16. Common concerns raised by patients

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Clinical practice guidelines for keratinocyte cancer > 16. Common concerns raised by patients



Background

Patients want considered answers to their questions, involvement in the process of making decisions about their health care, appropriate referral (particularly where the practitioner lacks expertise) and continuity of care. They expect to be treated with respect, kindness and patience.

When deciding on treatment for a keratinocyte cancer (KC) or related lesion, clinicians should discuss with patients the intent of treatment, suitable treatment options, and the risks and benefits of each option, including the likely outcomes and side effects.

This section addresses questions and objections that may arise during the skin cancer consultation and provides guidance for practitioners as to how these might be handled.

Common questions include:

Patients’ beliefs and preferences about skin cancer prevention and treatment also commonly include the following:

Each patient is different, of course. How you answer their queries may depend on multiple factors including likely adherence to treatment or management advice and the person’s underlying fears and concerns, as well as individual risk factors.

Great care should always be taken to protect privacy and confidentiality. Where appropriate, involvement of family and friends may be prudent. For some patients, the involvement of a medical interpreter should be considered.

It may also be helpful to refer patients to available support services in the community, which can be accessed via Cancer Council Australia.

The Cancer Australia-endorsed Optimal care pathway for people with basal cell carcinoma or squamous cell carcinoma may also be a useful reference for patients with KCs.

Written information addressing a concern or treatment protocol should be given, where available.

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I am worried about this spot, Doctor – could it be skin cancer?

If your patient raises concern about a skin lesion, it should be given special attention. Anecdotally, many patients can relate stories of friends or family having been reassured, sometimes with fatal consequences, when showing their doctor a skin cancer. It is important to have a high index of suspicion for malignancy to avoid missing a skin cancer that the patient has flagged.

It is prudent to take a careful history documenting why the patient is worried about the lesion, how long it has been there and how it has changed since first noticed. A lesion that has only been present for a week or so is more likely to be inflammatory. As such, simply covering it to avoid trauma and irritation for a few days may be all that is needed.

Histology is warranted in the following scenarios:

  • The lesion has changed over a period of weeks or months.
  • The lesion has bled repeatedly with minor trauma such as towelling off.
  • The lesion is painful when knocked or touched.
  • A sore has failed to heal fully within 6 weeks.

With sufficient training, examination of the lesion with a dermatoscope may greatly assist in reaching a clinical diagnosis.

Regardless of how it looks macroscopically or dermoscopically, however, a new or evolving firm, raised lesion must always be excised, rather than monitored, because of the possibility of nodular melanoma (see: Clinical practice guidelines for the diagnosis and management of melanoma).[1]

You may choose to do a biopsy rather than excision. However, if there is a possibility of melanoma, complete excision or incisional biopsy (including lesion/normal skin interphase) is paramount to help ensure accurate diagnosis.[1] Almost 1 in 4 melanomas are missed on partial punch biopsy.[2]

The differential diagnosis for a pink macule includes superficial multifocal basal cell carcinoma (BCC), cutaneous squamous cell carcinoma (cSCC) in situ, dermatitis and amelanotic melanoma. Always read the punch biopsy histology report very carefully, even where a benign diagnosis is given; if there are melanocytes within the biopsied pink lesion you should precede to full excision because of the possibility of a misdiagnosed melanoma.

If you decide to ask the patient to return for follow-up of the lesion, rather than perform biopsy or excision, it is important to document this clearly and to add your patient to the practice recall system so they can be contacted if they fail to attend for review. It may be prudent to leave sequential digital imaging to colleagues who are experienced in skin cancer diagnosis and dermoscopy, since the focal changes seen in early melanoma at dermoscopy follow-up can be quite subtle.

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What should I look for when I check myself for possible skin cancer?

Many patients want to be aware of how skin cancers present macroscopically so they can attend early for treatment if necessary. Self-monitoring should not replace a full skin check, particularly in higher risk patients.

Medical review of a lesion is warranted if a lesion:

  • has changed in size, colour or shape over a period of weeks or months
  • is new and stands out from the others (‘ugly duckling’)
  • is painful to touch or pressure
  • has bled easily (e.g. on drying off with a towel)
  • is a sore that has failed to heal completely over a few weeks

Does my tattoo protect me from skin cancer?

Some patients believe that tattoo ink can protect the underlying skin from sunburn. It is worth exploring this misconception with your patient explaining that tattooed skin needs the same protection with sunscreen and clothing as skin elsewhere; the pigment injected into a patient’s skin does not protect it from damage caused by exposure to ultraviolet (UV) radiation. Additionally it can be helpful to point out that tattoos may mask new and established skin lesions, making it harder to diagnose a skin cancer early.

