Skin cancer

3 Skin cancer

Saskia Reeken RN MSc

The incidence of skin cancer in the UK is rising: in 2016–2018 there were around 156000 new cases of non-melanoma skin cancer per year (a 42% increase over the last decade) and 16700 new cases of melanoma skin cancer per year (a 32% increase over the last decade).1,2 Furthermore, as basal cell carcinoma is not included in cancer registry data, exact numbers are likely to be higher. In 2017, melanoma skin cancer was the fifth most common cancer in the UK, accounting for 4% of all new cancer cases, and the incidence is predicted to continue to rise by 7% between 2014 and 2035.2

Nursing role

Nurses working in skin cancer have traditionally come from a dermatology or plastic surgery background. However, with the arrival of targeted treatments and immunotherapy, particularly for melanoma, the number of melanoma oncology and research nurses joining the specialty has increased.

Most nurses working in skin cancer are clinical nurse specialists (CNS), a role that became more common after publication of a National Institute for Health and Care Excellence (NICE) cancer service guideline entitled Improving Outcomes for People with Skin Tumours Including Melanoma. 3 Subsequent skin cancer measures published through the Quality Surveillance Programme included a requirement for all patients with a skin cancer diagnosis to have access to a skin cancer CNS. This resulted in the recruitment of skin cancer CNSs in all UK hospitals. The role can vary according to service needs, and in many places it is still evolving.

Many of the skin cancer nursing roles are sponsored by Macmillan and those CNSs will have Macmillan as part of their title. As in many areas of specialist nursing practice, titles and roles may vary, for example: • skin cancer CNS (with or without Macmillan prefix) • melanoma CNS (with or without Macmillan prefix) • skin cancer advanced nurse practitioner • skin cancer nurse consultant.

Scope of practice. The Agenda for Change (AfC) banding awarded to nurses specialising in this field in the UK has been inconsistent. The BDNG role descriptors provide some generic guidance in this area

(see page 12) and should help to improve consistency around the country.4 Most are employed at CNS level, AfC band 7, and have: • a qualification at Masters level (MSc), or are working towards one • an expert knowledge base (educators) • the ability to work autonomously • complex decision-making skills and clinical competences for extended practice • the ability to manage their own caseload • the ability to apply evidence-based holistic care • an independent prescribing qualification • research skills.

The high level of independent decision-making required means that a skin cancer CNS must work at band 7 or 8. As in other fields of dermatology nursing, the greater the level of independent decisionmaking, particularly around diagnosis and planning and evaluation of therapeutic interventions, the higher the grade. A band 7 CNS will be involved with skin cancer screening and will work independently in complex clinical situations that require liaison and initiative. Undertaking more advanced roles, such as diagnosis, should be reflected by a higher grade of band (8a or above). Figure 3.1 summarises the CNS’s roles and responsibilities.

The patient care setting. Patients with skin cancer are seen in a variety of settings, including chemotherapy units, research departments, outpatient clinics and hospital wards. The skin cancer CNS will usually work within a local skin cancer MDT or specialist skin cancer MDT (there are only two melanoma MDTs in the UK at hospitals that provide specialised melanoma services) comprised of dermatologists, plastic surgeons, histopathologists, medical/clinical oncologists and an MDT coordinator. The MDT discusses each patient with a skin cancer diagnosis and devises a treatment plan. The CNS may sometimes lead the MDT, but primarily advocates for patients and supports both patients and the team.

Supportive role. Any patient who receives a cancer diagnosis will have a variety of responses, ranging from the relief of knowing what the problem is/having a diagnosis to despair. It is essential that patients are given clear and comprehensive information to enable

Core MDT member/leadership within the MDT and wider cancer team

Advanced communication and advocacy skills

In-depth knowledge of tumour area Education/ information

Acting as a key worker across the whole pathway

Autonomous practice

Skin cancer clinical nurse specialist

Innovation, project and change management

Excellent decisionmaking skills Advanced clinical and diagnostic skills

Auditor/ researcher

Empathy for patients and their families

Ability to assess patients' holistic needs

Figure 3.1 The roles and responsiblities of the skin cancer CNS are wide and depend on the individual’s competence level/band.

them to make sometimes complex decisions. Empathic support during such a consultation is key to helping patients face their treatment pathway and follow up. In many services, it is the CNS who provides this support and continuity of care (see page 47).

