherited genetic traits and lifestyle trends can predispose a patient to skin cancer. Children receive 80% of their lifetime sun exposure before the age of 18. 2s,z9 In some families, excessive UVR exposure in ehildhood may result in skin cancer in adulthood. 3°

Occupational Exposures Ultraviolet radiation and chemical exposures may augment risk for farmers, fisherman, sailors, and chemical workers, especially those exposed to arsenic or nitrosureas. Nonmelanoma skin cancer is associated with outdoor occupations plus outdoor recreational habits (cumulative UVR exposure), while melanoma is associated with indoor occupations plus outdoor recreational habits

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(pulse/intermittent intense UVR exposure). A white-collar occupation has been associated with slightly increased risk (RR 1.3) for melanoma, 31

Social History Questions about tobacco exposure, sexual behaviors, sunbathing, and indoor tanning gather information about social history. Tobacco use is associated with SCC of the lower lip. Exposure to the human papilloma virus or human immunodefieiency virus are risk factors for NMSC. Artificial tanning increases the risk of skin cancer. 32 Lower socioeconomic status is associated with delayed diagnosis and a poorer prognosis for most skin cancers 33 PHYSICAL EXAMINATION (OBJECTIVE DATA) ecause melanoma often develops at sites of intermittent sun exposure, a total body skin B examination (TBSE) is imperative for detecting suspicious lesions. Proper surveillance requires examination of the entire skin surface. One study found that TBSE detected six times more melanomas than a partial examination. 34 It is important that the patient be emotionally prepared for the examination. Many dermatology practices provide patients with information sheets that delineate the benefits of TBSE. 35 To ensure a relaxed atmosphere during TBSE, the practitioner should be comfortable with performing the examination. A well-lit and warm environment also enhances relaxation. Equipment necessary for TBSE includes a metric ruler, flow sheet for documenting findings, magnifying lens with light, drape, hand-held mirror, blow dryer, flashlight, Wood's light, dermatoseope with or without mineral oil, and camera (see section on Visual Tools). 36-3s A chaperone should be provided if warranted or desired. Inspection and palpation are the techniques used in TBSE. Inspection may require the aid of a magnifying lens, flashlight, dermatoseope, or Wood's light. The focus of the examination is to identify suspicious or premalignant lesions. A suspicious lesion may be defined as any lesion with malignant characteristics or persistence despite appropriate treatment (see Table 2). A uniform or standard approach to the examination may improve the aeeuraey of the examination. One approach for TBSE begins with the patient in a sitting position and covered with a gown or

46

MARYELLEN

MAGUIRE-EISEN

TABLE 2. Characteristics of Suspicious Skin Lesions 1. Any new pigmented lesion 2. Changing pigmented lesion 3. Persistent papule, nodule or patch, pigmented or nonpigmented 4. Atypical features including rolled border, central crater, ulceration, or pain 5. Any persistent papule, nodule, or plaque that does not resolve with treatment 6. Characteristic features of a premalignant lesion: atypical mole, actinic keratosis, congenital nevus, or nevus sebaceous

drape. Initiate the skin examination by examining the sealp. If necessary, use a hair blower to move hair away from the scalp. Continue the examination with a thorough inspection of the face, neck, and ears. Determine phenotypie risk factors for skin cancer including light eyes, fair skin, and freckling tendency. Oral examinations are recommended for patients with atypical mole syndrome or who are post-organ transplant. Examine the entire anterior skin surface then proceed to the posterior surface. Palpate the skin surface for any rough raised lesions, which may be a sign of AKs. Palpate all erythematous lesions to determine if they are scaly or blanching, which

