I‘ll U 1‘ HHHWl thl’ l HUI [H 136 776 TH _ PRIMARY CARE GUIDELINES FOR EARLY MELANOMA RECOGNITION ‘ Scholarly Projectfor the DegreeofMQSfi‘ -‘ MICHIGAN STATE UNIVERSITY DENISE A. CHIN‘NI ' ~ 2001 “' LIBRARY Michigan State University PLACE IN RETURN Box to remove this checkout from your record. To AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE 6/01 cJCIRClDatoDua.p65-p.15 PRIMARY CARE GUIDELINES FOR EARLY MELANOMA RECOGNITION By Denise A. Chinni A SCHOLARLY PROJECT Submitted to Michigan State University in partial fiilfillment of the requirements for the degree of MASTERS OF SCIENCE IN NURSING College of Nursing 200] ABSTRACT PRIMARY CARE GUIDELINES FOR EARLY MELANOMA DETECTION By Denise A. Chinni Malignant melanoma is a skin cancer with a prognosis ranging from being almost 100% curable to fatal. Early detection is crucial for a favorable prognosis. Since advanced practice nurses in primary care see many patients for acute conditions, they could potentially save numerous lives through early detection of malignant melanoma. By being knowledgeable of the risk factors and early signs and symptoms of melanoma, advanced practice nurses in primary care can quickly and easily integrate a limited but focused history and physical exam into the context of any primary care visit. The purpose of these guidelines is to provide the primary care advanced practice nurse with the knowledge necessary to detect suspicious skin lesions and refer to the appropriate specialists for follow-up. This scholarly project is dedicated to Scott Alan Murphy, October 16. 1955 - November 16, 2000. You are my beloved friend, lover, soul mate, and fiancee. iii ACKNOWLEDGMENTS I would especially like to thank my family members and fi'iends for their interest in, support for, and faith in my ability to complete this project. I feel truly blessed to have each and every one of you involved in my life. A very special thanks to Dr. Timothy Johnson. Your clinical expertise, exceptional talent in teaching. and unique ability to create an environment where one’s personal and professional strengths can flourish has been of immeasurable importance to me. A very special thanks to the entire cutaneous surgical oncology staff. Your encouragement and friendship have helped me in this endeavor more than you may ever realize. I would like to thank Linda Keilman. Your unending patience and guidance have made it possible for me to complete this project. You have given me both personal and professional support and I am gratefiil for that. You are truly a role model. I would also like to thank Kathy Dontje and Dr. Georgia Padonu for all of the work, guidance and support that you have given me. I would also like to especially thank Dr. John Gall. What you have taught me has influenced my personal and professional growth in ways that are beyond words. If I can give even a fraction of that to my clients, the world will be a better place. iv TABLE OF CONTENTS LIST OF FIGURES Introduction Problem Statement Purpose Conceptual Framework Description and Definition of Concepts Relevancy of the Theoretical Framework to the Guidelines Literature Review Summary Implementation Implications for Advanced Practice Nursing in Primary Care Educational Implications Practice Implications Research Implications Conclusion APPENDIX A APPENDIX B APPENDIX C BIBLIOGRAPHY vi 14 15 16 16 17 17 18 20 22 25 38 LIST OF FIGURES A Model Depicting the Relationship Between Four Basic Concepts of Orem’s Self-Care Deficit Theory A Model Depicting the Relationship Between the Melanoma Guidelines, the Advanced Practice Nurse in Primary Care, the Client, and Two Basic Concepts of Orem’s Self-Care Deficit Theory of Nursing Introduction Melanoma is a type of skin cancer that has the potential to produce devastating effects. Its rate of occurrence is rising faster than any other type of cancer (Rigel & Carucci, 2000; Rigel, Friedman, & Kopf, 1996). In 1935, l in 1500 persons developed melanoma over their lifetime. By 1980 that ratio increased to 1 in 250 (Rigel & Carucci, 2000; Rigel et al., 1996). It is estimated that by the year 2010, 1 in 50 persons will deveIOp melanoma (Rigel & Carucci, 2000). Melanoma is the fifth most common type of cancer (Johnson, Dolan, Hamilton, Lu, Swanson, & Lowe, 1998). Melanoma mortality rate is second only to lung cancer and second only to leukemia in average years of life lost due to death to disease in the United States. It is the most common type of cancer in women aged 25-29 and is second only to breast cancer in women aged 30-34 (Rigel et al., 1996). One person dies of melanoma every hour in the United States. Problem Statement