Skin Cancer Screening. (Case Report).

Skin cancer is the most common malignancy occurring in humans, (10 affecting 1 in 5 Americans at some time during their lives. (2) Skin malignancies can be divided into 2 categories: melanoma and nonmelanoma cancer. In 2000, the American Cancer Society estimated that 53,600 new cases of melanoma were diagnosed in addition to over 1 million cases of nonmelanoma (basal and squamous cell) skin cancers. (3) This was an increase from the 27,600 cases of melanoma and 600,000 cases of nonmelanoma skin cancers estimated in 1990. (4)

Melanoma accounts for three quarters of the deaths caused by skin cancer each year, whereas the mortality rate for those diagnosed with nonmelanoma skin cancer is relatively low, with an estimated 95% 5-year survival rate. (5,6) Nonmelanoma skin cancer can be locally aggressive, however, and can result in considerable disfigurement, loss of function, and health care costs. (5) Also of concern is that patients diagnosed with basal cell carcinoma have an almost 50% risk for a second primary nonmelanoma skin cancer developing within a 50-year period. (7,8) These patients are also 3 times more likely to develop melanoma later. (9)

The risk factors and warning signs of melanoma and nonmelanoma skin cancer have been described by the American Academy of Dermatology and Center for Disease Control and Prevention (Tab. 1). (10) Risk factors for melanoma include age greater than 15 years, fair complexion, persistently changed or changing mole, many moles, atypical moles, personal or family history of melanoma, sun sensitivity, and excessive sun exposure. (10) Warning signs for melanoma include new, changing, or changed moles; unusual moles; or symptomatic moles (eg, pain, itching, burning), (10) Risk factors for nonmelanoma skin cancer include older age, fair complexion, . male sex, inability to tan, and prolonged redness after exposure to the sun. (10) Warning signs for nonmelanoma skin cancer include a sore that will not heal, a scaly spot, an enlarging pink or red growth, or a pearly bump. (10) Both types of malignancies have been shown to have a greater incidence in white people living near the equator because of greater ultraviolet light exposure per unit of time. (11) Medical conditions of chronic osteomyelitis sinus tracts, burn scars, chronic skin ulcers, xeroderma pigmentosum, and human papillomavirus infection also are associated with an increased risk of melanoma occurrence. (11) Outdoor workers have an increased incidence of nonmelanoma skin cancer, and intense, intermittent exposure and blistering sunburn episodes in childhood and adolescence are associated with a greater risk of melanoma skin cancer. (5,11)

Clinical characteristics of melanoma include a darkly pigmented lesion with color variegation and irregular, asymmetric borders. (1) The lesion may be flat or slightly elevated, with a diameter measuring greater than 6 to 8 mm. (1) Usually a history of a gradually changing lesion over 1 to 5 years is reported. (1) Most frequently, the upper back in men and the lower leg in women are the sites for these lesions. (1)

The American Joint Committee on Cancer has defined the clinical and pathologic staging classifications of melanoma. (12(pp153-158)) Staging is based on the thickness of the lesion because this has the greatest association with outcome. (12(pp153-158)) Because of the need for knowing the thickness of the lesion for staging and, therefore, for prognosis, clinical staging (or "length by width" classification) is not used, but rather pathologic staging performed by microscopic measurement after removal of the tumor. (12(pp153-158)) Upon removal of the lesion, it is classified by the depth of invasion and the maximum thickness. (12(pp153-158)) Classification also is dependent on the involvement of regional lymph nodes and distant metastasis (Tab. 2). (12(pp153-158)) The clinical characteristics of the lesion are important to the physical therapist, however, for screening purposes.

Basal cell carcinoma can be divided into histologic types that each have a characteristic clinical appearance. (1,13) Generally, as they enlarge, telangiectatic vessels may be visible and the borders may become irregular. (1,13) The superficial form is a discrete plaque with fine scale, similar to eczema or psoriasis. (1,13) Morphea-form basal cell carcinoma appear as flat, waxy-textured, white or yellow plaques with irregular and indistinct margins. (1,13) Their irregular growth pattern makes removal difficult. (1) Metatypical basal cell carcinoma may have a variety of histologic differentiation, causing diagnosis to be confusing. (1)