The CNS is usually appointed as the patient’s ‘key worker’ to help them (and those supporting them) make sense of their diagnosis and treatment options, and explain the potential effects of both the disease and the available treatments (Table 3.1).

TABLE 3.1

Supportive role of the key worker/CNS

• Provides contact details • Provides reassurance and one-to-one care/emotional support • Helps patient to understand and get through their treatment, including management of side effects or symptoms • Supports patient while in hospital or attending outpatient clinics • Ensures good communication between the patient and the MDT • Liaises with and facilitates communication with and between the patient’s family and other members of the healthcare team (e.g. primary care provider, community nurse, palliative care team, social worker) • Provides details of support groups and other useful organisations • Provides details of how to access benefits and financial and welfare advice

Core competencies

The core competencies for nurses working in the field of skin cancer are split over six domains: • an underpinning knowledge that supports professional practice • assessment and investigation • therapeutic interventions and radiological investigations • caring for the patient • understanding and managing the psychological effect of living with skin cancer • patient education and health promotion.5

Each of these competencies is divided into three levels. • Level 1: nurses new to skin cancer, who may be limited to supporting more senior colleagues and doctors in the provision of patient care. • Level 2: competent nurses with a minimum level of knowledge and expertise in varied roles, depending on service needs. • Level 3: specialist nurses in a diverse range of roles, including nurse-led services.

Competence levels are developed over time through education (often to MSc level in a relevant specialist area) and practice. Competence is assessed in a variety of ways, including self-assessment, peer review and case-based discussions. Direct observation of procedural skills (DOPS) and mini clinical evaluation exercises are also important to assess competence in specific practical skills and clinical encounters with patients, respectively.

Knowledge. Nurses working in skin cancer must demonstrate awareness, knowledge and understanding (depending on competence level) of benign and malignant skin lesion recognition, nonmelanoma and melanoma epidemiology (including risk factors and causes), and national/local guidelines and policies in relation to clinical practice. The skin cancer CNS should have a comprehensive knowledge in all these areas, as well as the ability to critically discuss and disseminate the knowledge to others.

Assessment and investigation. In the UK, individuals are referred on a 2-week wait pathway by primary care providers to dermatology clinics designated to deal with cancer referrals. The healthcare professionals who run these clinics, including the CNS, aim to assess, diagnose and plan treatment/investigation or reassure and discharge.

Patient history. Risk factors for skin cancer include fair complexion, freckles, red/blond hair and blue eye colour, inability to tan, a history of prolonged sun exposure and/or severe sunburn and high sunbed use. In addition, people with multiple normal or atypical nevi (moles) may be more at risk. Some people may have a genetic predisposition for skin cancer, or may have other medical conditions (for example, if they are immunosuppressed) that put them more at risk. The CNS must take all these factors into consideration when taking the patient’s history, as well as finding out the history of the lesion itself – how long the patient has had it and whether it has changed during that time.

Lesion assessment. Dermoscopy (or dermatoscopy) is examination of the skin using skin-surface microscopy. It allows for inspection of skin lesions unobstructed by skin-surface reflections, enabling the CNS

to differentiate benign lesions from premalignant and malignant lesions (Figure 3.2).

Further investigation. For all suspected malignant skin lesions, a biopsy will confirm the diagnosis. The CNS will prepare and support patients undergoing further investigation of skin lesions and, depending on competence level, will either perform the relevant surgical intervention or refer the patient to another member of the MDT. For more information on skin surgery see Chapter 4. Biopsy results are interpreted and actioned in liaison with the MDT, and will enable staging of melanoma according to the 8th editions of the Union for International Cancer Control’s tumour-node-metastasis (TNM) classification of malignant tumours and the American Joint Committee on Cancer (AJCC) melanoma staging system.5,6 A holistic needs assessment (HNA) should also be performed after diagnosis.