How often should I have a full skin check?

The individual’s skin cancer risk must be carefully weighed up before answering this question.

Factors to take into account include:

  • the number and seriousness of previous skin cancers
  • age
  • Fitzpatrick skin type
  • recreational sun habits
  • work-related sun exposure
  • frequency of sunscreen use
  • visible active sun damage
  • immune status.

For those at low risk of skin cancer, annual skin checks may be a waste of valuable resources. Conversely, for those at the highest risk of skin cancer, regular skin checks will assist with early diagnosis, thereby reducing associated morbidity and the need for complex intervention.

For example, you might advise a skin check at 5-year intervals for a 22-year old indoor worker who has never had a previous skin cancer and is aware of and uses sun protection. On the other hand, a 6-monthly skin check may be prudent for a 60-year old outdoor worker who has already had 20 or more invasive skin cancers.

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At what age should my child have a skin check?

In children, a skin check is extremely unlikely to reveal skin cancer. However, diligent parents may nonetheless wish to have concrete reassurance and this medical visit can be used to reinforce the message to both parents and children of the importance of sun avoidance and protection during the child’s most vulnerable sun-exposure years.

Adults who have been habitually exposed to Australia's high UV index in childhood are much more likely to develop skin cancer than those who spent their early years at latitudes with lower UV indices likely to develop skin cancer than those who spent their early years at latitudes with lower UV indices (see: Epidemiology).

See also: Strategies for protection from excessive exposure to ultraviolet radiation

Am I at less risk of developing skin cancer because I tan easily/have a tan?

There is no such thing as a healthy suntan. Developing a suntan should be avoided regardless of Fitzpatrick skin type.

It is certainly true that someone with Fitzpatrick type 1 skin is at greater risk of developing KC than someone with Fitzpatrick 3 skin after the same amount of sun exposure. Having a tan, however, is no protection from developing skin cancer, regardless of Fitzpatrick skin type.

I never even go out in the sun, so why have I developed skin cancer?

It is a common myth that skin cancers will only develop after erythematous or blistering sun burn. As the UV index is so high for much of the day throughout the year in Australia and New Zealand, intermittent cumulative, chronic low-grade sun exposure can also cause skin cancer.[3][4]

The Bureau of Meteorology and the SunSmart app provide up-to-date information on the UV index and sun protection times across Australia.

It may be worthwhile inviting your patient to closely observe sun damage on others. Actinic keratosis (AK) and skin cancer are seen much more frequently on the right forearm, dorsum of the hand, temple and cheek than the left on account of low grade sun exposure through glass with everyday driving.

Skin cancers may also occur on relatively covered areas of the body because of inadequate sun protection factor (SPF) afforded by clothing, especially when people habitually wear lighter-coloured or thinner materials.

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Why should I have a biopsy? Why not just cut it out?

It is understandable that many patients might prefer to go straight to excision rather than agreeing to the expense and time commitment of an intervening biopsy.

You should carefully explain (and document) why you wish to do a biopsy so your patient is able to give informed consent or dissent.

Biopsy is usually done for a suspected KC for one of the following reasons:

  • You are uncertain that surgery is actually warranted and a biopsy is much less invasive, faster and cheaper than an unnecessary complete excision.
  • You know it is a skin cancer but want more information about the aggressiveness or depth of the tumour to help guide you with ideal excision margins.
  • Establishing the diagnosis before referring the patient for surgery will inform triage, so the patient will be seen faster if it is warranted.

What does the subtyping of my basal cell carcinoma mean?

Subtyping of BCC is important for ongoing management of the patient and deciding on optimal clinical excision margins.

It may be helpful to refer patients to available patient information, which can be accessed via Cancer Council Australia.

My pathology report says there is perineural invasion (PNI) associated with my skin cancer. What does this mean?

Perineural invasion means that the tumour has invaded into a nerve. This finding is of particular concern on the head and neck, especially if the tumour is closer to a cranial nerve foramen. Keratinocyte cancers are able to spread further from the tumour body following PNI as the nerve affords much less resistance to tumour growth than dermis.

When PNI is reported, further discussion with the histopathologist may be helpful to ascertain whether this was seen within or beyond the tumour body and, if the latter, how close to the free margin it was. In most cases of PNI, a wider and deeper excision will be required. If you are not comfortable to do the wider excision, explain to the patient that referral to a surgeon will be required.

If PNI is associated with a KC on the head and neck an expert opinion regarding the need for radiation therapy following the wider excision should be sought. This is particularly important if it involves a nerve greater than 0.1mm in diameter or multiple smaller nerves. Additionally, if your patient is immunocompromised, early referral is imperative.