The prognosis for persons with melanoma range from being almost 100% curable for melanoma in situ, to fatal, with the critical factor dependent on early diagnosis and correct treatment (Johnson, Smith, Nelson, & Chang, 1995). Primary care practitioners have a significant role in melanoma recognition (Stephenson, From, Cohen, & Tipping, 1997; Weinstock, Goldstein, Dube. Rhodes, & Sober, 1996). Since many people enter the health care system at the primary care level, particularly for acute care concerns, primary care practitioners see a large proportion of the population (Kirsner, Muhkerjee, & Federman, 1999). This offers an unprecedented opportunity for early melanoma recognition and education. There is no literature on how primary care advanced practice nurses (PCAPNs) are functioning in the role of melanoma recognition and education. There is evidence however, that many primary care physicians lack the knowledge, skill and confidence necessary to appropriately assess, diagnose, educate, and refer patients with malignant melanoma (Dolan, Martin, Robinson, & Rademaker, 1995; Federman, Concato, Pangiota, Caralis, Hunkele, & Kirsner, 1997; Geller et al., 1992; Kirsner et al., 1999). Given these two factors, it is probable that PCAPNs also lack this ability. PCAPNs must be knowledgeable of risk factors and early signs and symptoms of malignant melanoma. By being knowledgeable of risk factors and early signs and symptoms, PCAPNs can integrate a brief but focused history and physical exam into the context of any primary care visit. This focused history and physical exam may be done quickly, resulting in many people being screened for melanoma. Numerous lives could potentially be saved. Purpose The purpose of this project is based on three factors. First, a person’s prognosis is critically dependent on early detection (Johnson et al., 1995; Rigel & Carucci, 2000; Schwartz, Wang, Hamilton, Lowe. Sondak, & Johnson, 2001). Second, PCAPNs have a key role in this early detection (Stephenson et al., 1997; Weinstock et al., 1996). Third, PCAPNs must be knowledgeable about the risk factors and early signs and symptoms of melanoma and be able to incorporate these principles into the context of a primary care visit (Stephenson et al., 1997; Weinstock et al., 1996). The purpose of this project is to provide the PCAPN with guidelines that outline the necessary components (with respect to malignant melanoma), of a brief but focused history and physical exam, as well as pictorial examples of lesions which should be suspect. The scope of this project focuses specifically on the role of the PCAPN who is seeing patients for acute care concerns. Comprehensive care of the patient coming in for a routine physical is extensive and includes a meticulous skin assessment and preventive education (Johnson et al., 1995). This extensive assessment needs to be addressed but is beyond the scope of this project. Conceptual Framework Orem’s Self-Care Deficit Theory of Nursing (OSDTN) can provide valuable perspective with respect to melanoma detection and education for the PCAPN. It consists of three interrelated theories (Orem, 1985). The theory of self-care refers to all actions people engage in to care for themselves - for example, performing self-skin examinations. The theory of self-care deficit refers to all actions people cannot do for themselves (for various reasons), such as not performing self-skin examinations (Orem, 1991). The theory of nursing systems refers to all of the things nurses do to help people maintain their health, such as teaching them how to do self-skin examinations (Orem, 1985). Description and Definitions of Concepts A model depicting four basic concepts of OSDTN is shown in Figure 1. Orem IV Self-Care < > Therapeutic Self- Agency A Care Demand Self-Care Deficit V \\l . Nursnng Agency Figure 1. A model depicting the relationship between four basic concepts of Orem’s Self-Care Deficit Theory of Nursing. (Adapted from Orem, 1991.) defines self-care as “the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being” (Orem, 1991, p. 117). Orem defines therapeutic self-care demand as the “summation of measures of self-care required at moments in time and for some duration” (Orem, 1991, p. 65). The definition of self- care deficit by Orem is the “relationship between self-care agency and therapeutic self- care demands of individuals in which capabilities for self-care, because of existent limitations, are not equal to meeting some or all of the components of their therapeutic self-care demands” (Orem, 1991, p. 173). The self-care deficit can be less than the therapeutic self-care demand in which