The precursor of squamous cell carcinoma is the actinic (or solar) keratosis. (1,13) These precursors are usually on the head, neck, forearms, and hands, which are areas of maximal cumulative sun exposure. (1) They appear as scaly plaques or papules with a hyperkeratotic surface, and most are between 2 and 6 mm in diameter. (1) They may be flesh-colored, pigmented, or erythematous. (1) Characteristically, the invasive squamous cell carcinoma is a flesh-colored or erythematous nodule with elevated borders. (13) Ulceration and erosion may be present in the center of the lesion. (1,13)

Nonmelanoma skin cancers (both basal cell and squamous cell carcinomas) have identical clinical and pathologic classifications. (12(pp147-151)) The benign lesions exhibit cell differentiation, uniform cell size, infrequent cellular mitoses and nuclear irregularity, and intact intercellular bridges. (12(pp147-151)) Malignant tumors exhibit opposite histopathologic signs to these, with the depth of invasion correlating with the degree of tumor malignancy (Tab. 3). (12(pp147-151)) These signs, therefore, should be noted in the screening process.

Because millions of Americans are seen daily by health care practitioners other than physicians, screening of the skin by these professionals is warranted. (14) Physical therapists can perform a dermatologic screening as part of their routine examination of patients. (14) This case report describes a patient who was being treated for cervical stenosis and the process by which I did a dermatologic screening and decided to refer the patient to her physician for further diagnostic testing.

Case Description

Patient Description

The patient was 79-year-old woman who was referred for physical therapy with a prescription from her primary care physician to be evaluated and treated for cervical stenosis. She reported a gradual onset of neck pain and was seeking relief of this pain. Her prior medical history was nonsignificant for other medical conditions, and she reported no history of cancer.

Examination

During the initial visit, the patient donned a gown, and I examined her cervical spine and upper extremities. During the examination, I noted that this patient had several moles of various shapes, sizes, and colors throughout her head, neck, and upper extremities. Knowing the importance of detecting malignant skin lesions as early as possible and also knowing that detecting changes in one's own skin lesions can be very difficult, (15) I believed a screening of the skin was appropriate.

To screen the skin, I used the ABCD checklist (Tab. 4). (11,16,17) The 4 items on the checklist are all physical examination features, and referral for biopsy is recommended if one or more of the elements are suspiscious. (11) I also questioned the patient about any recent changes in size, shape, or color of the moles. (11,17)

I noted one mole in particular in the left supraclavicular region that looked suspicious. The lesion was symmetrical but had irregular borders. It was 2 different shades of brown and black and measured approximately 2 mm. The patient was not aware of any recent changes in this mole, and she was not aware of the length of time that it had been present. No other moles had any concerning signs. I explained to the patient the signs of the lesion that were of concern to me and recommended that she have her primary care physician examine this area at her upcoming appointment.

The patient's treatment for cervical stenosis was completed prior to her appointment with her physician. She had a reduction in pain and was to continue a self-stretching program at home. Prior to her discharge, I discussed signs of skin lesions that warrant concern and further evaluation and the importance of avoiding excessive sun exposure.

This patient was seen by her family physician shortly after discharge from physical therapy. She expressed understanding of the importance of having this lesion examined by her physician, but patients may require a more proactive approach, including direct communication with the physician or assistance in scheduling a timely appointment, if an appointment with a physician is not pending or if they are reluctant to have the lesion examined.

The physician examined the skin lesion in the left supraclavicular area and also was concerned about its appearance. He removed it, using a shave excision, and cauterized the area at the base. The microscopic diagnosis on the pathology report was basal cell carcinoma with clear margins.

Discussion

Early detection is important in reducing morbidity and mortality from skin cancers. (13) Koh et al (15) surveyed patients who had been diagnosed with melanoma to assess patterns of melanoma discovery and to determine the patients' role in finding their own lesions. They found that approximately half (53%) of melanomas were self-discovered, and the remaining cases were detected by medical providers (26%), family members (17%), and others (3%). (15) Nearly one third stated they could not see their own lesions easily. (15) Medical personnel detected the lesions most often in older patients. (15)

Historically, principal barriers to skin cancer detection have included the low priority of skin cancer screening in primary care, the lack of significant findings in the majority of examinations, and the lack of expertise of providers to adequately identify high-risk lesions. (18) Deterrents for screening also include lack of reimbursement for preventive care, inadequate time for complete skin examinations, and distraction by other health problems. (10) These barriers support the need for physical therapists to become more involved in skin cancer screenings.

