Melanoma Skin Cancer

DRG Category:	580
Mean LOS:	5.2 days
Description:	SURGICAL: Other Skin, Subcutaneous Tissue, and Breast Procedure With CC
DRG Category:	595
Mean LOS:	7.7 days
Description:	MEDICAL: Major Skin Disorders With Major CC

Melanoma skin cancer is a type of skin cancer that originates from the melanocytes, frequently a nevus or mole. Melanocytes are melanin-producing cells that are interspersed in the inner layer of the epidermis. Melanin is a dark brown pigment that protects the epidermis and the superficial vasculature of the dermis. Nevi or moles are small, circumscribed aggregates of melanocytes. It is thought that the ultraviolet (UV) radiation (from direct sunlight or tanning beds) damages the DNA of melanocytes, impairing the DNA control over how and when cells grow and divide. These skin lesions tend to be hereditary, begin to grow in childhood, and become more numerous in young adulthood.

Skin cancer is the most common cancer in the United States, and melanoma accounts for 4% of all skin cancer cases. Although the lifetime melanoma risk for the overall population is less than 2%, melanoma is responsible for approximately 80% of skin cancer deaths. According to the American Cancer Society, approximately 75,000 new diagnoses of melanoma are expected annually, with more than 9,000 deaths anticipated. Diagnoses of melanoma increased sharply in the 1970s, 1980s, and 1990s but have leveled off since 2000. The mortality rate per 100,000 people has increased by 50%; much of this increase in mortality is in older white males. Early diagnoses have led to significant improvement in overall survival. The two most important factors that predict outcomes from treatment are the thickness of the lesion and the status of the regional lymph nodes.

Causes

Characteristics associated with an increased risk for melanoma include fair skin that does not tan well and that burns easily, blond or red hair, the tendency to develop freckles, and the presence of a large number of nevi. A strong association exists between exposure to UV light (UV-B radiation) and the development of cutaneous melanoma, but the exact nature of this relationship is unclear. Other risk factors include a positive family history, sunburns early in life, use of tanning beds, and immune suppression.

Genetic considerations

While both sporadic and familial forms of this disorder seem to exist, family history has been associated with an earlier onset, less invasiveness, and smaller lesions. A pattern of autosomal dominant transmission is seen in some populations. A person with one first-degree relative affected by melanoma has two to three times the risk of the general population and six times the risk if the relative was affected before age 50. The risk increases 13-fold if more than one first-degree relative is affected.

Gender, ethnic/racial, and life span considerations

Men have a 1 in 57 chance of developing melanoma; women have a 1 in 81 chance. The incidence of melanoma increases with age; 50% of cases occur in people who are older than 50. Mortality rates are increasing most rapidly among European American men older than age 50. Although melanomas are rare in children, the incidence among today’s younger people is proportionally higher than among people of the same age decades ago. Melanoma is one of the most common cancers in people who are younger than 30. European Americans have a 20 times higher risk factor for melanoma than African Americans. Melanoma most often appears on the trunks of fair-skinned men and the lower legs of fair-skinned women; however, people with more darkly pigmented skin do develop melanoma on their palms, soles, and under the nails.

Global health considerations

The World Health Organization reports that 132,000 melanoma skin cancers occur globally each year and rates are increasing. The global incidence of melanoma skin cancer is 2.6 per 100,000 females per year and 2.5 per 100,000 males per year. The incidence is 15 times higher in developed than in developing regions, a statistic that may be related to recreational exposure to the sun.

Assessment

History

Reports of a change in a nevus or mole or a new skin lesion require careful follow-up. Ask the patient the following questions: When did the lesion first appear or change? What is the specific nature of the change? What symptoms and characteristics of the lesion has the patient noticed? What is the patient’s history of exposure to UV light or radiation? What is the history of thermal or chemical trauma? What personal or family history of melanoma or precancerous lesions exists?

Physical examination

The most common symptom is a change in an existing lesion or development of a new lesion. To identify potentially cancerous lesions, inspect and palpate the scalp, all skin surfaces, and the accessible mucosa. Examine preexisting lesions, scars, freckles, moles, warts, and nevi closely. The “ABCD rule” can be useful in identifying distinguishing characteristics of suspicious lesions (Table 1).