the person does have the capability to perform a certain self-care function (i.e., self-skin exam) (Orem, 1991). The self-care deficit can be greater than the therapeutic self-care demand in which the person does not have the capabilities to perform a certain self-care function (Orem, 1991). Orem (1991) defines the nursing agency as the ability of persons educated and trained as nurses to directly meet the client’s needs and/or help the client become more aware of their needs and/or help the client become more able to take care of their own needs (Orem, 1991). Other key concepts in this paper include that of melanoma and PCAPN. For the purpose of this paper, melanoma is defined as any lesion which when biopsied, reveals certain histological features consistent with such a lesion as defined by a dermatopathologist. A PCAPN is defined as any graduate of a certified masters nursing program who is licensed to practice as an advanced practice nurse (APN), and is practicing in a primary care setting. Relevancy of the Theoretical Framework to the Guidelines Generally, with respect to the role of the APN in melanoma detection and education, the relationship between Orem’s concepts of the nursing agency and self-care agency has particular relevance. A self-care agent can develop the ability to care for themselves. A nursing agent can develop the ability to help a person care for themselves and assist them in becoming a more proficient self-care agent. Specifically, with respect to the PCAPN’s role in melanoma detection and education, the relationship between the nursing agency and self-care agency also has particular relevance. PCAPNs can develop their knowledge and skills which help clients engage in self-care practices that may detect and possibly prevent melanoma. These guidelines help enhance the PC APN’s knowledge of melanoma risk factors and early signs and symptoms. This will allow them to prioritize the critical components which guide the limited but focused history, physical exam, and education plan for the client entering the health care system with an acute care concern. With this knowledge, clients can be taught to monitor themselves and alert the PCAPN in a timely fashion should such signs and/or symptoms occur. They can then be referred for appropriate life-saving treatment. They can also be taught how to manipulate risk factors which are modifiable (i.e., sun exposure). The PCAPN’s nursing agency is enhanced, which can guide the client in strengthening their self-care agency. This relationship is depicted in Figure 2. '3 <—> z = O. o i < Primary Health \ Care ViSit Enhanced Self- / Care Agency Perceived or Unperceived Skin Assessment/Health Promotion Needs Improved Client Melanoma Assessment/Education Information Tool \ Enhancement of Nursing Agency Figure 2. A model depicting the relationship between the melanoma informational tool, the APN in primary care, the client, and two basic concepts of Orem’s Self-Care Deficit Theory of Nursing. (Adapted from Orem, 1991.) Literature Review Melgiomg Trends Statistics indicate a rise in the number of melanoma cases (Rigel & Carucci, 2000; Rigel et al., 1996). The incidence of melanoma occurrence is rising faster than any other type of cancer (Rigel & Carucci, 2000; Rigel et al., 1996). There will be an estimated 51,400 new cases of invasive melanoma and 30,000 cases of melanoma in situ diagnosed in the year 2001 (Greenlee, Hill-Harmon, & Thun, 2001). The mortality rate of melanoma is rising by 2% each year (Rigel et al., 1996). The survival rate of melanoma is also rising (Rigel et al., 1996). The survival rate for persons with stage I disease was 50% in 1950 and rose to 90% in 1996 (Rigel et al., 1996). This rate has leveled off during the past decade highlighting the importance of new educational programs (Johnson et al., 1998). Definition and Growth Phases Melanoma arises in the melanocytes of the skin located between the epidermal- dermal junction (NIH, 1992). It originally spreads laterally over the skin. After a period of time it begins to grow in a vertical fashion and develops depth. It can then spread to the regional lymph nodes, and then to other distant visceral parts of the body. During the time period in which it is confined to the upper part of the skin (epidermis), it is considered melanoma in situ (NIH. 1992). Once it develops and spreads to the dermis, it is considered invasive. Causation and Risk Factors There are both genetic and environmental factors involved in the development of malignant melanoma (Johnson et al., 1998; Rigel et al., 1996). The primary known environmental cause is sun exposure (Johnson et al., 