McGovern and Litaker (19) studied the ABCD checklist to determine sensitivity and specificity in the detection of skin cancer. The sensitivity was 100%, and the specificity was 98.4%. Healsmith et al (20) documented sensitivity of 100% and specificity of 37.0% for the revised 7-point checklist, an alternate screening method. The revised 7-point checklist assigns 2 points for each major criterion noted at the lesion, including change in size, shape, or color, and 1 point for each of the minor criteria at the site, including inflammation, crusting, or bleeding; sensory change; or diameter equal to or greater than 7 mm. (17) If a score of 3 points or more is noted, a referral for further evaluation is warranted. (17) Regardless of the screening method used, the gold standard for diagnosis is the histopathological evaluation of excised tissue. (17)

The American Academy of Dermatology and the Centers for Disease Control and Prevention have defined the role of allied health care professionals in national efforts to reduce skin cancer incidence and mortality. (10) They states that "a basic set of core information for these professionals should include what skin cancer is, what it looks like, its cause, and preventive measures, including both primary prevention and detection of skin cancer warning signs." (10(p754)) The Guide to Physical Therapist Practice described the role of physical therapists in secondary prevention, or "decreasing duration of illness, severity of disease, and number of sequelae through early diagnosis and prompt intervention." (21(p533)) The assessment of integumentary integrity is included under each patient/client diagnostic classification, further emphasizing the role of physical therapists in this area?

Boissonault (22) described the prevalence of selected comorbid conditions, surgical histories, and medication use in an observational study that was performed to describe the medical histories of individuals receiving outpatient physical therapy services. Skin cancer was found to be the most prevalent cancer reported. (22) Boissonault (22) suggested that physical therapists often have the opportunity to observe exposed body areas, and knowledge of the characteristics of benign and pathologic skin lesions might facilitate a referral for further evaluation and diagnosis and treatment, if necessary.

Due to the nature of physical therapist examination and treatment techniques, physical therapists often may be able to screen for skin cancer. Knowledge of the basic screening techniques for skin cancer is necessary for the early detection of cancerous lesions and for the reduction of the morbidity and mortality caused by these lesions.

Table 1.
Risk Factors for Skin Cancer

Melanoma                               Nonmelanoma Skin Cancer

Age greater than 15 years              Old Age

Fair complexion                        Fair Complexion

Persistently changed or changing mole  Male sex

Presence of many moles                 Inability to tan

Presence of atypical moles             Prolonged redness after
                                         exposure to the sun

Personal or family history of
  melanoma                             White race

Sun sensitivity                        Residence near equator

Excessive sun exposure

Medical conditions of chronic
  osteomyelitis sinus tracts, burn scars,
  chronic skin ulcers, xeroderma
  pigmentosum, and human
  papillomavirus infection

White race

Residence near equator

Table 2.
Melanoma Staging (American Joint Committee on Cancer Classification)
(12(pp153-158))

Stage    Primary Tumor

0        Melanoma in situ, not an invasive malignant lesion

I        Tumor 0.75 mm or less in thickness and invades the papillary
           dermis, or tumor more than 0.75 mm but not more than
           1.5 mm in thickness and/or invades to papillary-reticular
           dermal interface

II       Tumor more than 1.5 mm but not more than 4 mm in
           thickness and/or invades the reticular dermis

III      Tumor more than 4 mm in thickness and/or invades the
           subcutaneous tissue and/or satellite(s) within 2 cm of the
           primary tumor

III      Any primary tumor classification

IV       Any primary tumor classification

                                                         Distant
Stage    Regional Lymph Nodes                            Metastasis

0        No metastasis                                   No metastasis

I        No metastasis                                   No metastasis

II       No metastasis                                   No metastasis

III      No metastasis                                   No metastasis

III      Metastasis 3 cm or less in greatest dimension   No metastasis
           in any regional lymph nodes, or metastasis
           more than 3 cm in greatest dimension in any
           regional lymph node(s) and/or in-transit
           metastasis

IV       Any regional lymph node classification          Distant
                                                           metastasis

Table 3.
Nonmelanomatous Cancer Staging (American Joint Committee on Cancer
Classification) (12(pp147-151))

Stage   Primary Tumor

0       Carcinoma in situ

I       Tumor 2 cm or less in greatest dimension

II      Tumor more than 2 cm in greatest dimension

III     Tumor invades deep extradermal structures
          (ie, cartilage, skeletal muscle, or bone)

III     Any primary tumor classification

IV      Any primary tumor classification

                                                    Distant
Stage   Regional Lymph Nodes                        Metastasis

0       No metastasis                               No metastasis

I       No metastasis                               No metastasis

II      No metastasis                               No metastasis

III     No metastasis                               No metastasis

III     Regional lymph node metastasis              No metastasis

IV      Any regional lymph node classification      Distant metastasis

Table 4.
ABCD Checklist for Skin Cancer Screening

A = asymmetry
  When bisected, one half of the lesion is not identical to the
  other half.

