What Lies Beneath
Nurses who specialize in skin cancer treatment and research advise patients to listen to their bodies for early detection

By Joan Sosin, JD, RN
November 18, 2002

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."

Spotlight on prevention

One such nurse is Lorrie Graaf, RN, a public health adviser who works for the CDC. She was assigned to Iowa's Department of Public Health in Des Moines to establish and manage its comprehensive cancer control program.

Having no funds for skin cancer prevention activities, Graaf has come up with innovative ways to educate the public. One example is the partnership created with Pioneer Hi-Bred International Inc., a seed company in Des Moines, to spread the word about sun exposure.

In order to raise seed corn, seasonal field workers are employed to detach the tassels from corn. Most of them are teenagers earning money during the summer. This year, Pioneer expected to have more than 27,000 employees in 10 states involved in de-tasseling efforts.

"That's a fairly significant population that's at risk for sun exposure," Graaf said, "so we offered to partner with Pioneer and offer them material developed by the CDC called 'Choose Your Cover.' "

Pioneer printed it and distributed it to its worksites. Graaf hopes these efforts will increase awareness about the dangers of sun exposure.

Under a legislative mandate, the Iowa Department of Public Health completed a study of comprehensive cancer control. Based on the findings, Graaf learned that while the new case rates for skin melanoma are relatively low in Iowa compared with other cancers, the new case rates have increased in the past five years. Although the rate of new cases is still low, the death rate for melanoma is relatively high.

Graaf believes melanoma may be emerging as a more aggressive form of cancer with a significant health burden on the state.

Clinical research

"One of the more challenging things about melanoma [and skin cancer in general] is that it's thought of as being a disease of elderly individuals," said Peggy Esper, MSN, CS, RN, an advanced oncology certified nurse and a nurse practitioner in the Department of Medical Oncology at the University of Michigan Comprehensive Cancer Center in Ann Arbor.

Melanoma, however, is a disease or type of malignancy that has no preference for age. A majority of patients are men aged 25 to 55.

"In looking at the statistics for cancer," Esper said, "you see most of the malignancies have leveled off and we're not seeing the increases in incidence rates that we had seen in previous years except for melanoma and non-Hodgkin's disease lymphoma.

In addition to clinical trials research looking at different therapies under investigation for patients with stage III and IV melanoma, Esper is conducting her own study. She has seen an inordinate number of melanoma patients with a previous history of hypothyroidism and questions whether the disease may be related to thyroid function or medication.

By carrying out a retrospective chart review, Esper is trying to find a commonality that will provide insight into factors that cause or contribute to the development of melanoma.

"When it comes to research, the reality is that you can see the potential for a drug to help people," Hill said, "and I've seen it."

She recalls a female patient with advanced T-cell lymphoma who had large, visible tumors. As a result of research protocols and drugs, the tumors subsided. "She's now a functioning member of society," Hill said. "She goes out to eat. She's not a recluse."

At M.D. Anderson, Hill is the study coordinator for research protocols concerning cutaneous diseases, including T-cell lymphoma and basal cell carcinoma. That research is aimed at discovering what will put the disease in remission or at least give patients with end-stage disease a better quality of life.

Skin cancer research doesn't receive the publicity that other types of cancers do, some specialists say.

"We are not a glamorous specialty," Hill said. "I tell people dermatologic diseases or skin diseases are not acceptable diseases in our society."

But the fact remains that skin cancer can be difficult to detect.

"Melanoma can be a little black or discolored mole that is ignored and by the time it's noticed," Hill said, "the patient has disseminated disease."

As for Barbara, four years have passed. She has an excellent prognosis, most likely the result of early diagnosis and treatment. "Occasionally, we reflect on what might have been," Tawa said, " but we remind ourselves that listening to the patient changed the course of events."

Contact Joan Sosin at joansosin@aol.com