1998; Rigel et al., 1996), particularly acute episodes resulting in peeling or blistering sunburns (even only a few), occurring in childhood (Schwartz et al., 2001). Persons with certain characteristics are at increased risk for developing melanoma (Rigel, 2001). Those with blue eyes, fair skin, and blonde or red hair are at risk (Rigel, 2001). Those who have had a melanoma in the past as well as those who have a family history of melanoma are at risk (NIH, 1992; Rigel, 2001). A history of having more than 50 normal moles during childhood as well as the development of greater than 100 moles during adulthood is considered a risk factor. Persons with numerous atypical moles are also considered to be at risk. Prognosis The prognosis for persons diagnosed with melanoma is dependent on the depth measured in millimeters (referred to as the Breslow depth) at diagnosis and the presence or absence of ulceration (Buzaid, Ross, & Balch et al., 1997). In general, the higher the Breslow depth, the poorer the prognosis (Buzaid et al., 1997). The presence of ulceration is also associated with a poorer prognosis (Buzaid et al., 1997). A person who has their melanoma treated at an early stage has an excellent prognosis (Chang, Kamell, & Meneck, 1998). The five-year survival rate can range from greater than 95% for those diagnosed with a melanoma less than or equal to 1.00 millimeters and no ulceration to a 30-50% survival rate for those who have a melanoma greater than 4.00 millimeters with ulceration (Buzaid et al., 1997). Other critical factors influencing the survival rate include the number of lymph nodes testing positive for melanoma and the presence or absence of distant metastisis (Buzaid et al., 1997). Signs andflymptoms The earliest sign of a melanoma is a change in the size, shape, or color of a mole (Schwartz et al., 2001). The earliest symptom is persistent itching in a “spot” or mole (Schwartz et al., 2001). Other signs of lesions which should be suspect are those which are asymmetrical, have irregular borders. are black, or have shades of blue, red, or white, and those which are larger than 6 millimeters (NIH, 1992). Melanoma most often presents itself on the trunk in men and on the trunk and lower extremities in women but can occur anywhere on the skin (Johnson et al., 1998). It tends to occur more often on the soles of the feet in the African-American population (Vayor & Lefor, 1993). The Role of Primary Care Primary care practitioners see a significant proportion of the population (Kirsner et al., 1999). Eighty five percent of the population seeks the care of a primary care 10 practitioner every two years (Kirsner et al., 1999). Non-dermatologists examine 70% or more of the population on a regular basis (Weinstock et al., 1996). A routine examination is one of the top ten reasons given for patient visits to a physician (Kirsner et al., 1999). Many primary care practitioners manage both cancerous and precancerous skin lesions (Smith et al., 1998). Smith et al. (1998) found that general practitioners were second only to dermatologists in managing precancerous and cancerous lesions. Primary care practitioners, including PCAPNs, have a role in the diagnosis, education and referral of persons with melanoma (Stephenson et al., 1997; Weinstock et al., 1996). Population based screening on an annual basis is recommended by several major organizations such as the NIH Consensus Conference on Early Melanoma, The American Academy of Dermatology and The American Cancer Society (Edman & Wolfe, 2000; Kirsner et al., 1999). Other major organizations such as The American College of Preventive Medicine’s Practice Policy Statements, The Canadian Task Force on the Periodic Health Examination. and The US. Preventive Services Task Force Guide to Clinical Preventive Services recommend periodic screening of individuals who are at high risk (Edman & Wolfe, 2000). There are not enough dermatologists to routinely screen those who are at risk for developing melanoma (Weinstock et al., 1996). Since primary care practitioners are the first line of contact in the health care system, they need to become more involved in recognizing melanoma, persons at risk of developing melanoma, and education of patients with respect to melanoma (Stephenson et al., 1997; Weinstock et al., 1999). In spite of the importance of early melanoma detection and the increased access primary care providers have to the population, evidence suggests that processes that may result in melanoma detection are not being done (Geller et al., 1992; Kirsner et al., 1999; Dolan et al., 1995; Federman et al., 1997). There is no information in the