B = border
  The border is uneven or ragged as opposed to smooth and
  straight.

C = color
  The lesion is more than one shade of pigment.

D = diameter
  The diameter is greater than 6 mm.
  Presence of one or more of these elements raises suspicion that
  lesion is cancerous.

References

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(2) Sachs DL, Marghoob AA, Halpern A. Skin cancer in the elderly. Clin Geriatric Med. 2001;17:715-738.

(3) Jemal A, Thomas A, Murray T, Thun M. Cancer statistics, 2002. CA Cancer J Clin. 2002;52:23-47.

(4) Silverberg BS, Boring CC, Squires TS. Cancer statistics, 1990. CA Cancer J Clin. 1990;40:9-26.

(5) Gloster HM, Brodland DG. The epidemiology of skin cancer. Dermatol Surg. 1996;22:217-226.

(6) Liu T, Soong S. Epidemiology of malignant melanoma. Surg Clin North Am. 1996;76:1205-1222.

(7) Karagas M, Stukel T, Greenberg R, et al. Risk of subsequent basal cell carcinoma and squamous cell carcinoma of the skin among patients with prior skin cancer. JAMA. 1992;267:3305-3310.

(8) Morghoob A, Kopf A, Bart R, et al. Risk of another basal cell carcinoma developing after treatment of a basal cell carcinoma. J Am Acad Dermatol. 1993;28:22-28.

(9) Bower C, Lear J, Bygrave S, et al. Basal cell carcinoma and risk of subsequent malignancies: a cancer registry-based study in southwest England. J Am Acad Dermatol. 2000;42:988-991.

(10) Goldsmith LA, Koh HK, Bewerse BA, et al. Full proceedings from the national conference to develop a national skin cancer agenda. J Am Acad Dermatol. 1996;35:748-756.

(11) Jerant AF, Johnson JT, Sheridan CD, Coffrey TJ. Early detection and treatment of skin cancer. Am Fam Physician. 2000;62:357-368, 375-376, 381-382.

(12) American Joint Committee on Cancer. AJCC Cancer Staging Handbook. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1998: 147-151, 153-158.

(13) Garner KL, Rodney WM. Basal and squamous cell carcinoma. Primary Care: Clin Office Pract. 2000;27:447-458.

(14) Shapiro C, Skopit S. Screening for skin disorders. In: Boissonnault WG, ed. Examination in Physical Therapy Practice. 2nd ed. Philadelphia, Pa: Churchill Livingstone Inc; 1995:303-317.

(15) Koh HK, Miller Dr, Geller AC, et al. Who discovers melanoma? J Am Acad Dermatol. 1992;26:914-919.

(16) Friedman RJ, Rigel DS, Kopf AW. Early detection of malignant melanoma: the role of physician examination and self-examination of the skin. Cancer J Clinician. 1985;35:130-151.

(17) Whited JD, Grichnik JM. Does this patient have a mole or a melanoma? JAMA. 1998;279:696-701.

(18) Wender RC. Barriers to effective skin cancer detection. Cancer. 1995;75:691-698.

(19) McGovern TW, Litaker MS. Clinical predictors of malignant pigmented lesions: a comparison of the Glasgow seven-point checklist and the American Cancer Society's ABCDs of pigmented lesions. J Dermatol Surg Oncol. 1992;18:22-26.

(20) Healsmith MF, Bourke JF, Osborne JE, Graham-Brown RA. An evaluation of the revised seven-point checklist for the early diagnosis of cutaneous melanoma. Br J Dermatol. 1994;130:48-50.

(21) Guide to Physical Therapist Practice. Phys Ther. 2001;81:9-744.

(22) Boissonault WG. Prevalence of comorbid conditions, surgeries, and medication use in a physical therapy outpatient population: a multicentered study. J Orthop Sports Phys Ther. 1999;29:506-525.

M Wills, PT, MHS, OCS, is Manager of Physical Therapy, Department of Physical Therapy, Shelby Memorial Hospital, 200 S Cedar St, Shelbyville, IL 62565 (USA) ([e-mail]).

This article was submitted January 22, 2002, and was accepted June 29, 2002.