Essay Example on Melanoma Screening: Reduce Risk in Primary Care Settings

Introduction

Melanoma Screening in Primary Care SettingSkin cancer is among the most common cancer worldwide and in the United States (US) (Linares, Zakaria, & Nizran, 2015). Malignant melanoma (MM) is a potentially fatal form of skin cancer (Shenenberger, 2012). Although MM occurs in three to five percent of all skin cancer incidents, invasive melanoma is accountable for approximately 75 percent of all deaths from skin cancers (Shenenberger, 2012). Melanoma incidence is 20 times more common in whites than in African Americans (Shenenberger, 2012). According to the American Cancer Society ([ACS], 2020), there is a diagnosis of about 100,350 new melanomas, and an expectation of about 6,850 people to die of MM in 2020. The incidence of MM worldwide is rising quicker than any other solid cancer, with an estimated doubling of rates every 10-20 years in countries with Caucasian populations (Emery, Hunter, Hall, Watson, Moncrieff, & Walter, 2010). Melanoma is often lethal, but a cure is possible if diagnosed early (Argenziano et al., 2006). Guiding the focus of the public towards decreasing modifiable risk factors and encouraging improved screening rates between healthcare providers, may prevent 20 percent of new predicated cases of MM within the next 15 years (ACS, 2020).

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Exposure to ultraviolet (UV) rays is a major risk factor for most melanomas (ACS, 2020). Risks for developing melanoma also include fair skin and hair, multiple or atypical moles, history of severe sunburns, exposure to certain chemicals, compromised immune system, and personal or family history of skin cancer (ACS, 2020). More than one in three Americans report getting sunburned every year (Centers for Disease Control and Prevention [CDC], 2015). Having five or more sunburns may double the risk for melanoma (Skin Cancer Foundation [SCF], 2019). About 6,200 invasive melanomas are estimated to be triggered each year by indoor tanning (CDC, 2015). Individuals who have used tanning beds 10 or more times in their lives have a 34 percent increased risk of developing melanoma compared with those who have never used tanning beds (SCF, 2019). Even though indoor tanning among U.S. high school students decreased by 53 percent between 2009 and 2015, more than 90 percent of melanoma skin cancers still happen due to skin cell damage from UV radiation exposure (SCF, 2019; CDC, 2015). Melanoma will continue to increase in the next 15 years without additional prevention efforts (CDC, 2015).

Early detection and treatment is the best strategy to reduce mortality and morbidity associated with melanoma (Argenziano et al., 2006). Some organizations recommend involving a skin examination during routine health examinations for adults (Shenenberger, 2012). However, the U.S. Preventive Services Task Force (USPSTF) concluded that there is not enough evidence to recommend for or against annual whole-body skin examination by a primary care physician or patient for early detection of skin cancers in the general adult population (USPSTF, 2016). For the diagnosis of skin cancer, dermoscopy is more accurate than a naked-eye examination because dermoscopy allows the visualization of features that are not visible to the naked eye. Experienced clinicians currently use dermoscopy as a second-level procedure for the evaluation of selected lesions that were considered suggestive of skin cancer by the initial clinical examination. Under these circumstances, dermoscopy decreases the number of unnecessary excisions of benign lesions (Argenziano et al., 2006).

Across all stages of melanoma, the average five-year survival rate in the U.S. is 92 percent. Due to the high mortality of melanoma cancer in the U.S., there is research on screening techniques, benefits, risks, and logistics. The purpose of this paper is to identify melanoma cancer screening barriers amongst providers in primary care settings and to suggest an educational intervention aimed at increasing dermoscopy usage for melanoma cancer screening and decreasing MM mortality rates.

Operational Definitions

Key Terms

Melanoma

MM results from the malignant transformation of melanocytes. The key triggers leading to malignant alteration of melanocytes have yet to be fully clarified, but are multifactorial and involve UV radiation damage and genetic susceptibility (Shenenberger, 2012). According to National Cancer Institute ([NCI], 2019), more than 90 percent of melanomas that arise in the skin can be recognizable with the naked eye. Skin cancer screening with a total body skin examination (TBSE) is questionably the safest, simplest, and probably the most cost-effective screening test in medicine, however, there is no national consensus regarding its advantage or implementation (Johnson et al., 2017).

Dermoscopy

To improve the diagnosis of MM, dermoscopy has been presented to assist health care providers in the clinical examination due to it is non-invasive skin imaging techniques that offer clinicians high-quality visual perception of skin lesion (Yu et al., 2019). An estimated 81% of dermatologists used dermoscopy in their practice in 2014 compared with only 40% in 2010 (Murzaku, Hayan, & Rao, 2014). There is documentation of increases use among primary care providers as well as increased diagnostic skills with the practice of dermoscopy. Similarly, Kownacki's (2014) study showed that a day of teaching providers on the correct lesion identification with dermatoscopy had reduced patients referrals for 18:1 to 4:1 benign to malignant lesions (Kownacki, 2014).

