Two out of three Australians will be diagnosed with skin cancer in their lifetime, with approximately 16,000 individuals diagnosed with Melanoma each year.
In this post, we will brush up on how as skin health professionals we assist to educate about the dangers of cumulative UV sun damage and the role we can potentially play in the early detection of skin problems.
What is skin cancer?
According to statistics, Australia has one of the highest rates of skin cancer in the world. With one in three people living with skin cancer, this is the most common cancer affecting Australians. The size of the issue to the health care system is considerable with over 700 million dollars in health care funding associated with hospitalisations due to non-melanoma skin cancer and according to medicare records more than 100 million treatments or about 100 per hour (Sunsmart Australia, 2022). Melanoma is the third most common skin cancer with 16,000 individuals diagnosed each year, it is the most common cancer affecting young people from 20-39 years of age.
Skin cancer is defined as the uncontrolled growth of abnormal cells in the skin. The most common cause for the development of skin cancer is prolonged UV exposure and damage to the skin cells. Skin cancer becomes more common as we age due to the decline in the capacity of our bodies to repair that cellular damage as well as for our immune system to identify abnormal cells.
There are three main types of skin cancer. These are Melanoma and the two non-melanoma skin cancers (NMSC's), basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). This post will focus on presenting a brief overview of skin cancers with information on how to identify who is at risk, what to do if you identify something that is atypical in your clients and how you can engage in further education.
Basal Cell Carcinoma (BCC)
BCC's are the most common form of skin cancer and present most commonly on the upper body and face. They are slow growing and because of this are associated with being less 'dangerous' or having the lowest mortality rates.
These are usually associated with presenting as red, pale or pearly coloured lesions or lumps and may also appear dry and scaly. They can become ulcerative or look like a sore that does not heal or heals and breaks down again.
Dermatoscopy can be used by those trained in this technique to view lesions that may assist to identify features of pigmented and non-pigmented lesions. For more information, you may want to read an overview of dermoscopy of BCC's
Dermoscopy of basal cell carcinoma - DermNetnz.org
Images courtesy of DermNetnz.org
Squamous Cell Carcinoma (SCC)
SCC's are also most associated with areas of the body with prolonged UV exposure. They grow over a period of months and if untreated can metastasise to other areas of the body.
These skin cancers tend to be red, scaly, crusty, and thickened lesions that may bleed quite easily. SCC's can also be associated with or develop from actinic keratoses.
Images courtesy of DermNetnz.org
This form of skin cancer is the most life-threatening. While it can occur on non-sun-exposed areas of the body, 95% of melanomas are associated with UV overexposure. If melanomas are detected early, many of these can be cured through surgery, however, if left undetected they can metastasise quite quickly to other areas of the body. Pigmented lesions are monitored for skin changes using the ABCDE rule as a guide for a skin examination.
It is important to be aware that melanoma can be non-pigmented and also nodular and doesn't always follow the ABCDE rules. So for skin changes, anything that is changing quickly hasn't healed in 4-6 weeks or causes concern should be checked.
Images courtesy of DermNetnz.org
Role of skin checks in skin surveillance for skin changes?
Population-based screening for skin cancer is not currently recommended due to a lack of evidence to support that implementation of this would reduce mortality or morbidity. A recent research review provides an overview of how early detection of skin cancer is approached in Australia currently as well as opportunities for the future particularly as technologies emerge and consumers are more aware of the risks of skin cancer.
Due to the prevalence of skin cancer, it is recommended that we should all know how to monitor our own skin for changes and seek skin checks if there are concerns. This is termed opportunistic skin screening. There are also recommendations based on risk factors for skin cancer development on when we should start checking our skin, how often, and who can support us with skin checks.
Risk for skin cancer development
The Royal College of General Practitioners has published a stratified risk rating and protocol for skin checks in primary practice. This is a tool that can be used by skin health professionals to support educating clients as well as when making decisions regarding performing procedures that involve possible removal of markers for skin cancer monitoring.
Risk for skin cancer development
Encourage 3 monthly self examination and 6-12 monthly skin checks with a doctor
Fitzpatrick I age 25-45 years
Fitzpatrick II age 45-65 years
Fitzpatrick III age more than 65
Family history of NMSC
Multiple episodes of sunburns with blistering
more than 20 solar keratoses
Encourage 3-6 monthly self examination and opportunistic checks with a doctor. This is to seek advice if any lesions are of concern.
Average to low risk
Fitzpatrick I less than 25 years
Fitzpatrick II less than 45 years
Fitzpatrick III less than 65 years
Fitzpatrick IV and V skin
Encourage self examination annually and opportunistic skin checks with a doctor
Sinclair. R. (2012) Skin Checks. Australian Family Physician. 41(7) 464-469
Arasu.A., Meah. N., & Sinclair. R. (2019). Skin checks in primary care. The Australian Journal of General Practice. 48(9), 614-619
Who can perform skin checks?
Sun Smart Australia has an information sheet that is used to guide the public with advice on who can perform skin checks and questions to ask.
As a skin health professional, you may also receive questions or want to know who can assist with skin checks.