(a) (b)

(c) (d)

Figure 3.2 Examples of benign and malignant lesions. (a) benign compound nevis; (b) premalignant actinic keratosis on patient’s forehead; (c) malignant lentigo maligna melanoma on a sun-exposed area; (d) malignant superficial spreading melanoma.

Therapeutic interventions. The management of melanoma and non-melanoma skin cancer is subject to national guidelines.7–13 Skin cancer nurses must demonstrate understanding of different therapeutic options for patients within the MDT setting. Treatment can be complex and many factors, including the different treatment modalities and their side effects, risks, benefits, expectations of treatment and trial options, need to be considered and discussed with the patient. The skin cancer nurse plays an important part in guiding and supporting the patient and family through the appropriate information at what is inevitably a difficult time and helping them to make informed treatment choices, while fostering trust and rapport.

Skin cancer nurses of band 8 or above may plan and administer treatment, as well as mentoring colleagues who are learning new procedural skills. Excisional surgery is the gold standard for the treatment of most established skin cancers (see Chapter 4), but there are also several non-surgical options (Table 3.2). An important element of the skin cancer nurse’s role is to support patients through the side effects of treatment, which in some cases may be life threatening.

TABLE 3.2

Non-surgical treatments for premalignant and malignant skin lesions*

Topical therapies • Used to treat premalignant and non-melanoma skin cancer • Chemotherapy (e.g. 5-fluorouracil) or immunotherapy (e.g. imiquimod) creams • Side effects include redness and tenderness, flaking, peeling, crusting and itching Cryotherapy • Used to treat actinic keratoses (premalignant lesions) • Application of liquid nitrogen to the skin to freeze and destroy precancerous cells • May need more than one treatment; may leave small white scar on skin

CONTINUED

TABLE 3.2 CONTINUED

Curettage and electrocautery • Used to treat some non-melanoma skin cancers • After injection of local anaesthetic, lesion is scraped off with curette and heat is applied to wound surface • Takes 2–3 weeks to heal; often leaves a scar Photodynamic therapy • Used to treat some non-melanoma skin cancers • Combines a light-sensitive drug with light treatment to optimise cancer cell death • Side effects include stinging/burning during treatment and redness/ swelling for several days after treatment; final cosmesis is good Radiotherapy • Used to treat some non-melanoma skin cancers in areas where surgery may be difficult or if resection was incomplete or close to margin in difficult-to-treat anatomical areas • Number and duration of sessions vary depending on histology and site of lesion • Side effects include redness and swelling for up to 1 month after treatment; may cause scarring • Can be used in melanoma brain metastases to control symptoms, but not with curative intent Targeted systemic therapies (see Chapter 6) • Oral treatment for advanced non-resectable melanoma in patients with certain gene mutations (e.g. in BRAF, MEK genes) • Slows growth of tumour and prolongs survival; may also be used after surgery (adjuvant therapy) to reduce risk of recurrence • Combinations of drugs may be given • Common side effects include rash, nausea, diarrhoea, itching and sensitivity to sunlight • Less common but serious side effects include bleeding, infections, and heart, liver and eye problems