Primary care setting

Due to the increasing incidence of invasive melanoma, healthcare providers play an essential role in encouraging and completing full-body skin examinations. Melanoma prognosis is dependent on tumor thickness at the time of diagnosis; there is an association of thinner tumors with an improved cure rate. Multiple studies have confirmed that melanoma tumors found by healthcare providers during routine skin examinations are thinner or at an early stage than those the patients discovered (Geller & Swetter, 2016). The primary care setting will include a clinic, healthcare facility, private practice, or any facility that patients can visit to see a primary care provider (i.e., a nurse practitioner, physician assistant, or medical doctor). This definition will include family practices, community health clinics, retail facilities, and private clinics. The primary care setting does not include hospitals, skilled nursing facilities, long-term acute care facilities, or rehabilitation centers. This paper will primarily include melanoma screening that is done in a primary care setting settings.

Pathophysiology and Health Issues Associated with Melanoma

The skin is the largest organ in the body, which provides the outer protective wrapping for all the body portions. Skin is an airtight, waterproof, and flexible barrier between the environment and internal organs. Melanocytes are the pigment-producing cells responsible for the color of skin (Shenenberger, 2012). Exposing melanocytes are exposed to ultraviolet light; there is an accumulation of genetic mutations that activate oncogenes, inactivate tumor suppressor genes, and impair DNA repair (Linares, Zakaria, & Nizran, 2015). This process may cause an uncontrolled proliferation of melanocytes and, eventually, MM (Linares, Zakaria, & Nizran, 2015).

The skin is divided into three layers, which are the epidermis, the dermis, and the subcutaneous layer. Melanoma usually develops in the epidermal layer of the skin, where a tumor can remain for several years, growing horizontally (Swetter & Geller, 2015). This horizontal growth phase can provide a lead time for early detection (NCI, 2019). When MM infiltrates the dermis, the tumor starts growing vertically and has a high metastatic potential. Survival rates are indirectly proportionate to tumor thickness at diagnosis and vary from 92 percent when lesions are less than 1.01 mm to 50 percent when lesions are greater than four mm thick (Swetter & Geller, 2015). The growth of MM depends on the different subtypes. There are four major subtypes, such as superficial spreading melanoma, lentigo maligna, acral lentiginous, and nodular melanoma (Little & Eide, 2012). Although more than 95% of malignancies are found in the skin, MM is not solely a skin cancer. Ocular, mucosal, gastrointestinal, genitourinary, leptomeninges, and lymph nodes melanomas are considered as extracutaneous (Marcovic et al., 2007).

The clinical diagnosis of MM is created on several morphologic features and summarized by the asymmetry, border irregularity, color variegation, and diameter of more than 5 mm (ABCD) rule (Argenziano et al., 2006). However, ABCD criteria achieve only 65% to 80% sensitivity. The ABCD rule fails to recognize melanomas that are small or less than 6 mm or that regular exhibit shape and homogeneous color. MM usually appears on the lower extremities in women and on the trunk in men. Most melanomas develop on sun-exposed skin, particularly sunburned skin. Men and women with high total body nevus counts, atypical nevi, family or personal history of skin cancer, certain genetic makeup components, and specific phenotypic traits are at a higher risk for the development of melanoma (Curiel-Lewandrowski, 2016). Treatment of screen-detected melanoma commonly contains excision, with or without lymph node management, depending on the stage at diagnosis (USPSTF, 2016).

Early detection of melanoma is vital in survival rates and patient outcomes. Recognition may be challenging due to the variability of presenting factors associated with melanoma subtypes; nevertheless, the use of diagnostic tools such as dermoscopy and full-body skin examinations are linked to thinner tumor recognition and increased survival rates (Swetter & Geller, 2015). Dermoscopy is a useful and moderately inexpensive tool for MM detection in a primary care setting. This technique can increase primary care providers' (PCP) confidence in their referral accuracy to dermatologists and can assist in decreasing unnecessary biopsies.

The APRN Role

A nurse practitioner (NP) is an APRN with a master's or doctorate of education. NPs are in an ideal position for delivering sun protection instruction and skin screening expertise, which may decrease skin cancer morbidity and mortality (Bradley, 2012). Educating NPs in skin cancer detection, screening, and the use of a skin cancer screening tool such as dermoscopy is an efficient way to improve the quality of services offered to patients. The NP may recognize patients at high-risk for melanoma and perform dermoscopy screening during routine physical examination. The results can provide further follow-up, dermatology referrals, and collaboration with interdisciplinary team members. The incidence of melanoma has been increasing for at least 30 years (NCI, 2019). The long-term growth in incidence rates is caused by screening in primary care clinical settings and self-examination resulting from promotions to upsurge skin cancer awareness (NCI, 2019).

Personal Impetus

Health maintenance and cancer screening are vital to prevent illness, promote wellbeing, and improve health. Only 8% to 15% of people in the US report having received a recent skin examination by the health care provider (Anderson, Kirkwood, & Ferris, 2016). Skin cancer, including melanoma screening, may be incorporated in the routine PCP visit, cutting the necessity for an additional physician visit for the patient. During my numerous clinical rotations in different clinics of San Diego County, I noted inadequate practice on skin cancer screening in primary care settings. Although PCPs are in a unique position to deliver effective and potential life-saving skin cancer screening and skin protective counseling. Therefore, improving NPs' potential and awareness to detect suspicious skin...