literature regarding how PCAPNs are performing in their role with respect to melanoma detection and education. There is, however, information on how other primary care providers such as physicians are doing in this area. This information can be useful in assisting PCAPNs in acknowledging their role in and developing skill in practices leading to melanoma detection and education. In a survey by Geller et al. (1992), 87% of persons diagnosed with melanoma reported having a regular physician and 63% had contact with their physician one year prior to being diagnosed with melanoma. Of those, 20% had received a skin exam (Geller et al., 1992). Kirsner et a1. (1999) showed that only 31% of primary care physicians routinely perform skin cancer screening on all of their patients. Of the primary care physicians who don’t routinely screen all of their patients, only 31% do it on high risk patients (Kirsner et al., 1999). Dolan et a1. (1995) reported that only 15% of physicians performed a skin exam on patients with risk factors. Federman et al. (1997) did a retrospective study of medical records and found references to skin examinations only 28% of the time, and of those, 10% had come in with a complaint of a skin lesion. Schwartz et a1. (2001) found that only 16% of the melanomas were detected by physicians. They also found that melanomas detected by physicians tended to be thinner (Schwartz et al., 2001). Studies reveal that primary care practitioners need and desire more education/ experience in melanoma detection (Brochez, Verhaeghe, Luc Bleyen, & Naeyaert, 2001; Kirsner et al., 1999; Stephenson et al., 1997). Brochez et al. (2001) showed groups of 12 dermatologists and general practitioners multiple pictures of pigmented lesions. Only one out of two lesions were diagnosed correctly by general practitioners (Brochez et al., 2001). When evaluating pictures of early staged melanomas, one out of three were considered benign by general practitioners. When pictures of late staged melanomas were evaluated by general practitioners, one out of five were considered benign (Brochez et al., 2001). General practitioners correctly identified the biological behavior of a lesion 72% of the time compared to dermatologists who correctly identified it 94% of the time (Brochez et al., 2001). Stephenson et a1. (1997) gave primary care physicians a questionnaire assessing their knowledge of malignant melanoma. Of those surveyed, only 28% identified itching as a possible symptom and only 25-43% considered color variegation as a possible sign. A study by Kirsner et a1. (1999) showed that 70% of the primary care physicians did not feel comfortable with diagnosing melanoma or squamous cell skin cancer. Stephenson et al. (1997) found that 55% did not feel confident in recognizing melanoma in general and 78.2% did not feel comfortable in identifying subtle or early signs of melanoma in particular. Many physicians cite lack of confidence in identifying suspicious lesions as a considerable barrier (Kirsner et al., 1999). They also feel that additional training, including clinical experience, is needed (Kirsner et al., 1999). Numerous physicians desire more information on performing reliable skin examinations, recognizing suspicious nevi, and triaging lesions (Edman & Wolf, 2000; Weinstock et al., 1996). Brochez et al. (2001) found that physicians with greater exposure to pigmented lesions showed better diagnostic accuracy. They also found that physicians who were exposed to 13 increased numbers of educational slides and lectures on melanoma reported improved confidence levels and a significantly greater number of physicians switched incorrect to correct answers when given a test on lesion identification (Brochez et al., 2001). This information could also apply to the advanced practice nurse in primary care. Physician studies also suggest that PCAPNs also need to address patients’ educational needs regarding melanoma recognition (Schwartz et al., 2000; Weinstock et al., 1996). The majority of lesions are brought to the phySician’s attention by the patient (Schwartz et al., 2001). Patients need to be taught how to view their lesions and when to bring such lesions to the attention of the PCAPN. One study showed that 40% of patients did not seek medical attention for a lesion until late signs of melanoma were present (bleeding or ulceration) (Krige et al., 1991). An educational campaign in Scotland regarding health care practitioner notification of changing nevi resulted in a decrease in melanoma thickness and mortality rate in women (Mackie & Hole, 1992). Many experts feel that clients, particularly those at risk, need