Jane Freak, NNEB, EN, RGN, is a clinical nurse specialist in skin cancer prevention, Wessex Cancer Trust Marcs [Melanoma and Related Cancers of the Skin] Line, Dermatology Treatment Centre, Salisbury District Hospital.
Skin cancer can cause disfigurement and, in some cases, can lead to death. It differs from other cancers in several important instances. As the cancer is on the skin surface, it can be detected as soon as it starts to develop. While the condition has a cure rate of 85-99 per cent, the vast majority of cases can be prevented by taking simple precautions (Robins, 1990).
Studies carried out around the world clearly indicate that excessive sun exposure in early childhood is an important risk factor for developing, two or three decades later, both melanoma and non-melanoma skin cancers. This information has clear implications for skin cancer prevention campaigns (MacKie, 2001).
Nurses in all specialties have a role in preventing and managing skin cancer (Buchanan, 1998). It is, therefore, vital that nurses know what advice to give, and where and how to access appropriate information and services for patients with suspicious lesions (Moore, 1999). Increased vigilance is crucial if more patients are to have earlier diagnoses and interventions.
Dermatology or oncology courses for nurses involved in managing patients with skin cancer contain little education on skin cancer prevention. Increasingly, health care trusts and organisations seek to employ nurse specialists to take on this role, but few nurses fulfil these criteria and they depend on experiential and informal learning.
Incidence of skin cancer
The incidence of all skin cancers in the UK has been rising steadily over the past two decades, prompting major concerns - malignant melanoma is associated with high mortality (Office for National Statistics, 2000).
Skin cancer is now the most common cancer in the UK, with more than 57,000 new cases of non-malignant melanoma diagnosed annually (Cancer Research UK, 2003). The total may be higher because this type of cancer tends to be under-reported.
For people aged 15-39 years, melanoma is the third most common cancer (Oppenheim, 2002), with over 6,000 cases diagnosed every year (Cancer Research UK, 2003). Four out of five cases of skin cancer can be prevented, and up to 80 per cent of malignant melanomas are caused by sun exposure (Turner, 2002; Cancer Research UK, 2003).
Although the sun is vital to life, exposure increases risk of developing skin cancer (Turner, 1999). Ultraviolet (UV) radiation is the most harmful component of sunlight and is divided into three layers - UVA, UVB and UVC.
UVA radiation is known to cause premature ageing of skin, including loss of elasticity, thickening and wrinkling. About 50 per cent of UVA rays penetrate the dermis. UVB radiation is known to cause sunburn and tanning. Although the epidermis cells absorb most UVB rays, about 10 per cent reach the dermis. UVC rays are potentially more dangerous, but the atmosphere filters these out. However, there are fears that damage to the ozone layer is enabling UVC radiation to penetrate the atmosphere, which could be contributing to the rise in the incidence of melanoma (Turner, 2002).
Pre-malignant and malignant skin conditions
Skin that has been clinically sun damaged often looks wrinkled and freckled, and is seen more often in younger people (Chu, 1997). The most common forms of skin cancer - basal-cell carcinoma and squamous-cell carcinoma - rarely metastasise and do not carry the high morbidity and mortality rates associated with malignant melanoma. However, if they are extensive, they can be disfiguring and difficult to treat (Buchanan, 2002) (Table 1).
A seven-point checklist (Box 1) has been established for suspected melanoma in any pigmented lesion (Cancer Research UK, 2002; Moore, 1999).
Non-malignant skin cancers include basal-cell papilloma (BCP) and Bowen’s disease.
- BCP is also known as seborrhoeic keratosis or seborrhoeic warts. It is sometimes inherited and tends to develop as thick warty lesions in people aged over 30 years. BCPs do not develop into skin cancer. Thin lesions are treated with cryotherapy, while thicker ones are excised surgically;
- Bowen’s disease is an early form of skin cancer which, if untreated, can progress to invasive squamous-cell carcinoma. It presents as an isolated, scaling, erythematous plaque, usually on the trunk or lower leg. It may also appear as an isolated patch of psoriasis and is often treated as such. Treatment is with cryotherapy, photodynamic therapy or fluorouracil cream. In some cases a watch-and-wait approach may be taken and in others a biopsy will be taken to confirm diagnosis (MacKie, 2001).
Reducing the risks
Adults with the following characteristics are at greatest risk of developing skin cancer:
- Fair skin (skin type I and II), freckled skin, blue eyes, fair or red hair, so know your skin type (Table 2);
- A tendency to burn easily;
- A family history of skin cancer;
- A lot of moles or those with atypical mole syndrome;
- A past history of a ‘cured’ malignant melanoma;
- A pre-existing medical condition (for example, organ transplant patients on immunosuppressant drugs).
Health care professionals are in an ideal position to offer advice, and should encourage people to adopt safe behaviours to reduce the risks. The Australian Cancer Network runs the successful SLIP, SLAP, SLOP campaign:
- SLIP on a shirt;
- SLAP on a hat;
- SLOP on the sunscreen (Tarpey, 2001).
