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Case Reports |
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) (mwills{at}one-eleven.net)
Submitted January 22, 2002;
Accepted June 29, 2002
 | Abstract |
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Key Words: Dermatology • Screening • Skin cancer
| Introduction |
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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
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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.
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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.
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| Case Description |
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TopAbstractIntroductionCase DescriptionDiscussionReferences |
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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
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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 |
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TopAbstractIntroductionCase DescriptionDiscussionReferences |
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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 Litaker19 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 al20 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.21
Boissonault22 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 Boissonault22 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.
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This article has been cited by other articles:
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  S. K Carter and J. A Rizzo Use of Outpatient Physical Therapy Services by People With Musculoskeletal Conditions Physical Therapy, May 1, 2007; 87(5): 497 - 512. [Abstract] [Full Text] [PDF]
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