to be taught about the risk of sun exposure (Edman & Wolfe, 2000). Summary The incidence of melanoma is increasing and poses a serious health threat to a significant portion of the population (Rigel & Carruci, 2000; Rigel et al., 1996). The prognosis is dependent on early detection (Johnson et al., 1995), and PCAPNs, particularly in their role of managing acute care, are in a unique position to detect melanoma in their patients and teach patients about early detection and prevention. Though there is no information in the literature regarding the practices of PCAPNs, the information on primary care physicians suggest a need for increased education and exposure to information in this area (Brochez et al., 2001; Mackie & Hole, 1992; Krige et al., 1991; Stephenson et al., 1997; Weinstock et al., 1996). The purpose of these guidelines is to provide information to the PCAPN which will enhance their competency in integrating melanoma detection and educational strategies into the context of a primary acute care visit. Implementation Implementation of melanoma screening can be achieved in the following. way. Local area PCAPNs could be contacted via phone and asked to participate in a program where the guidelines would be instituted over a three month period of time. Once ten volunteers were enrolled, a copy of the guidelines, along with an introductory letter (see Appendix A) explaining their purpose, would be mailed. After an initial three month period of use, a meeting would be arranged where feedback and ideas would be shared. Several questions could provide valuable information regarding the usefulness of the guidelines. Were the guidelines clear? Were any melanomas found since implementing the guidelines? Did the PCAPN become more comfortable assessing the skin? Were the guidelines easy to implement? How much time did it take to implement them? Was it easy to integrate all of the different parts into the context of the primary care visit? What difficulties did they encounter? What would they change about the guidelines? Answers to these questions could yield valuable information for future guideline revision and development. Other methods of achieving implementation could involve disseminating the guidelines through publication in professional nursing and medical journals. The guidelines could be integrated into a website for primary care practitioners. They could also be used as an outline for speaking at professional conferences and continuing education courses. Implications for Advanced Practice Nursing in Primary Care Education There are important educational implications. PCAPNs need more exposure to detecting, triaging and diagnosing pigmented lesions in general and melanoma in particular. Information in the form of lectures, exposure to photographs/slides, and possibly computer guided instructions should be integrated into the APN educational curriculum. Also, clinical rotations in dermatology should be part of APN graduate programs. Many suspicious lesions can be easily and safely biopsied in the office setting by a practitioner who is properly trained to do so. Possessing competency and precision in the ability to do this is highly beneficial to both patients and the primary care practice. APNs need to become proficient and certified in correctly performing biopsies and this should be incorporated into certification workshops at APN conferences. Practice Melanoma poses a serious threat to a significant portion of the population. Its impact on morbidity and mortality is critically dependent on early detection and correct treatment. PCAPNs are in a unique position to detect melanoma in many of their patients. The available literature clearly suggests a need for increased exposure to education and information in this area (Brochez et al., 2001; Mackie & Hole, 1992; Krige et al., 1991; Stephenson et al., 1997; Weinstock et al., 1996). The purpose of these guidelines is to provide the PCAPN with the necessary information. They can then integrate the skills required to detect melanoma in their clients. Given the scarcity of time inherent in clinical practice today, these guidelines are particularly useful. The screening process is painless and noninvasive. No expensive equipment or additional healthcare personnel are necessary. By prioritizing the critical components of a brief assessment and physical exam, screening and education can be done in minutes. Numerous lives could potentially be saved. Rem The efficacy of the guidelines could be researched by conducting a retrospective chart review. A comparison of information obtained before and afier implementation of the guidelines