may help to differentiate them from telangieetasia (a benign collection of small terminal blood vessels that disappear with pressure). Inspect and palpate the arms, axillae, chest, and submammary area. Palpation of suspicious lesions to determine if they are infiltrating provides a better sense of the extent of local invasion. Then palpate to see if the lesion is fixed to underlying structures. After examining the upper body, place the patient in a supine position and examine the lower half. Examine the abdomen, genitalia (patient diseretion), legs, feet, and web spaces. Then have the patient lie on each side and examine the trunk and extremities. Examine the gluteal crease and perireetal area for lesions. Patients with atypical mole syndrome should have an internal gynecologic examination because melanoeytie lesions may develop on any epidermal surface. Calculate the number and size of common, atypical, and congenital nevi. Pigmented lesions may be evaluated using the A-B-C-D criteria (Table 3), 39 A banal or common nevus is a small, symmetrical lesion with homogeneous color and a regular border. An atypieal/dysplastie nevus has abnormal features that include large size, irregular shape, variable color, and irregular borders that may fade into the surrounding skin. Usually these lesions are greater than 6 mm in size, with slightly notched borders, and are dark in color in at least a small portion of the lesion (but with less varia-

TABLE 3. A-B-C-D Criteria

Unaided Description Asymmetry Border

Color

Diameter/ differential structures

Lesion is dissected, one half does not match the other half Lateral margins, may be ragged, notched, hazy, or blurred Shaded with tan, brown, black. Evaluate for mottled appearance (blue-gray) with presence of red, white, or blue streaks >6 mm or enlarging

Scoring*

Weight Factor

Quarter lesion; evaluate contour, color, structures Divide into 8 sections, evaluate for abrupt ending of pigment pattern in each section. Evaluate for white, red, light-brown, dark-brown, blue-gray, black

0 to 2

x1.3

0 to 8

×0.1

1 to 6

×0.5

Presence of network, structureless or homogenous areas, streaks, dots, globules

1 to 5

×0.5

Aided (Epiluminescence) Description

*Total Dermatoscopy Score (TDS): Each criteria is evaluated independenttyand then assigned a score relative to its degree of significance (weight factor). TDS scores less than 4.75 indicate benign melanocytic nevus, values 4.8 to 5.45 indicative of suspicious lesion, values greater than 5.45 are highly suspicious for melanoma. Adapted and reprinted with permission.4~

RISK ASSESSMENT

tion than melanoma). Melanomas are usually more bizarre and demonstrate the "ugly duckling sign," which is a clinical impression that a pigmented lesion differs or "stands out" in comparison to other pigmented lesions on the body_

Visual Tools: Wood's Light and Dermatoscope Two visual tools for evaluating pigmented lesions are the Wood's light and the dermatoscope. The Wood's light is helpful in distinguishing the peripheral margins of a lentigo maligna or an acral lentiginous melanoma. These lesions have indiscrete borders and the Wood's light accentuates the margins, which helps determine the size_ The Wood's light may help identify leukoderma, an important sign of melanoma regression. Leukoderma is accentuated by the UV spectrum emitted from the Wood's light. This tool is useful for evaluating patients with metastatic melanoma of unknown primary site. 4° A dermatoseope or skin microscope facilitates use of epilumineseenee microscopy. Epiluminescence microscopy is a noninvasive technique that visualizes the surface and subsurface structures of the skin to identify characteristics of benign versus malignant lesions. 41 Epiluminescence microscopy requires a skin microscope or dermatoseope. The dermatoseope is used with oil immersion and provides 6 to -100 × magnification (Fig 1). 39 Incidental light that is absorbed, scattered, and reflected by the structures below the skin's surface, provides better visualization and aids in the identification of malignant features. Visualized skin is assessed according to epiluminescence microscopy criteria, which are descriptive terms that have been correlated with histologie features and patterns found in benign, premalignant, and malignant lesions. 42 Epiluminescence microscopy examination requires searching for the presence or absence of each criterion, which include color, border, and structures. Color is an important finding and is related to the location of the lesion within the sMn and/or the presence of regression_ For example, the presence of a bluish-white veil is pathonomonic for melanoma. Structure may include the pigmentary network, black and/or brown dots, globules, pseudopods, and radial streaming. Pseudopods are curved, coiled, finger-like projections in the periphery of the pigment network. Radial streaming is the presence of brown or black streaks radiating from the border of the lesion into the surrounding skin. Border thinning is another characteristic.