ABCD Rule of Assessment for Melanoma

Table 1. ABCD Rule of Assessment for Melanoma
A = Asymmetry	Change in shape; unbalanced or irregular shape
B = Border irregularity	Indistinct or splayed margins; notching of the borders
C = Color variation	Spread of color from the edge of the lesion into the surrounding skin; multiple shades or colors within a single lesion; dark brown or black, red, white, or blue
D = Diameter	Sudden or continuous increase in size: Diameter > 6 mm (although there has been an increase in 3- to 6-mm melanomas)

Psychosocial

For many people, the diagnosis of any type of cancer is associated with death. Because cancerous skin lesions are readily visible, the patient with melanoma may experience an altered body image. Ask open-ended questions as you assess the patient’s emotional response to the diagnosis of melanoma.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Shave biopsy	No cancer cells present	Presence of melanoma cells	Scrapes off the top layers of skin; may not be thick enough to determine the degree of cancer invasion
Punch biopsy	No cancer cells present	Presence of melanoma cells	Removes a deep sample of skin melanoma cells after numbing the site; cuts through all layers of skin
Incisional and excisional biopsy (preferred method)	No cancer cells present	Presence of melanoma cells	Uses a surgical knife to cut through the full thickness of skin and removes a wedge of skin: Incisional biopsy removes only a portion; excisional biopsy removes entire tumor
Fine-needle aspiration biopsy, lymph node biopsy	No cancer cells present	Presence of melanoma cells	Uses a thin needle to remove a very small tissue fragment; may be used to biopsy a lymph node near a melanoma to determine the extent of the disease

Other Tests: To diagnose metastases, tests include computed tomography scan, magnetic resonance imaging, and x-rays.

Primary nursing diagnosis

Diagnosis

Impaired skin integrity related to cutaneous lesions

Outcomes

Tissue integrity: Skin and mucous membranes; Wound healing: Primary intention; Knowledge: Treatment regimen; Nutritional status; Treatment behavior: Illness or injury

Interventions

Incision site care; Wound care; Skin surveillance; Medication administration; Infection control; Nutrition management

Planning and implementation

Collaborative

After diagnostic testing, the cancer is staged. Because the thinner the melanoma, the better the prognosis, the Clark level of a melanoma may be used. This system uses a scale of 1 to 5 to describe which layers of skin are involved. The higher the number, the deeper the melanoma.

The primary treatment for melanoma is surgical resection. Excision of the cancerous lesion with a 2- to 5-cm margin is recommended when feasible. The width of the surrounding margin should be wider for larger primary lesions. When the melanoma is on a finger or toe, surgical treatment is to amputate as much of the finger or toe as is necessary. Elective regional lymph node removal is controversial. Proponents believe that this procedure decreases the possibility of distal metastases, but scientific evidence to support this belief is lacking.

The prognosis for metastatic melanoma is poor; it is highly resistant to currently available chemotherapeutic agents. Radiation is not often used to treat the original melanoma but is rather used for symptom management as a palliative measure if the cancer has spread to the brain.

Pharmacologic highlights

General Comments: Cytokines may cause side effects such as chills, aches, fever, severe fatigue, and swelling.

Medication or Drug Class	Dosage	Description	Rationale
Chemotherapeutic agents	Varies with drug	Dartmouth regimen: dacarbazine (DTIC), carmustine, cisplatin, and tamoxifen; other: cisplatin, vinblastine, DTIC	Decrease replication of malignant cells and kill them
Immunotherapy (adjuvant immunotherapy with cytokines)	Varies with drug	Interferon-alpha; interleukin-2	Enhances immune system to recognize and destroy cancer cells; shrinks metastatic melanomas (effective in 10%–20% of patients)

Independent

Patient and family education is the most important nursing responsibility in preventing, recognizing, and treating the disorder. Educational materials and teaching aids are available from various community and national organizations and the local or state branches of the American Cancer Society (http://www.cancer.org) and the National Cancer Institute (http://www.cancer.gov). Nursing care of patients who have had surgery is focused on patient education because most of these patients are treated in an ambulatory or short-term stay setting. Instruct patients to protect the site and inspect the incision and graft sites for bleeding or signs of infection. Immobilize recipient graft sites to promote engraftment. Evaluate limbs that have surgical incisions or local isolated chemotherapy to prevent edema.