CONTINUED

TABLE 3.2 CONTINUED

Non-surgical treatments for premalignant and malignant skin lesions*

Immunotherapy • Used to treat advanced non-resectable melanoma; may also be used as adjuvant treatment after surgery to reduce risk of recurrence • Helps the body’s immune system to recognise and kill cancer cells • Immune checkpoint inhibitors (e.g. pembrolizumab, nivolumab, ipilimumab) are given as multiple infusions every few weeks over several months • Common side effects include fatigue, cough, nausea, rash, poor appetite, constipation, joint pain and diarrhoea • Serious side effects include allergic infusion reactions and lifethreatening autoimmune reactions (organ-related problems) • T-VEC (talimogene laherparepvec) ia an oncolytic virus therapy, injected directly into melanoma in the skin or lymph nodes every 2 weeks; common side effects include fatigue, pain at injection site and flu-like symptoms Chemotherapy and electrochemotherapy • Used to shrink advanced melanoma, usually as second-line treatment after immunotherapy or targeted drugs; administered orally or by injection • Isolated limb perfusion or isolated limb infusion can be used under general anaesthetic to confine high doses of chemotherapy to a single limb (reduces side effects). Side effects depend on type of drug (or combination of drugs) and dose, but include fatigue, hair loss, mouth ulcers, nausea and vomiting, diarrhoea or constipation, loss of appetite, increased risk of infection, and bleeding and bruising • Electrochemotherapy, usually given under general anaesthesia, combines low-dose intravenous chemotherapy with a small electrical current applied directly to a tumour; with the electrical current, lowerdose chemotherapy can penetrate the cancer cells more easily

*Non-exhaustive list: new treatments and/or combinations are always in development.

Caring for the wellbeing of the patient. Patients’ need for information varies and may change at different points of their cancer pathway. It is important to address their concerns and fears, involve them in the decision-making process, and help to promote patient wellbeing and quality of life. In addition to physical treatments, all patients with a diagnosis of squamous cell carcinoma (SCC) or melanoma are offered an HNA as part of a ‘recovery package’. The HNA, which is usually offered at diagnosis and at different points in the patient care pathway, is a discussion about the patient’s physical, psychological, spiritual and social needs. It can be carried out by any member of the MDT, but it is usually part of the CNS’s role. It can help to address specific concerns and needs and allows an individual care plan to be developed that may include signposting and referral to additional support services.

Patient education and health promotion. It is important for the CNS to identify factors that may be detrimental to the patient’s health (for example, reasons for non-adherence to treatment) as well as building the patient’s self-esteem and confidence and actively promoting self-management options to empower them. Health promotion should include information on: • sun protection • self-examination of skin and, if appropriate, lymph-node basins • other family members’ risk of skin cancer • vitamin D3 supplementation • healthy living • organ/blood donation • additional support: for example, financial services • survivorship.

Communication skills

All members of the MDT who deliver cancer diagnoses, including the skin cancer CNS, are required to attend an ‘advanced communication course’, usually facilitated by various local cancer alliances (Table 3.3). Healthcare professionals tend to have limited training in this area, particularly in relation to delivering ‘bad news’. This can make it a poor experience for patients and their families, compromising therapeutic relationships.

TABLE 3.3

Key aspects of an advanced communication course

• Increases awareness of the participant’s own communication skills • Explores strategies to improve the quality of clinical communication • Increases ability to deliver information effectively • Increases confidence in responding to difficult communication situations and enhances interpersonal communication • Provides the opportunity to work on real-life clinical challenges (the course is experiential and learner led) • Includes discussion of research on communication in cancer care, interactive exercises and role play in small groups with actors • Provides a safe and supportive environment to practise skills and receive feedback • Provides CPD points and a certificate on completion: the course is a peer-reviewed requirement for all MDT members seeing patients with skin cancer, led by accredited, nationally approved facilitators

CPD, continuing professional development.

Such conversations are also difficult for the healthcare professional. Every CNS working with patients with skin cancer (melanoma or SCC) will have access to clinical supervision with a trained psychologist or psychotherapist. This is a formal and mandatory process of professional support that enables the healthcare worker to share their feelings and discuss situations with peers in a supportive confidential environment.14

Challenges and opportunities

As the incidence of skin cancer continues to increase, services have generally struggled with capacity, especially complying with cancer waiting-time targets.15 Workforce challenges, including too few consultant dermatologists, have led to opportunities for the skin cancer CNS to develop more advanced roles and services. Specific roles in skin surgery are discussed in Chapter 4.

