Skin cancer is the most common form of cancer in the UK, but thankfully most skin cancers can be cured if detected early. Skin cancer is an umbrella term for two main sub-types: melanoma and non-melanoma (basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)), which are named after their cell origin (Cancer Research UK, 2021). However, there are other types which are rare. A melanoma skin cancer often poses the most significant threat to life. However, non-melanoma cancers are responsible for significant disease burden and account for 90% of all skin cancers registered in the UK and Ireland (The National Cancer Registration and Analysis Service, 2022). In 2015 more than 142 000 non-melanoma cases were diagnosed – 80% BCC and 20% SCC – an increase of 77% between 1994 and 2014 (Jones et al, 2020). However, these figures represent an underestimation of the true impact of disease, as only first tumours are recorded. The burden of disease is relentless and on the increase; therefore, health professionals must educate themselves to better screen for skin cancers, provide advice to patients and ensure they are referred appropriately and receive timely care.
Melanoma and non-melanoma skin cancer: what are they and how do they present?
Basal cell carcinoma
A BCC is the most common type of skin cancer and is defined as a locally invasive, slow-growing tumour (Nasr et al, 2021). BCCs can look like open sores, red patches, pink growths, shiny bumps, scars or growths with slightly elevated, rolled edges and/or a central indentation (Figure 1). At times, BCCs may ooze, crust, itch or bleed. The lesions commonly arise on sun-exposed areas of the body. In patients with darker skin, about half of BCCs are pigmented (meaning brown in colour) (Skin Cancer Foundation, 2022). BCCs often present as a skin lesion that will often be described as ‘a spot that won't heal’. The main clue for a BCC is in the history. Patients will report having a ‘spot’ for many months that is relatively stable in growth, perhaps getting slightly bigger over a long period of time. Bleeding at night is often a reported nuisance and a clue to the lesion being a likely BCC. There are a number of BCC subtypes:
- Nodular
- Superficial
- Infiltrative
- Morphoeic.
These subtypes define a particular growth pattern that often dictates the most appropriate treatment modality, of which there are many. The disease burden and impact for healthcare services is high, as patients will often develop many BCCs throughout their lifetime, and so managing patients from a holistic perspective, and utilising the various treatment modalities, will improve outcomes for patients.
Nurses should only consider a suspected cancer pathway referral (for an appointment within 2 weeks) for a possible BCC if there is particular concern that a delay may have a significant impact, because of factors such as lesion site or size, as per National Institute for Health and Care Excellence Guidance (NICE, 2021).
Squamous cell carcinoma
SCCs present as fast-growing skin lesions which can prove fatal if left untreated (Mayes, 2018). SCCs can appear as scaly red patches, open sores, rough, thickened or wart-like skin, or raised growths with a central depression. At times, SCCs may crust over, itch or bleed (Figure 2). The lesions most commonly arise in sun-exposed areas of the body. SCCs can also occur in other areas of the body, including the genitals. An SCC will often grow rapidly and present as a large nodule with or without surface keratin and erythema at the base. The clue to an SCC is the rate of growth. Pain upon palpation is also an indication of SCC, especially with a background of sun damage. Although most SCCs do present as an obvious growth, there are many that can present as subtle ulcerations and therefore caution needs to be undertaken. SCCs are removed surgically and if performed early the outcome and prognosis is good.
Melanoma
Melanoma is the fifth most common type of cancer for men and women in the UK, and accounts for 4% of all new cancer diagnoses (Mayes, 2018) (Figure 3). Incidence rates for melanoma are predicted to rise by 7% between 2014 and 2035. Around 25% of melanomas are diagnosed in those under 50 years of age and more than 80% are attributed to ultraviolet (UV) exposure. Melanoma originates from the melanocytes in the skin and is most associated with a change to an existing mole. Although 20–30% of melanomas are histopathologically ‘nevus associated’, the majority of melanomas arise de novo, ie in clinically normal skin with no associated neavus (Guerra et al, 2021). This explains why removing existing moles does not reduce the risk of melanoma diagnosis. Exposure to tanning beds before the age of 30 increases a person's risk of developing melanoma by 75% (Melanoma UK, 2016). Patients with one first-degree relative with melanoma are 1.7 times more likely to be diagnosed with melanoma, whereas having two first-degree relatives incurs a 9-fold increase in risk. In addition, as patients with a positive family history grow older, the cumulative risk of melanoma also increases (Ward et al, 2017). Melanomas need to be surgically removed and if caught early the outcome can be excellent.