Reactions to skin disfigurement that occur with some treatments may vary widely. Determine what the cancer experience means to the patient and how it affects the patient’s perception of his or her body image. Help the patient achieve the best possible grooming as treatment progresses. Suggest a support group, or if the patient is coping ineffectively, refer for counseling.

Evidence-Based Practice and Health Policy

Lazovich, D., Vogel, R.I., Berwick, M., Weinstock, M.A., Anderson, K.E., & Warshaw, E.M. (2010). Indoor tanning and risk of melanoma: A case-control study in a highly exposed population. Cancer Epidemiology, Biomarkers and Prevention, 19(6), 1557–1568.

A study among 1,167 cases of melanoma, which were compared to an age- and gender-matched sample of 1,101 control participants, revealed that indoor tanning increased the risk of melanoma by 1.74 times (95% CI, 1.42 to 2.14). In this study, 62.9% of participants with a melanoma reported indoor tanning compared to 51.1% of the control participants.
When compared to no use of indoor tanning, the risk of melanoma increased by 1.46 times with 1 to 9 hours of use (95% CI, 1.15 to 1.85) and up to 3.18 times with more than 50 hours of use (95% CI, 2.28 to 4.43) (p < 0.001). The risk of melanoma also increased by 1.80 times with 11 to 24 sessions (95% CI, 1.3 to 2.49) and up to 2.72 times with more than 100 sessions (95% CI, 2.04 to 3.63) (p = 0.002). When compared to no use, a duration of use more than 10 years increased the risk of melanoma by 2.45 times (95% CI, 1.83 to 3.28; p = 0.006).
Melanoma risk was increasingly marked when ultraviolet A (UVA)–emitting tanning devices were reported (4.44 times increased risk; 95% CI, 2.45 to 8.02) when compared with ultraviolet B (UVB)–enhanced devices (2.86 times increased risk; 95% CI, 2.03 to 4.03).

Documentation guidelines

Description of any suspicious lesions: Specific location, shape, size, color, condition of surrounding skin, sensations reported by the patient
Description of incision sites: Presence of redness, swelling, drainage, warmth, tenderness
Pain: Description of the qualities and location of the pain, effectiveness of pain relief measures

Discharge and home healthcare guidelines

Teach the patient to protect the incision site from thermal, physical, or chemical trauma. Instruct the patient to inspect the incision site for signs of bleeding or infection. Teach the patient to notify the physician of fever or increased redness, swelling, or tenderness around the incision site. Provide instructions as indicated for specific adjuvant therapy: chemotherapy, radiation, immunotherapy.

Teach the patient strategies for prevention and for modifying the risk factors:

Skin self-examination and identification of suspicious lesions: Moles or nevi that change in size, height, color, texture, sensation, or shape; development of a new mole.
Limitation of UV light exposure: Avoid the sun between the hours of 10 a.m. and 3 p.m. when the UV radiation is the strongest. Wear waterproof sunscreen with a sun protection factor of greater than 15 before going outdoors. Apply sunscreen on cloudy days because roughly 70% to 80% of UV rays can penetrate the clouds. Reapply sunscreen every 2 to 3 hours during long sun exposure. Be aware that the sun’s rays are reflected by such surfaces as concrete, snow, sand, and water, thereby increasing exposure to UV rays. Wear protective clothing when outdoors, particularly a wide-brimmed hat to protect the face, scalp, and neck area. Wear wraparound sunglasses with 99% to 100% UV absorption to protect the eyes and the skin area around the eyes. Be aware of medications and cosmetics that increase the sensitivity to UV rays. Minimize UV exposure as much as possible and use sunscreen that contains benzophenones. Avoid tanning booths and sunlamps.