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Have we got it all or could the skin cancer to come back?

Even with reported ‘clear’ histological margins it is important for patients to realise that tumour recurrence is possible, so they can be vigilant of any change within or close to their excision scar.

It is helpful to ask your pathologist to routinely provide you with actual histological clearance margins in millimetres for KC, so you can judge yourself whether a wider excision may in fact be warranted.

Whether the KC margins are adequate is often an educated guess on the part of the treating doctor that will be made in light of the following information (see: Prognosis):

  • tumour margin in millimetres provided by the histopathologist
  • histological subtype in the case of a BCC
  • the degree of differentiation in the case of a cSCC
  • presence of associated perineural invasion
  • size, depth and anatomical site of the tumour
  • whether the patient is immunocompromised.
  • whether the tumour is recurrent.

See: Table 4.1 in Prognosis of BCC and Table 4.3 Prognosis of cSCC.

If you judge that a wider excision or a second opinion is warranted, explanation (with the use of a descriptive diagram) of how their specimen has been assessed in the laboratory is often helpful for your patient. Explain that the specimen is cut into three or four larger pieces that are then embedded in wax so that a few very thin slices (4µm; four thousandths of a millimetre thick) can be shaved off with a microtome and then reviewed under the microscope after staining. This is referred to as ‘breadloafing’ of the specimen and means that only a few ultra-thin slices (and perhaps less than 0.1% of the perimeter) of the tumour are in fact examined on histology.

Armed with this information, your patient will understand that the clearance margin reported is not representative of the entire tumour and that it is quite possible for a histology report to claim that ‘the tumour appears completely excised’ even though there is residual tumour left behind. This will be important for higher risk tumours.

I don’t use sunscreen because it feels unpleasant/causes low vitamin D/contains dangerous nanoparticles

Research confirms that daily, rather than discretionary, sunscreen use reduces the risk of AK and prevents skin cancer. Patients are often keen to start daily sunscreen when you present the evidence, though some raise concern about the thick sticky feel of sun screen, the fear that it will lower their vitamin D levels, or concern that the nanoparticles most sunscreens contain may be dangerous.

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Responding to concerns about the consistency or feel of sunscreen

If your patient is not going to be sweating or swimming, an option is to use a lighter-weight non-waterproof sunscreen. This may be an ideal option for the indoor worker wishing to protect themselves while driving to and from work and for brief outdoor lunchtime or after-school activities.

Responding to concerns about vitamin D deficiency

Studies show that people who spend time outdoors with sunscreen on are more likely to have normal and high vitamin D levels than people who avoid going outside.

If sunscreen were applied thickly enough, it would completely block UVB and hence vitamin D production. However, studies show that people habitually apply sunscreen at much lower than recommended volumes. This amount of sunscreen while sufficient to help prevent erythema and sun damage does not block vitamin D production.[5]

See also: Vitamin D

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Responding to concerns about exposure to nanoparticles

Most sunscreens do contain nanoparticles and as a result are transparent rather than white once applied. However, no study to date or evidence of any kind has shown that sunscreen may be harmful to the human body.

It’s too late for sunscreen: the damage is already done!

There is irrefutable evidence that daily use of sunscreen reduces established AK and prevents future skin cancer. Studies comparing daily sunscreen use with discretionary sunscreen use show that daily use is the key to prevention,[6][7] because chronic intermittent low-grade sun exposure as well as sunburn is implicated in the development of sun damage and skin cancer (see: Strategies for protection from excessive exposure to ultraviolet radiation).[3][4]

Additionally, if your patient has already had multiple skin cancers it is worth also considering oral nicotinamide (vitamin B3 500 mg twice daily) as this has been shown to reduce visible AK as well as prevent KCs.[8] At this time, nicotinamide is not recommended as prophylaxis for someone who has not previously had skin cancer or has had only a few (see: Chemoprevention).

It is also likely that treating visible sun damage with an approved topical AK field treatment (applied to both visibly damaged and normal looking skin in the treatment area) will reduce future skin cancer (see: Topical treatments).

Studies have shown that photodynamic therapy used as an AK field treatment may additionally be helpful in treating established sun damage and preventing future skin cancer.

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I’m planning to use black salve (e.g. Cansema) for my skin cancer

Black salve is a common name given to a number of escharotic agents. These are caustic agents that may destroy some skin cancer cells but also indiscriminately destroy healthy cells, usually leaving an ulcer that often heals with a suboptimal cosmetic outcome.[9][10] When a skin lesion has healed with scarring or has not resolved fully after the use of black salve, it is often challenging for the pathologist to make a histological diagnosis with confidence.[11] Despite evidence to the contrary, it is often falsely claimed that black salve does not affect healthy cells, promotes healing, and leaves no scar.