Sunscreen does not offer total protection but it reduces the risks. Advice from Cancer Research UK (2002) is to:
- Avoid the sun when it is at its highest (11am to 3pm);
- Take care never to burn;
- Stay in the shade whenever possible (trees, umbrellas, shelter and so on);
- Take extra special care of babies’ and children’s skin;
- Wear a wide-brimmed hat and sunglasses with UV protection;
- Cover up with tightly woven, loose-fitting clothing, long-sleeved tops, trousers or long skirts;
- Use a broad-spectrum sunscreen (SPF15 or higher);
- Avoid using sunbeds or tanning lamps;
- Do not assume you are safe from the sun in water. You may feel cooler, but the sun’s rays will still burn;
- Check your skin regularly and report any unusual changes to your doctor without delay.
The role of the nurse
Nurses are ideally placed to implement opportunistic skin cancer prevention strategies. Sun awareness campaigns should seek to address the following five steps:
- Identify the target group;
- Identify your resources;
- Clarify the health education message;
- Deliver the health education message;
- Make policy decisions (Buchanan, 1998).
Patients should be taught to examine pigmented lesions several times a year, be able to recognise signs of melanoma, understand who is at risk and know what action to take if a questionable lesion is found (Guill and Orengo, 2001). The ultimate aim is to modify or change sun-seeking behaviour to sun-avoidance behaviour.
Preventive health strategies are traditionally categorised according to the stage of the disease at which they are intended to have an effect (Muir-Gray and Fowler, 1984; Buchanan, 2002).
These aim to prevent the disease before it begins (complete avoidance) and is achieved through major health campaigns and health promotion. Health education at an early age may influence attitudes and subsequent behaviours. The main target groups are children, adolescents and their parents (Perkins, 1992). Children should be especially protected from exposure to intense sun because severe blistering sunburns in childhood greatly increase the risk of melanoma in later life (American Cancer Society, 2000; Guill and Orengo, 2001).
The message should be delivered positively: people should not be denied outdoor leisure time, but be made fully aware of the link between excessive sun exposure and skin cancer. The emphasis should be on preventing sun damage from childhood. One successful skin cancer prevention strategy used in Australian schools is the ‘No hat, no play’ policy, which has now been implemented in some British schools (Buchanan, 2002).
Cancer Research UK has implemented a prevention programme, with the launch this year of the SunSmart programme. Wessex Cancer Trust and Cancer Research UK are actively involved in developing literature on all skin cancers, preventive strategies and sun avoidance.
This approach promotes early diagnosis and treatment. Two key strategies are establishing rapid referral clinics supported by health education, to encourage self-examination, and early consultation (Buchanan, 2002).
Rapid referral skin cancer clinics with a two-week-wait enable GPs to make quick referrals of patients with suspected malignant melanoma and squamous-cell carcinoma. It is thus crucial for all community-based nurses to be able to recognise suspicious lesions. Nurses arguably see the skins of more patients than any other health professional, so knowledge of the early clinical signs of skin cancer is crucial (Buchanan, 2002).
This involves the care and management of patients with established disease. There are no curative treatments for advanced melanoma and some cases of metastatic squamous-cell carcinoma will be fatal. Tertiary prevention is concerned with holistic care, psychosocial support, education and care of the patient in remission, and during relapse, decline and death (Fawzy, 1995; Perkins, 1992; Buchanan, 2002).
Nurses in all specialties can contribute to promoting healthier lifestyles to prevent, and ensure early detection of, skin cancer. They should strive to do the following:
- Teach the general public that skin cancer, especially malignant melanoma, is preventable;
- Promote preventive behaviours;
- Advocate early detection of skin cancers and melanoma through tailored education programmes;
If health promotion programmes are to be effective all nurses need to be knowledgeable about skin cancers. The nurse education component of a programme on prevention and early detection of melanoma should aim to:
- Identify measures to help prevent skin cancer;
- Recognise the characteristics of those at risk of developing melanoma;
- Be aware of the reasons for the increase in incidence of melanoma, despite efforts to educate the public;
- Offer sunscreens to parents and patients, to facilitate discussion about the hazards of the sun;
- Refer patients at high risk of skin cancer or with a suspicious lesion to a dermatologist for skin examination;
- Serve as a role model by practising preventive mechanisms themselves and within their families.
One way to achieve this would be to develop an education programme for nurses on the importance of skin cancers and melanomas. This could, for example, be presented as a computer slide presentation (Harris, 2000).
It is important to consider ways to protect our skin from the sun’s damaging rays. In addition, patients on certain medications should exercise caution because many prescription and non-prescription drugs can cause photosensitivity. Tanning beds should be avoided as they emit UV radiation that is more intense than the UV rays from the sun and tanning-bed operators may not be aware of someone’s medical conditions (Schober-Flores, 2001).
Finally, it is crucial to undertake monthly skin examinations, starting at the head and finishing at the toes. Mirrors should be used to check areas difficult to see. Early detection is the key to survival; the best defence, however, is to limit time in the sun and to use good sun protection. The latter should begin from as early as six months of age and continue throughout a lifetime - but it is never too late to start (Schober-Flores, 2001).