Patients presenting with lesions suspicious for SCC and MM should be referred using a suspected cancer pathway for an appointment within 2 weeks (NICE, 2021).
Who gets skin cancer and what are the causes?
All skin types can develop skin cancer and at any age. It is more common among people with light (fair) skin (Fitzpatrick type 1 and 2 skin). Skin cancer can affect both men and women. Even teenagers and, rarely, younger children can develop skin cancer. The main risk factor for all skin cancer is preventable, namely exposure to UV radiation. This not only includes long-term exposure but also short periods of intense sun exposure or burning, especially in childhood or with sunbed use. Chronic sun exposure is the main cause of non-melanoma skin cancer (BCC and SCC), whereas the development of melanoma appears to be related to intense and intermittent sun exposure. A tan is a reaction to damage in the skin cells when they are exposed to too much UV radiation. There is no such thing as healthy UV tanning.
Skin cancer prevention requires a holistic and comprehensive approach and protecting patients from the harmful effects of UV radiation is the single greatest intervention. Sun damage accumulates and occurs during normal daily activities such as walking to the shops every day (Poon and Barnetson, 2002). This is due to UV radiation not only occurring on sunny days, but even when it is overcast.
There are two main forms of radiation that contribute to the development of skin cancer: UVA and UVB. UVB plays the greatest role in the development of skin cancers, especially melanoma. UVB is associated with causing sunburn and this is due to the UVB rays only reaching the outer layer of the skin (the epidermis). UVB rays significantly cause cellular DNA damage by interfering with DNA replication. Therefore, this leads to mutations in the DNA (Poon and Barnetson, 2002). UVA radiation also alters DNA and causes mutations in cells causing photoaging. The accumulation of sun damage from both UVA and UVB rays over many years can accumulate and therefore protecting against UVA and UVB can significantly reduce the likelihood of developing skin cancer over a lifetime (Romanhole et al, 2015).
Skin cancer assessment
Patients will often present with multiple lesions of concern, especially during the summer months when clothing becomes lighter. The majority of skin lesions are benign and seborrhoeic keratosis (Figure 4) or angioma are likely to be among the most common. Taking a comprehensive history is the starting point of the potential skin cancer consultation and will help guide your level of suspicion. You should ask:
- How long have you had the lesion of concern?
- What have you noticed about it?
- In what way is it changing?
This will give you the information you need even before inspection of the skin occurs. For instance: a patient that states they have had a slow to heal spot for many months that hasn't really changed may make you think of a BCC before casting your eyes on the skin. Obtaining a medical history and establishing patient risk factors should become embedded in the consultation, as this will help guide your decision making (Table 1).
Table 1. Establishing risk factors
| 1. History of UV exposure |
| Lived/worked abroad? |
| Reported episodes of sunburn; severity and at what age |
| Outdoor hobbies (walking/gardening etc) |
| History of sunbed use, frequency and at what age |
| 2. Family history |
| Is there a family history of skin cancer? If so, document type if known and age of onset. What side of the family was it? How is that family member now? |
| Is there a family history of pancreatic cancer? If so, document type if known and age of onset. What side of the family was it? How is that family member now? |
| 3. Fitzpatrick skin type |
| 4. Any immunosuppressive medication? |
| 5. Any previous known skin cancer? |
| 6. Does the patient have multiple moles/atypical moles? |
| 7. Previous sunbed use? Age and frequency of use |
Inspecting the skin should start with a broad overview of the patient's skin so that you can assess what appears to be ‘normal’. Inspect the skin for the ‘odd one out’, often referred to as the ugly duckling sign. General inspection of the skin allows for a comparison of the patient's other skin lesions. Often finding an identical lesion to the one of concern will provide a certain degree of reassurance. Furthermore, the ABCDE checklist (Table 2) is a useful tool for both health professionals and patients alike.
