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Nurses like Marianne Tawa (right), MSN, ANP, RN, a nurse practitioner at the Dana-Farber Cancer Institute in Boston, have a better opportunity to observe the skin than other health care professionals, so they're in the best position to detect a melanoma or cutaneous leukemia before anyone else.

Barbara, a 50-year-old woman, had come to Dana-Farber Cancer Institute in Boston to evaluate a new, somewhat itchy, pigmented lesion on her right thigh. She liked the sun and didn't always use sunscreen, but Barbara had no known risk factors for melanoma: She didn't have a fair complexion, light hair and eyes, freckling or history of blistering sunburns as a child.

At first, nurse practitioner Marianne Tawa, MSN, ANP, RN, of the cutaneous oncology program wasn't overly concerned.

After a full skin examination, Tawa used a dermatoscope to magnify the thigh lesion. Finding characteristics of a benign seborrheic keratosis, Tawa debated whether a biopsy was needed. Then, Barbara said something that caught Tawa's attention. She thought something was "not quite right" about the lesion. It felt "funny" or "tingly."

Tawa stopped examining and started listening. Benign findings or not, she was doing the biopsy. Two days later, the pathologist confirmed the specimen was a .44 mm malignant melanoma.

When Tawa called Barbara, they talked about the treatment plan (a wide surgical excision), her prognosis, follow-up, sunscreen and sun exposure. Most of all, they talked about listening to your body and your patient.

Vantage point

Because nurses have a better opportunity to observe the skin than other health care professionals, they're in the best position to detect a melanoma or cutaneous leukemia before anyone else.

"We picked up leukemias [in the skin] that were pre-bone marrow," said Marcia Hill, MSN, RN, senior research nurse in the Department of Dermatology at the University of Texas M.D. Anderson Cancer Center in Houston. "When the bone marrow [tests] were done on these people, they were pre-leukemic."

But the ability to make that kind of assessment requires a thorough knowledge of the skin and skin lesions.

Unfortunately, what you were taught about skin cancer in nursing school may not have been much more than warnings about sun exposure and sunscreen. "Although nursing school curricula are getting a little better, nurses get very little education about skin," Hill said.

Tawa estimates that only 20 to 30 nurse practitioners across the country specialize in skin cancer. Although that doesn't take into account all of the primary care/family practice NPs who screen patients and educate them about the sun and skin cancer risks, nurses with specialized training and experience are scarce.

"There's a big need out there for primary care people to be able to diagnose and treat skin disorders," Tawa said, "And nurses have a lot of independence and creativity in the field."

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