Given the many new therapies being developed to treat advanced melanoma, clinical trials of new or combination drugs are becoming

increasingly available to patients. This may mean expanded roles for the skin cancer CNS in identifying patients who are eligible for clinical trials and responding to researchers’ data requests, for example recording and reporting adverse events that occur while the patient is involved in the study. The CNS will be important in maintaining effective communication between patients, carers and all healthcare professionals involved in their care to ensure high-quality service delivery. Future trials evaluating survivorship and quality of life after new treatments may also involve the skin cancer CNS, for example in extended follow-up of patients and data collection.

Next steps

If you are interested in a career in skin cancer nursing, talk to a skin cancer CNS at any UK hospital; most will be happy to discuss the role and advise on where to find further information. Also consider joining the BDNG and British Association of Skin Cancer Specialist Nurses (BASCSN) for access to useful online resources, study days and conferences. The BDNG has a subgroup for skin cancer nurses, offering contact, support and training. Other useful resources to learn more about skin cancer are outlined in Table 3.4.

TABLE 3.4

Examples of useful resources for further learning

British Association of Skin Cancer Specialist Nurses www.bascsn.com

Cancer Research UK DermNet NZ Macmillan Cancer Support Melanoma Focus www.cancerresearchuk.org www.dermnetnz.org www.macmillan.org.uk www.melanomafocus.org

Melanoma UK

www.melanomauk.org.uk Primary Care Dermatology Society www.pcds.org.uk Skcin: The Karen Clifford Skin Cancer Charity www.skcin.org

Familiarise yourself with local and national skin cancer guidelines,7–13 and consider higher education options: for example, the MSc in skin lesion management at the University of Hertfordshire.16

Personal reflection

Working in skin cancer has been a very rewarding experience. I have been privileged to work in excellent MDTs, where patients’ interests were always at the centre of decision-making, but where it was also recognised that sharing expertise and knowledge and supporting each other was, and is, integral to a well-functioning service that benefits patients. I have also been fortunate to practise at a time when treatment options for melanoma have significantly changed, leading to better outcomes for patients. Although, because of these developments, discussions with patients have become more complex, as an advocate of patient choice it is immensely satisfying to help patients make informed decisions that are right for them.

As the incidence of skin cancer continues to rise, the role of the skin cancer CNS and advanced nurse practitioner will continue to be much needed. There will be many opportunities to expand roles, including involvement in national and local guidelines, with the possibility of influencing patient care policies.

Having been involved in some of the skin cancer MSc programmes, I strongly recommend taking the opportunity for academic learning to support clinical practice in this area, as it facilitates evidence-based practice and ultimately helps our patients.

I recommend joining the skin cancer nursing groups mentioned above, as peer support, sharing knowledge and meeting colleagues is so important, especially as, for some, the role can be an isolated one.

Key points – skin cancer

• Most nurses working in skin cancer are a CNS or advanced nurse practitioner at band 7 or above with or working towards an MSc academic qualification. • All patients with a skin cancer diagnosis should have access to a CNS; the CNS is usually appointed as the patient’s key worker to support them through diagnosis, treatment and follow up. • Underpinning knowledge that supports clinical practice includes recognition of benign and malignant skin lesions, awareness of non-melanoma and melanoma epidemiology, and an understanding of relevant guidelines and policies. • The skin cancer CNS is an integral member (sometimes leader) of the MDT, which determines the patient’s treatment plan. • The CNS must guide and support the patient and their family through surgical and non-surgical treatment options, including the management of side effects, which in some cases may be life-threatening (for example, the autoimmune reactions associated with immunotherapy). • Patient education and health promotion are vital. All patients with a diagnosis of SCC or melanoma are offered an HNA to discuss their physical, psychological, spiritual and social needs.

References and resources

1. Cancer Research UK. Non-

Melanoma Skin Cancer Statistics.

Cancer Research UK, 2016–2018. www.cancerresearchuk. org/health-professional/cancerstatistics/statistics-by-cancertype/non-melanoma-skincancer, last accessed 22 March 2022. 2. Cancer Research UK. Melanoma

Skin Cancer Statistics. Cancer

Research UK, 2016–2018. www. cancerresearchuk.org/healthprofessional/cancer-statistics/ statistics-by-cancer-type/ melanoma-skin-cancer, last accessed 22 March 2022.

