By Darrell Hulisz, RPh, PharmD
Associate Professor, Department of Family Medicine
Case Western Reserve University, School of Medicine
In the United States, skin cancer is the most common form of malignancy, and is diagnosed in about 1 million Americans each year (Glanz, et al. 2008).
There are various types of skin cancer, such as basal cell (BC) and squamous cell (SC) carcinoma. Malignant melanoma (MM) is a form of skin cancer that carries a much higher mortality rate than BC or SC. Although melanoma accounts for only 5-6% of skin cancer diagnoses, it is accounts for about 75% of the mortality due to skin cancer (US Preventive Services Task Force (USPSTF), 2009). Melanoma, BC and SC carcinoma are caused by exposure to ultraviolet (UV) light, mostly from excessive sunlight. The incidence of skin cancer is increasing, though it considered one of the most preventable types of cancer (Lazovich, et al, 2008). Squamous cell carcinoma is more likely to become metastatic than BC, but still only about 3-4% of cases metastasize (Stulberg, Crandell & Fawcett, 2004).
The main risk factors for developing skin cancer include a history of severe sunburn and intense intermittent exposure to the sun at an early age. Patients with cutaneous lesions that may possibly be pre-malignant, such as actinic keratoses are also at risk. Other risk factors include lighter skin color, family or personal history of skin cancer, skin that burns, freckles or reddens easily in the sun. Less established risk factors include having blue or green eyes, blond or red hair, certain types and a large number of moles. The main skin cancer preventive strategy is to reduce UV radiation exposure, especially in those at risk. All individuals should adopt effective sun protection habits, such as wearing sunscreen, hats, shirts, and sunglasses. Pharmacists should counsel patients on proper use of sunscreens and encourage patients to limit or abstain from using indoor tanning equipment, especially if risk factors are present.
Both healthcare providers and patients share responsibility for routine examination of the skin. The arms, face, back and upper chest are of particular concern. Patients may present with complaints of moles or skin lesions that have changed, relative to their original size, shape or color. Patients may also experience some local discomfort, bleeding, or notice a lesion that does not heal.
Basal cell carcinoma can appear to be waxy, translucent, or pearly, whereas SC cancer often presents as an indurated nodular tumor with or without keratinization. Pharmacists should refer these patients to their primary care provider, or a dermatologist for medical examination. A biopsy is usually necessary to confirm any suspected cutaneous malignancy. A simple ABCDE mnemonic has been used to aid in the early detection of malignant melanoma: Asymmetric moles, Border irregularity, Color variation, Diameter > 6mm, Evolving moles (Lang, 2002).
Treatment for skin cancer is primarily surgical. A variety of surgical techniques are used, depending on the type, extent and stage of malignancy, as well as location. These include curettage, cauterization, and cryosurgery with liquid nitrogen and radiotherapy. Basal cell carcinoma can be treated with topical agents, such as 5-fluorouracil 5% cream (5-FU) and imiquimod. Topical 5-FU is an antineoplastic antimetabolite that is applied twice daily to the lesion. Treatment results in an inflammatory response consisting of erythema, vesiculation, desquamation, erosion, and re-epithelialization. Patients are treated for three to six weeks but may be as long as 10 to 12 weeks. Topical therapies are generally not used for SC carcinoma, as it is usually treated surgically (Wong, Strange & Lear, 2003).
Pharmacists and pharmacy personnel are in a great position to educate patients on the importance of minimizing solar exposure to decrease the risk of skin cancer. They can also promote regular skin self-exams, teaching patients to pay careful attention to moles, especially those with changing border shapes and sizes, or those that bleed or itch. Pharmacists should refer patients back to their primary care physicians in the event that suspicious lesions are detected.
References:
Glanz K, Yaroch AL, Dancel M, Saraiya M, Crane LA, Buller DB, Manne S, O'Riordan DL, Heckman CJ, Hay J, Robinson JK. Measures of sun exposure and sun protection practices for behavioral and epidemiologic research. Arch Dermatol 2008;Feb;144(2):217-22.
Lang PG. Current concepts in the management of patients with melanoma. Am J Clin Dermatol 2002;3:401-426.
Lazovich D, Stryker JE, Mayer JA, Hillhouse J, Dennis LK, Pichon L, Pagoto S, Heckman C, Olson A, Cokkinides V, Thompson K. Measuring nonsolar tanning behavior: indoor and sunless tanning. Arch Dermatol 2008;Feb;144(2):225-30.
Stulberg DL, Crandell B, Fawcett RS. Diagnosis and treatment of basal cell and squamous cell carcinomas. Am Fam Physician 2004;70:1481-1488.
U.S. Preventive Services Task Force. Screening for skin cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009;Feb 3;150(3):188-93.
Wong CM, Strange RC, Lear JT. Basal cell carcinoma. BMJ 2003;327:
794-798.
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