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OF S K I N C A N C E R

47

Borders may be sharp, hazy, or moth eaten. 43 It is important to determine if the pigmentary network is regular or irregular. Inspection for black dots, brown globules, radial streaming, pseudopodia, or veiling is essential. The presence and location of each finding should be documented. Pattern analysis is helpful in determining subtle differences and improves diagnostic accuracy. Experience with epilumineseenee microscopy is highly correlated with diagnostic accuracy. 17 A numerical rating system may be used to evaluate the degree of atypia in a lesion ('Fables 3 and 4). PATIENT MANAGEMENT he plan of care should include diagnostic proeedures, treatment, surveillance, and patient education. Proper documentation of problem lesions is imperative.

T

Biopsy All suspicious lesions and presumed malignancies should be biopsied as soon as possible. Knowing how and when to perform a biopsy is essential and is affected by clinical expertise. Whenever possible, patients with a history of noncompliance should not have their biopsies deferred to the next visit. If clinical suspicion persists despite a benign pathology finding, the practitioner must perform a subsequent biopsy. Experienced practitioners on occasion are surprised by pathologic findings (ie, when a benign or noninvasive lesion is suspected but find confirmation of an aggressive neoplasm on biopsy). This uncertainty reinforces to the clinician the need to biopsy persistent lesions. Pathologic confirmation of cell types has an impact on prognosis, treatment, and follow-up. Performance of skin biopsies by advanced practice nurses can benefit patients and physicians. These benefits include shorter waiting time for appointments and extended patient contact. 44 A biopsy can be either incisional or excisional. An exeisional biopsy, removal of the lesion in tote, is indicated for lesions suspicious for melanoma, congenital nevi, or dysplastie nevi. If the lesion is too large to excise, a punch biopsy may be obtained from the area that appears clinically most abnormal. 45 An improper biopsy can yield an inaeeurate diagnosis. An ineisional or tangential (shave) biopsy can be obtained to confirm the diagnosis of basal cell eareinoma, SCC, and nevus s e b a c e o u s . 46

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MARYELLEN MAGUIRE-EISEN

TABLE 4. Epiluminescence Microscopy Criteria for Pigmented Lesions Melanocytic Nevi

Atypical Nevi

Malignant Melanoma

Regular, discrete

Irregular

+/Centrally/peripherally Absent Absent Absent

++ Regular, periphery Rarely present + Variable Rare

Absent Absent

Absent Absent

Irregular, abrupt discontinuation +++ Bizarre Variable Present Irregularly distributed in periphery Present Present

Pigmentary network Border thinning Depigmentation Radial streaming* Brown globules Black dots PseudopodialVeilings

*Pseudopodia: presence of curved or finger like projections found in the periphery of the pigment network, -i-Radial streaming: presence of brown or black streaks radiating from the border of the lesion into the surrounding skin. :l:Veiling is associated with fibrosis and regression, A blue/white veil develops secondary to fibrosis (white areas) and melanosis (blue areas). Adapted and reprinted with permission. 41

Treatment

Factors that may influence treatment include number and location of lesions, malignant potential, patient and physician preference, eosmesis, and government regulation regarding reimbursement. Dermatologists treat most malignant and premalignant skin lesions. Patients with NMSC of the face or melanoma may be referred to a Mohs, plastic, or oneologie surgeon. Information regarding treatment for melanoma and NMSC is described elsewhere in this issue. 47-49

Although AKs have a low (1% to 10%) potential to become malignant 8CC, they should be eradicated, s° Patients must be counseled on preventive measures. Treatments for AK include cryotherapy, topical 5-fluorouraeil, laser resurfaeing, and chemical peels. These are described elsewhere in this issue. 49,51 Surveillance

Scheduled surveillance or follow-up will determine if the patient's lesion has resolved, pro-

TABLE 5. Skin Cancer Tutorials Web Address www.afraidtoask.com/skinCA Matrix.ucdavis.edu/tumors/ tradition/tumors.html Meddean.luc.edu/lumen/MedEd/medicine/ dermatology/Melton/content1.htm Matrix.ucdavis,edu/tumors/ new/tutorial-intro.html EMedicine.com/derm/topic257.htm