Table 2. ABCDE checklist
| A – Asymmetry | Refers to the shape of the moleMelanomas are likely to have an uneven shape. The two halves of the area may be different shapes (asymmetrical)Normal moles usually have a more even shape and the two halves are similar (symmetrical) |
| Β – Border irregularity | Refers to the edges of the moleMelanomas are more likely to have an irregular border that might be blurred or jaggedNormal moles usually have a smooth, regular border |
| C – Colour variation | Refers to the colour of the moleMelanomas are often an uneven colour and contain more than one shade. It may have different shades of black, brown and pinkNormal moles usually have an even colour |
| D – Diameter | Refers to the width of the moleMost melanomas are more than 6 mm wideNormal moles are usually about the size of the end of a pencil or smaller |
| E – Evolution/changing mole | Evolving means changingMelanomas might change in size, shape or colour. There may be other changes such as a mole bleeding, itching or becoming crustyNormal moles usually stay the same size, shape and colour |
Cancer Research UK, 2020
The consultation will often lead to one of three outcomes:
- The lesion is benign and the patient can be given monitoring advice
- The diagnosis is unclear and you need to seek advice, provide first-line treatment and monitor
- The patient requires referral for a suspected skin cancer diagnosis.
It is important to refer appropriately as secondary care services are struggling to cope, and therefore referring all patients to be cautious only serves to delay patient care overall. If in doubt, it is reasonable to seek a second opinion, or perhaps provide first-line topical treatment and review back in 4 weeks’ time with patient safety netting advice.
Sun safety and health promotion
Prevention is the key. Patients should be advised to seek out shade during the warmest parts of the day (between 10am and 4pm), use of a broad spectrum (UVA/UVB) sunscreen with at least SPF 30 every day, making sure to reapply every two hours or after swimming/excessive sweating (Poon and Barnetson, 2002). Patients should be advised to wear protective clothing when possible and the use of accessories such as a wide-brimmed hat. Patients often forget to reapply sunscreen, which is how they get caught out. Remind them that the top of the ears catch the sun too, as this is an area that is often forgotten about. Patients should be advised to avoid tanning and the use of UV tanning beds.
Patients often feel cheated at the concept of being sun avoidant and so advising about lifestyle modification usually helps alleviate anxiety. For instance, reassure patients they can still enjoy time outdoors, but perhaps plan activities first thing in the morning and early evening while seeking out shade. Advising on such practical measures can often empower patients to feel like protecting their skin from the sun is manageable.
The majority of skin cancers can be prevented; however, this requires participation from the general public through sun protection techniques, routine self-checking and seeking advice early if they are concerned. Encourage patients to ask a friend or family member to check their back for them on a regular basis such as once a month, and encourage taking photographs on mobile phones as a baseline comparison to enable patients to identify if a skin lesion or mole has changed. Patients can often feel overwhelmed at monitoring their skin as there are often many skin lesions to monitor and it is difficult for them to know what to be concerned about.
Therefore, advising patients to simply get into the habit of looking at their skin will assist in pattern recognition and help patients identify what is ‘normal’ for them. This will hopefully help patients to feel confident in noticing changes to an existing skin lesion, or notice when a new lesion appears. Ultimately, patients should be advised to seek advice from a medical professional if they notice any new or changing lesions of concern. ‘If in doubt, check it out!’
Conclusion
Skin cancer is the most common form of cancer in the UK, but thankfully most skin cancers can be cured if detected early. Anyone of any skin type can develop skin cancer and at any age. Patients will often present with multiple lesions of concern. Taking a comprehensive history is the starting point of the potential skin cancer consultation and will help guide the level of suspicion. The NHS is struggling to meet the upward trend of skin cancer diagnoses. Therefore, prevention through health promotion, adequate assessment and appropriate referrals will ensure patients are treated in a timely manner.
CPD REFLECTIVE PRACTICE:
- Are we referring patients to secondary care appropriately?
- Are we providing adequate health promotion to help patients avoid skin cancer?
- Should we change the way we manage patients presenting with skin lesions?
- How can we change the way we work to manage skin cancer better?
KEY POINTS:
- Skin cancer is an umbrella term for two main sub-types: melanoma and non-melanoma
- Skin cancer diagnoses are increasing, placing a huge burden on health services
- The main risk factor for all skin cancer is preventable, namely exposure to ultraviolet (UV) radiation
- Taking a comprehensive history is the starting point of the potential skin cancer consultation and will help guide the level of suspicion