Dermoscopists - These are often nurses or dermal clinicians with post-graduate qualifications in the field of dermoscopy. They assist with education about skin cancer risk, performing full-body skin checks, and digital imaging of lesions for surveillance purposes. They will provide a report and referral if any lesions require medical review or follow-up.
Skin Cancer GPs - Many general practitioners perform opportunistic skin cancer screenings as part of their routine practice. There are also general practitioners who have undertaken significant further education in the assessment, diagnosis and management of skin cancer. The Skin Cancer College of Australasia accredits skin cancer doctors and also provides a locator service to assist with finding an accredited skin cancer GP.
Dermatologists - A dermatologist is a medical professional who has undertaken an extra four years of specialist training in the assessment, diagnosis and management of up to 3000 disorders and diseases that affect the skin, hair, and nails. Usually, you will require a referral to see a dermatologist and they work with other medical specialties such as plastic surgeons, cancer surgeons and radiation specialists when required. You can read more about when to see a health professional with advice from the Australasian College of Dermatologists HERE.
As skin health professionals what role do we play?
As skin health professionals that often see our clients regularly and over long periods of time we have a role to play in skin screening and observing for skin changes. Through being well educated in skin cancer risk, detecting skin cancer, and understanding the medical pathways for diagnosis and treatment we can assist with early detection of skin cancer. This may assist to reduce mortality as well as morbidity such as more significant scarring that can result from delayed diagnosis requiring more extensive surgical removal.
Where can you get more education?
There are a few ways to increase your knowledge and skill set in monitoring for skin cancer depending on your current qualifications and clinical setting.
The Skin Cancer College of Australasia recently developed introductory training modules for anyone that works with or sees skin regularly including beauty therapists and hairdressers. As well as for medical professionals, nurses, and allied health professionals including dermal clinicians that are new to the field of skin cancer. From there depending on your background you may be able to complete further advanced training. This applies to allied health professionals including dermal clinicians, nurses, and medical professionals.
There are also other training organisations such as HealthCert that provide professional education and certification in dermoscopy for dermal clinicians and dermal therapists. As ASDC members you are also eligible for discounts when undertaking these programs. More information is in your member portal.
Education about reducing UV exposure
Skin health professionals play an important role in educating and supporting behaviour changes to reduce the risk of skin cancer development.
How to perform self-skin examinations
The infographic below was developed by students and staff of Victoria University and shared with the Australian Society of Dermal Clinicians to assist skin health professionals with educating clients or assisting them with performing skin checks.
Caution regarding treatments that may alter or remove markers for skin cancer diagnosis
There has been concern raised by medical professionals about treatments that are performed for cosmetic purposes by skin health professionals that can remove or alter markers that may be used to monitor the skin for changes or skin cancer development.
It is advised that all skin health professionals that perform these types of treatments seek further education and knowledge in order to undertake risk assessment about the patient's risk for skin cancer development in the future or underlying yet undiagnosed skin cancers and their suitability for treatment. It is important to be confident in educating clients about any risks as well as appropriate referral pathways when required.
The ASDC recommends using the skin cancer development risk matrix for decision-making regarding the suitability of clients for services. As well as implementing clinic policy or recommendations to provide evidence of a medical skin cancer screening before any further treatment as well as referral pathways for clients with increased or high-risk factors.
Guidelines to inform practice
For more information on current best practice recommendations and guidelines for melanoma and non-melanoma skin cancer diagnosis and management, there are many resources on the Cancer Council and Sun Smart websites.
Cancer Council. Skin cancer incidence and mortality [Version URL: https://wiki.cancer.org.au/skincancerstats_mw/index.php?title=Skin_cancer_incidence_and_mortality&oldid=802, cited 2023 Mar 4]. Available from: https://wiki.cancer.org.au/skincancerstats/Skin_cancer_incidence_and_mortality. In: Cancer Council Australia. Skin Cancer Statistics and Issues. Sydney: Cancer Council Australia. Available from: http://wiki.cancer.org.au/skincancerstats/
Cancer Council. Skin cancer types [Version URL: https://wiki.cancer.org.au/skincancerstats_mw/index.php?title=Skin_cancer_types&oldid=806, cited 2023 Mar 4]. Available from: https://wiki.cancer.org.au/skincancerstats/Skin_cancer_types. In: Cancer Council Australia. Skin Cancer Statistics and Issues. Sydney: Cancer Council Australia. Available from: http://wiki.cancer.org.au/skincancerstats/
The information in this document is of a general nature only and is not, and is not intended to be advice. Before making any decision or taking any action, you should consult with appropriate accounting, tax, legal or other advisors. No warranty is given as to the correctness of the information contained in this publication, or of its suitability for use by you. To the fullest extent permitted by law, the Australian Society of Dermal Clinicians Inc. (ASDC) is not liable for any statement or opinion, or for any error or omission contained in this publication and disclaims all warranties with regard to the information contained in it, including, without limitation, all implied warranties of merchantability and fitness for a particular purpose. ASDC is not liable for any direct, indirect, special or consequential losses or damages of any kind, or loss of profit, loss or corruption of data, business interruption or indirect costs, arising out of or in connection with the use of this publication or the information contained in it, whether such loss or damage arises in contract, negligence, tort, under statute, or otherwise