Dermis.net/bilddb/Index_e.htm

Title

Features

Afraid to Ask. Corn: Skin Cancer Guide UC (Davis) Tumors of the Skin

Images of benign, precancerous, and malignant growths General tutorial on tumors of the skin

Loyola University: Skin Cancer and Benign Tumor Image Atlas UC (Davis): How to Recognize Melanoma EMedicine: Malignant Melanoma

Images of 30 benign and malignant dermatologic tumors

University of Heidelberg and Erlangen: Dermatology Online Atlas

Differential diagnosis of pigmented skin lesions Overview of malignant melanoma including subtypes, causes, and risk factors Alphabetical index of dermatologic conditions with select images of lesions

RISK ASSESSMENT

gressed, or recurred after treatment. Another goal of surveillanee is to identify malignant, atypieal, or new lesions, sz The frequeney of follow-up depends on patient eireumstances and elinieal judgment. A therapeutic evaluation of an AK treated with eryotherapy or 5-fluorouraeil is usually performed at 1 month post-treatment. Patients with NMSC and AKs should be reassessed every 6 to 12 months for recurrenee of the primary lesion and the development of new lesions. After 5 years without evidence of reeurrenee or new diagnosis of NMSC, patients can progress to follow-up on an as-needed basis. Patients with melanoma should be evaluated every 6 months for at least 3 years, then progress to annual examinations if they are disease-free after 3 years and do not have atypieal moles.1e,53-56 Patients with atypical mole/dysplastie nevus syndrome should have TBSE every 6 months. Because these patients have a signifieantly higher number of oeular nevi they should undergo an ophthalmic examination, s7 Patients with atypical mole/dysplastie nevus syndrome and melanoma should have a TBSE every 3 months. An annual skin examination is recommended for individuals with a personal or family history of skin cancer.

Documentation Photography. Wallace H. Clark Jr, an eminent pathologist, believed that "any photograph was better than no photograph" (personal communication, Massachusetts Dermatology Nurses Meeting, May 1995). Medical photography requires a good camera system, high-quality film, proper positioning, and control of extraneous variables. 5s A good photograph should clearly show the lesion, its location, and a measuring scale. Cameras may be instant, single-lens reflex, or digital. 59-61 Macro features are essential to capture the subtleties of individual lesions. Baseline photographs of the skin can determine if lesions are "new" or "changing," which is especially helpful in patients with melanoma, multiple common nevi, atypical nevi, and congenital nevi. Patients with a personal or family history of melanoma may also benefit. Photographs are taken of a lesion when a tangential biopsy is performed to confirm location for follow-up treatment. Mole mapping creates a photographic record to provide a reproducible and systematic reference for follow-up evaluation, Dermatologists working in community- or university-based settings often provide mole mapping as a service to the patient.

& EARLY

DETECTION

OF SKIN

CANCER

49

The appropriate candidates for mole mapping are those with multiple nevi or a history of melanoma. Mole mapping requires multiple (24 to 34) standard serial sector photographs. Close-up photographs of atypical lesions are assigned to individual sectors and the atypical features are categorized according to the A-B-C-D criteria. Photographic comparisons are accomplished with computer imaging, transparencies, or photographs. Digital data may be stored on compact disks for practitioner and patient use. 62 Benefits of mole mapping include improved surveillance, reduced patient anxiety, and decreased cost of unnecessary biopsies. Software programs for mole mapping have become more user-friendly and less expensive in recent years. Dermagraphix (Derma Instruments, Dona Point, CA), a system from Mirror Image, is quite affordable (approximately $3,000, not including computer hardware). The average cost of photographs (about $300) is low, but is still contested by insurers. Third-party payers continue to deny reimbursement in most cases. 63 (The recommended CPT code for reimbursement is 96999. 64 ) Special requests for reimbursements may be approved when the practitioner can persuade the insurer that the procedure is in the best interest of the patient. Computerized digital scanning. Computerized digital scanning is available for the evaluation of patients at risk for melanoma. This system includes a video dermatoscope and computer with a data bank of characteristic lesions. Pictures of suspicious lesions are captured by a video scanning dermatoscope and analyzed by a computer program that assigns a score to each individual lesion. Biopsies are indicated for lesions above a preset threshold score. Sensitivity and specificity have been high, ranging from 93% to 100% and 82% to 95%, respectively. 43 Systems such as Mole Max II (Canfield Scientific Clinical Systems, Fairfield, NJ; Fig 2) are available for clinical use. The systems may vary in complexity and cost. Prices range from $5,000 for a basic system to $40,000 for the most advanced. Other types of documentation. Diagrams depict the location of problem lesions. Stencils and diagram stickers are available for chart notes and aid in documenting. It is helpful to keep flow charts of malignant lesions to include fields for date, site, diagnosis, pathology laboratory arid number, treatment, and follow-up. Problems should be delineated individually or grouped by diagnosis in a problemoriented medical record format.