could provide valuable perspective as to their usefulness. A range of concerns regarding melanoma detection could be addressed. The number of melanomas found before versus after implementation could be 17 compared, as well as differences in the average Breslow depth at diagnosis. Changes in the number of risk factors documented could be examined as well as references to the presence of melanoma signs and symptoms. The number of times a person was appropriately referred for a total body skin exam could be assessed. Another important comparison for determination would be how many times a person was appropriately referred to a dermatologist. Documented references to education of high risk clients could also be evaluated. Answers to these questions can yield valuable information which could support widespread usage of the guidelines. Conclusion The incidence of melanoma is increasing and poses a serious threat to numerous people. The prognosis is dependent on early detection and could be fatal if not diagnosed and treated promptly. Since PC APNs see numerous patients for acute care concerns, it is vital that they are prepared for this role. The purpose of these guidelines is to outline the critical components of a brief but focused history and physical exam related to melanoma detection/education as well as to provide the PCAPN with pictorial examples of lesions which should be suspect. It is hoped that these guidelines will enhance the PCAPN’s skill in melanoma detection and education, possibly resulting in numerous lives being saved. 18 APPENDICES l9 APPENDIX A LETTER INTRODUCING PRIMARY CARE GUIDELINES FOR EARLY MELANOMA DETECTION 20 LETTER INTRODUCING PRIMARY CARE GUIDELINES FOR EARLY MELANOMA DETECTION Dear , Thank you for volunteering to implement the “Primary Care Guidelines for Melanoma Recognition” in your practice. I would like to contact you afier three months and inquire about your experiences with the guidelines. Your feedback will be greatly appreciated. These guidelines have been established in hopes that lives will be saved due to early melanoma recognition. The rate of melanoma occurrence is rising faster than any other type of cancer and poses a serious threat to a significant portion of the population. The key to surviving melanoma is early detection. The survival rate of persons diagnosed with early melanoma is almost 100%. It is fatal if diagnosed in the later stages. With knowledge of risk factors, early signs and symptoms, and the characteristic appearance of malignant melanoma. the potential for early diagnosis is increased and lives could be saved. As a primary care provider, you have access to large numbers of clients. Some may presently have malignant melanoma. Others could be at risk for developing malignant melanoma in the fiJture. Despite this knowledge, many primary care providers are uncomfortable with assessing the skin and are unfamiliar with the risk factors, early signs and symptoms, and characteristic appearance of malignant melanoma. It is hoped that these guidelines will provide you with the knowledge needed to diagnose malignant melanoma and potentially save numerous lives. Thank you again for participating in this experience. If I can be of any assistance to you during this trial, please don’t hesitate to contact me at (734) 449-5946. Sincerely, Denise A. Chinni, RN. 21 APPENDIX B PRIMARY CARE GUIDELINES FOR EARLY MELANOMA DETECTION 22 I. PRIMARY CARE GUIDELINES FOR EARLY MELANOMA DETECTION Initial Surveillance Upon the patient entering the exam room, note the following characteristics: II. A. B C. D Skin type (fair skin most susceptible) Eye and hair color (blue eyes and blonde or red hair most susceptible) The presence or absence of excessively tanned or sun-damaged skin The presence or absence of excessive numbers of moles which appear atypical The presence of Actinic Keratoses Histog (subjective) If any of the above risk factors are noted. the following questions should be added to the HPI: III. DOW? Do you have any moles which have changed? Do you have any moles which itch? Have you had a history of blistering and peeling sunburns? Has any blood relative ever been diagnosed with melanoma? Have you had a history of melanoma, non-melanoma skin cancer or precancerous skin lesions? Physical Exam (objective) Any reported lesions should be inspected for the following: A. B. C. Asymmetry Irregular border Uneven color (shades of black, red, white, or blue) 23 IV. Diameter of 6mm or larger Perform a waist up inspection on men who have risk factors. Perform a waist up inspection on women who have risk factors and also view their lower