3. National Institute for Health and Care Excellence. Improving

Outcomes for People with Skin

Tumours Including Melanoma.

Cancer Service Guideline [CSG8].

National Institute for Health and Care Excellence, 2006 (updated 2010). www.nice.org.uk/guidance/csg8, last accessed 22 March 2022. 4. British Association of

Dermatologists Education

Board. Clinical Dermatology

Nursing Role Descriptors:

Guidance on Scope of Practice.

British Dermatological Nursing

Group, British Association of Dermatologists and Royal

College of Nursing, 2020. bdng.org.uk/wp-content/ uploads/2020/08/BAD-

BDNG-RCN-NURSING-

WORKSTREAM-A4-

LANDSCAPE-002.pdf, last accessed 20 June 2021. 5. Keung EZ, Gershenwald JE. The eighth edition American Joint

Committee on Cancer (AJCC) melanoma staging system: implications for melanoma treatment and care. Expert Rev

Anticancer Ther 2018;18:775–84. 6. Brierley JD, Gospodarowicz

MK, Wittekind C, eds.

TNM Classification of

Malignant Tumours, 8th edn.

Wiley-Blackwell, 2016. 7. Keohane SG, Botting J,

Budny PG et al. British

Association of Dermatologists guidelines for the management of people with cutaneous squamous cell carcinoma.

Br J Dermatol 2021;184:401–14. 8. Marsden JR, Newton-Bishop JA,

Burrows L et al. Revised UK guidelines for the management of cutaneous melanoma 2010.

Br J Dermatol 2010;163:238–56. 9. National Institute for Health and Care Excellence. Melanoma:

Assessment and Management.

NICE guideline [NG14]. National

Institute for Health and Care

Excellence, 2015. www.nice.org. uk/guidance/ng14, last accessed 22 March 2022. 10. Nasr I, McGrath EJ,

Harwood CA et al. British

Association of Dermatologists guidelines for the management of adults with basal cell carcinoma 2021. Br J Dermatol 2021;185:899–920. 11. Newlands C, Currie R,

Memon A et al. Non-melanoma skin cancer: United Kingdom

National Multidisciplinary

Guidelines. J Laryngol Otol 2016;130(Suppl 2):S125–32. 12. Scottish Intercollegiate

Guidelines Network. SIGN 140: Management of Primary

Cutaneous Squamous Cell

Carcinoma. A National

Clinical Guideline. Scottish

Intercollegiate Guidelines

Network, 2014. www.sign. ac.uk/media/1094/sign140.pdf, last accessed 14 March 2022. 13. Scottish Intercollegiate

Guidelines Network. SIGN 146:

Cutaneous Melanoma. A National

Clinical Guideline. Scottish

Intercollegiate Guidelines

Network, 2017. www.sign. ac.uk/media/1082/sign146.pdf, last accessed 14 March 2022.

14. Hession N, Habenicht A.

Clinical supervision in oncology: a narrative review.

Health Pyschol Res 2020;8:8651. 15. NHS England. Cancer Waiting

Times. www.england.nhs.uk/ statistics/statistical-work-areas/ cancer-waiting-times, last accessed 24 March 2022. 16. University of Hertfordshire. MSc

Skin Lesion Management [course details]. www.herts.ac.uk/ courses/postgraduate-masters/ msc-skin-lesion-management, last accessed 2 April 2022.

Further reading and resources

Agnew KL, Bunker CB, Arron ST. Fast Facts: Skin Cancer, 2nd edn. S. Karger Publishers Ltd, 2013. Melanoma Focus [online]. www.melanomafocus.org Melanoma UK [online]. www.melanomauk.org.uk SKCIN: The Karen Clifford Skin Cancer Charity [online]. www.skcin.org

© S. Karger Publishers Ltd 2023