No matter your specialty, at some point you will examine, radiate, puncture, prep, drape, dress, suture, inject, medicate, or place electrodes on a patient’s skin. And paying attention to abnormalities on your patients’ skin may save lives and protect you from potential liability.
One in five Americans will develop skin cancer in their lifetime—melanoma is the most common form of cancer for young adults ages 25 to 29 and the second most common form of cancer for adolescents and young adults ages 15 to 29. However, the five-year survival rate for melanoma diagnosed before spreading to the lymph nodes is 98 percent.1 Because early diagnosis is key, all doctors should act upon unusual or ominous lesions or moles on patients’ skin. Suspicious spots should trigger a referral to a dermatologist, because the urgency of the situation can only be determined by expert examination and biopsy.
This case study illustrates the importance of early detection and treatment. A 64-year-old male patient with a history of squamous cell carcinomas saw his internist for evaluation of a left shoulder lesion. The doctor thought it appeared consistent with another squamous cell carcinoma. He attempted to remove the lesion via cryotherapy and planned excision if it grew back. A recurrence appeared at six months, along with an additional lesion on the back. The medical record notes an offer to freeze the recurrent lesion one more time before excision would be needed.
Two months later, although no documentation was found in the record, the doctor said he informed the patient that the lesion needed to be excised, but the patient said he was too busy, so a third cryotherapy was performed. After being followed for other conditions over two years, the shoulder lesion was finally re-examined and excised, resulting in a diagnosis of invasive malignant melanoma. A PET-CT scan showed an isolated left upper lobe lesion confirmed to be a metastatic melanoma, which was wedge resected and treated with Leukine. The patient later developed vision changes from another solitary lesion in the visual cortex, which was resected. A repeat PET-CT scan showed a nodule in mediastinum. Despite additional therapy, the patient succumbed to the disease within months. This case highlights several issues, including inadequate assessment, failure to rule out an abnormal finding, delay in diagnosis, failure to obtain a consult, and insufficient and delayed documentation of history and clinical findings.
When you refer patients for evaluation of unusual lesions, you should also be prepared to inform patients about skin cancer risks and how early detection can mean more effective treatment. Voicing your concern, referring to a specialist, and providing information takes only a few minutes of your time but can make a big difference if a patient has undiagnosed melanoma. You should also ensure you have a mechanism in place to alert you if the consultation report is not received back from the specialist in a timely manner.
In addition, you should discuss skin cancer risks with all your patients when appropriate. Encourage your patients to examine their skin head-to-toe once a month, looking for suspicious lesions or other changes. Self-exams are important for identifying potential skin cancer early.
When appropriate, educate your patients about what to look for while performing self-exams. Brown spots are usually harmless, but not always. Having more than 100 moles puts a patient at greater risk for melanoma. While many melanomas develop in areas exposed to the sun, they also develop in areas that are usually hidden from the sun. Be sure to examine the areas between the toes, underneath the nails, the palms of the hands and soles of the feet, and the eyes.
Lina Feaster, MD, a family practice physician in St. Augustine, Florida, emphasizes the need for awareness: “I once found an unusual dark spot on the sole of a 12-year-old’s foot during a complete skin exam as part of a routine well-child physical. I sent the patient to a dermatologist for biopsy, which confirmed melanoma. Having caught this early, his life was spared from this particular lesion. I have never forgotten how important it is to watch out for melanomas not only in adults but also in children. Performing a complete skin exam entails not just examining sun-exposed areas, but also locations you’d least expect to find melanoma, like the sole of a foot.”
Here are the “ABCDEs” to look out for in moles or other skin lesions—if you or your patient notices any of these, refer the patient to a dermatologist for immediate follow-up:
You should also be aware of melanoma risk factors in order to identify patients who may be at higher risk:
Encourage all your patients to wear protective clothing and a sunscreen of at least SPF 30 when going out into the sun. Your patients can also take advantage of educational resources from the Skin Cancer Foundation at www.skincancer.org.
1. Skin cancer. American Academy of Dermatology. https://www.aad.org/media-resources/stats-and-facts/conditions/skin-cancer. Accessed March 19, 2015.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.