Although not approved for human use in Australia, black salve remains a controversial alternative skin cancer treatment that has gained recent popularity.[12]

Patients may have read unsubstantiated testimonials and believe that the main reason it is not an approved mainstream treatment is that pharmaceutical companies cannot benefit from it.

It is understandable that patients might wish to avoid surgery. It may be helpful to empathise with this sentiment, going on to explain your reasons for advising against the use of this topical preparation.

To protect patients, it may be helpful to explain that some cancer lines are in fact relatively resistant to black salve and that valuable time may be lost waiting for a surface ulcer to heal while the cancer continues to expand in the underlying tissues. The consequences could be significant in the case of a more aggressive skin cancer. Case studies have reported death from metastatic nasal BCC and development of metastatic melanoma following self-treatment with black slave. [13]

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References

  1. 1.0 1.1 Cancer Council Australia Melanoma Guidelines Working Party.. https://wiki.cancer.org.au/australia/Guidelines:Melanoma. [homepage on the internet] Sydney: Cancer Council Australia; Available from: https://wiki.cancer.org.au/australiawiki/index.php?oldid=198626.
  2. Ng JC, Swain S, Dowling JP, Wolfe R, Simpson P, Kelly JW. The impact of partial biopsy on histopathologic diagnosis of cutaneous melanoma: experience of an Australian tertiary referral service. Arch Dermatol 2010 Mar;146(3):234-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20231492.
  3. 3.0 3.1 de Pedro I, Alonso-Lecue P, Sanz-Gómez N, Freije A & Gandarillas A. Sublethal UV irradiation induces squamous differentiation via a p53-independent, DNA damage-mitosis checkpoint. Cell Death & Disease ;9:1094;1-12 Abstract available at https://www.nature.com/articles/s41419-018-1130-8.
  4. 4.0 4.1 Martincorena I, Roshan A, Gerstung M, Ellis P, Van Loo P, McLaren S, et al. Tumor evolution. High burden and pervasive positive selection of somatic mutations in normal human skin. Science 2015 May 22;348(6237):880-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25999502.
  5. Neale RE, Khan SR, Lucas RM, Waterhouse M, Whiteman DC, Olsen CM. The effect of sunscreen on vitamin D: a review. Br J Dermatol 2019 Apr 4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/30945275.
  6. Green A, Williams G, Neale R, Hart V, Leslie D, Parsons P, et al. Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: a randomised controlled trial. Lancet 1999 Aug 28;354(9180):723-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10475183.
  7. Ulrich C, Jürgensen JS, Degen A, Hackethal M, Ulrich M, Patel MJ, et al. Prevention of non-melanoma skin cancer in organ transplant patients by regular use of a sunscreen: a 24 months, prospective, case-control study. Br J Dermatol 2009 Nov;161 Suppl 3:78-84 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19775361.
  8. Chen AC, Martin AJ, Choy B, Fernández-Peñas P, Dalziell RA, McKenzie CA, et al. A Phase 3 Randomized Trial of Nicotinamide for Skin-Cancer Chemoprevention. N Engl J Med 2015 Oct 22;373(17):1618-26 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26488693.
  9. Croaker A, Lim A, Rosendahl C. Black salve in a nutshell. Australian Journal of General Practice ;47(12) Abstract available at https://www1.racgp.org.au/ajgp/2018/december/black-salve-in-a-nutshell.
  10. Eastman KL, McFarland LV, Raugi GJ. A review of topical corrosive black salve. J Altern Complement Med 2014 Apr;20(4):284-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24175872.
  11. Leecy TN, Beer TW, Harvey NT, Kumarasinghe SP, McCallum D, Yu LL, et al. Histopathological features associated with application of black salve to cutaneous lesions: a series of 16 cases and review of the literature. Pathology 2013 Dec;45(7):670-4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24150196.
  12. Therapeutic Goods Administration. Australian Government Department of Health Therapeutic Goods Administration. Black salve, red salve and cansema. [homepage on the internet] TGA; 2013 Available from: https://www.tga.gov.au/community-qa/black-salve-red-salve-and-cansema.
  13. Croaker A, King GJ, Pyne JH, Anoopkumar-Dukie S, Liu L. A Review of Black Salve: Cancer Specificity, Cure, and Cosmesis. Evid Based Complement Alternat Med 2017;2017:9184034 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28246541.

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