extremities. ClinicaADecision—Makinggnd Treatment A. B. Any suspicious mole or lesion needs to be biopsied by a practitioner trained to do so or referred to a dermatologist. Persons at risk should be scheduled to return for a total body skin exam. Patient Education Patient education should focus on anyone with risk factors for melanoma, should be brief at this point, and should include the need to follow-up in the near fixture for further assessment and education. A. The patient should be taught to immediately report any mole which changes size, shape, or color, or any mole or spot which itches for no apparent reason. The patient should be scheduled to return for a total body skin exam within three months. Pamphlets with pictures and information on melanoma, as well as the melanoma website address. should be provided. Provide information on sun avoidance and protection. Educate the need to get a total body skin exam with their primary care practitioner yearly. Educate the client to do a monthly self skin exam along with self breast and testicular exam and have significant other check the back and soles of feet. 24 APPENDIX C PICTORIAL GUIDE TO EARLY MELANOMA RECOGNITION Pictures were received with patient consent from Dr. Timothy Johnson. Courtesy of the University of Michigan Cutaneous Oncology Surgical Unit. 25 1. This is a classic melanoma discovered in the later stages. This should never be missed. Note the classic “ABCD” characteristics: asymmetrical shape, irregular border, black golor, and giameter greater than six millimeters. 26 2. A classic melanoma. Note the classic “ABCD” characteristics: asymmetrical shape, irregular horder, black _c_olor, and diameter greater than six millimeters. 27 3. A melanoma with characteristics which are not marked bu clearly present. The classic “ABCD” characteristics are present. 28 4. Melanoma with classic characteristics, but not as marked. 29 5. Melanoma with classic characteristics, but not as marked. 30 6. This melanoma has more subtle characteristics. Note the presence of the classic “ABCD” characteristics. 31 ,/ ‘1; . \¢-. '.'7‘9;2-./~ ‘r' «-' . I'D..- - .' Marx?" :01":' c ; ° ;-'_ 7. This is an early melanoma. The decision to biopsy this lesion was based not so much on the appearance but on the report by the patient that it had changed, with darkening color and increasing size. Note its smaller size and the absence of some of the classic characteristics such as an asymmetrical shape, irregular border, diameter greater than six millimeters. 32 The next four photos illustrate that melanomas also occur in uncommon areas which are not exposed to the sun. It is important that if a client coming in for acute primary care concerns also reports persistent itching, or a change in a mole on any part of the body, that area should also be assessed. 33 Melanoma found in the perianal area. 8. 34 9. Melanoma found on the scalp. 35. 10. Melanoma on the plantar aspect of the foot. This area is frequently forgotten when assessing clients for melanoma. 36 11. Melanoma located on the great toe. This is another area frequently forgotten when assessing a client for the presence of melanoma. 37 BIBLIOGRAPHY Buzaid, A.C., Ross, M.I., Balch. C.M. et a1. 1997. Critical analysis of the current American Joint Committee on Cancer staging system for cutaneous melanoma and proposal of a new staging system. Journal of Cliniaal Oncology, 15, 1039-1051. Chang, A.E., Kamell, L.H., & Menck, HR. 1998. The national cancer database report on cutaneous and noncutaneous melanoma. Cancer 83, 1664-1678. Dolan, N.C., Martin, G.J., Robinson, J .K., & Rademaker, AW. 1995. Skin cancer control practices among physicians in a university general medicine practice. Jouml of Generflnternal Medicine. 10, 515-519. Edman, R.L., & Wolfe, IT 2000. Prevention and early detection of malignant melanoma. Americagr Family Physician. 62, 2277-2284. Federman, D.G., Concato, J., Caralis, P.V., Hunkele, G.E., & Kirsner, RS. 1997. Screening for skin cancer in primary care settings. Archives of Dermatology, 113, 1423- 1425. Greenlee, R.T., Hill-Harmon, M.B., Murray, T., & Thun, M. 2001. Cancer statistics, 2001. CA: Cancer Journal for Clinicians. 51. 15-36. Johnson, T.M., Dolan, O.M., Hamilton, T.A., Lu, M.C., Swanson, N.A., & Lowe, L. 1998. Clinical and histologic trends of melanoma. Journal of the American Academy of Dermatology, 38, 681-685. Johnson, T.M., Smith, J.W., Nelson, B.R., & Chang, A. 1995. Current therapy for cutaneous melanoma. Journal of the American Academy of Dermatology, 32, 689- 706. Kirsner, R.S., Muhkerjee, S.. & Federman, D.G. 1999. 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