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MARYELLEN MAGUIRE-EISEN

Education

CONCLUSION

Patients should be i n s t r u c t e d o n how to p e r f o r m a skin self-examination. Although sMn self-examination has n o t b e e n p r o v e n to r e d u c e m o r b i d i t y a n d mortality, o n e s t u d y r e p o r t e d t h a t half of n e w mela n o m a s were self-diseovered. 6s Effieaey m a y be conflicting i n t h a t o n e s t u d y i n d i e a t e d a 34% r e d u e t i o n i n m e l a n o m a i n c i d e n e e in p a t i e n t s practicing selfe x a m i n a t i o n , 66 a n d a n o t h e r e o n c l u d e d t h a t p a t i e n t s were u n a b l e to reeognize artificial e h a n g e s i n size of nevi. 67 Skin s e l f - e x a m i n a t i o n is a simple, i n e x p e n sive e x a m i n a t i o n t h a t m a y aid i n the r e c o g n i t i o n of p r e e u r s o r lesions a n d early skin cancers. Teehn i q u e s for p e r f o r m i n g a skin s e l f - e x a m i n a t i o n are p u b l i s h e d 6s a n d readily available i n m a n y p a t i e n t e d u c a t i o n b r o e h u r e s p r o d n e e d b y dermatologic organizations (Table 5). Nurses should e n e o u r a g e patients with m e l a n o m a a n d NMSC to e d u c a t e their parents, siblings, a n d c h i l d r e n a b o u t the n e e d to have a b a s e l i n e dermatologie e x a m i n a t i o n . 69

ll n u r s e s e a n b e c o m e p r o f i c i e n t i n s k i n c a n cer a s s e s s m e n t . I n t e r n e t sites c a n p r o v i d e t h e p r a c t i t i o n e r w i t h u n l i m i t e d e x a m p l e s of b e n i g n a n d m a l i g n a n t l e s i o n s ( T a b l e 5). E p i l u m i n e s e e n e e m i c r o s c o p y is a tool t h a t p r o v i d e s n u r s e s w i t h t h e c l i n i c a l edge to i m p r o v e t h e i r d i a g n o s t i e a c c u r a c y . Proper screening requires patient consent, a thorough e x a m i n a t i o n , a n a p p r o p r i a t e e n v i r o n m e n t , referral i n f o r m a t i o n , a n d follow-up. N u r s e s s h o u l d c h e e k w i t h t h e i r s t a t e l i c e n s i n g b o a r d to e n s u r e t h a t s k i n e x a m i n a t i o n is p e r m i s s i b l e u n d e r n u r s e p r a c t i c e aets a n d w i t h m a l p r a c t i c e i n s u r e r s for a d e q u a t e p r o f e s s i o n a l p r o t e c t i o n . N u r s e s play a s i g n i f i c a n t role i n r e d u c i n g s k i n c a n c e r i n e i d e n e e t h r o u g h p r e v e n t i o n , e d u c a t i o n , a n d e a r l y detection. D e v e l o p i n g c l i n i c a l skills to d e t e c t this lifet h r e a t e n i n g m a l i g n a n c y is a c h a l l e n g e for all nurses.

A

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