DRG Category: 580
Mean LOS: 5.2 days
Description: Surgical: Other Skin, Subcutaneous Tissue, and Breast Procedures With Complication or Comorbidity
DRG Category: 595
Mean LOS: 7.5 days
Description: Medical: Major Skin Disorders With Major Complication or Comorbidity
Melanoma skin cancer is a type of skin cancer that originates from the melanocytes. Melanocytes are melanin-producing cells that are interspersed in the inner layer of the epidermis. Melanin is a dark brown pigment that protects the epidermis and the superficial vasculature of the dermis. It is thought that ultraviolet radiation (UVR) from direct sunlight or tanning beds damages the DNA of melanocytes, impairing the DNA control over how and when cells grow and divide. These skin lesions tend to be hereditary, begin to grow in childhood, and become more numerous in young adulthood.
Skin cancer is the most common cancer in the United States, and melanoma accounts for 1% of all skin cancer cases. Although the lifetime melanoma risk for the overall population is less than 2%, melanoma is responsible for approximately 80% of skin cancer deaths. According to the American Cancer Society, 106,110 new melanomas will be diagnosed and 7,180 people will die of melanoma in 2021. The current lifetime risk for developing an invasive melanoma is 1 in 54. Early diagnosis has led to significant improvement in overall survival. The two most important factors that predict outcomes from treatment are the thickness of the lesion and the status of the regional lymph nodes. In early stages, the 5-year survival rate for melanoma is 99%, and in late stages it is 20% to 30%. Complications include scarring, lymphedema (if lymph nodes were removed during treatment), emotional distress, recurrence, and death.
The majority of melanomas (90%) occur on the skin. Approximately 65% of skin melanomas develop on clear skin, 30% on preexisting moles or nevi (small, circumscribed aggregates of melanocytes), and 5% on age spots. Melanoma cells develop because of gene mutation, followed by inappropriate cell growth and proliferation. Genetic damage occurs for uncertain reasons, but among the theories are exposure to carcinogens in the environment, DNA damage from UV radiation, or heredity. Characteristics associated with an increased risk for melanoma include fair skin that does not tan well and that burns easily, blond or red hair, the tendency to develop freckles, and the presence of a large number of nevi. A strong association exists between exposure to UV light (UV-B radiation) and the development of cutaneous melanoma. Possible mechanisms of damage from UV radiation include suppression of the immune system of the skin, induction of melanocyte cell division, free radical production, and damage of melanocyte DNA. Other risk factors include a positive family history, sunburns early in life, use of tanning beds, and immune suppression because of disease or medications.
Melanoma has a significant genetic component, with heritability estimated at 58%. A pattern of autosomal dominant transmission is seen in some populations. A person with one first-degree relative affected by melanoma has two to three times the risk of the general population and six times the risk if the relative was affected before age 50 years. The risk increases 13-fold if more than one first-degree relative is affected. Approximately 5% to 10% of melanoma cases are familial. Genes implicated in melanoma susceptibility include CDKN2A, CDK4, WNT3, and VPS41.
Men have a 1 in 57 chance of developing melanoma; women have a 1 in 81 chance. The incidence of melanoma increases with age; 50% of cases occur in people who are older than age 50 years and average age of diagnosis is 65 years. Although melanomas are rare in children, the incidence among today's younger people is proportionally higher than among people of the same age decades ago. Melanoma is one of the most common cancers in people who are younger than age 30 years, particularly among young women.
Mortality rates are increasing most rapidly among White men older than age 50 years. White persons have a 1 in 38 lifetime risk for melanoma, Black persons have a lifetime risk of 1 in 1,000, and Hispanic persons have a lifetime risk of 1 in 167. Melanoma most often appears on the trunks of fair-skinned men and the lower legs of fair-skinned women; however, people with more darkly pigmented skin often develop melanoma on their palms and soles, and under the nails. While the prevalence of melanoma is lower in Black and Hispanic persons as compared to White persons, Black persons have a two- to threefold risk for mortality as compared to White and Hispanic persons. Persons who are Black, Hispanic, over 80 years of age, or who get care at community as compared to university hospitals are less likely to receive the standard of care than other groups (Restrepo et al., 2019 [see Evidence-Based Practice and Health Policy]). Sexual and gender minority status has no known effect on the risk for melanoma, although sexual and gender minority persons may be less likely to have skin cancer screening because of discrimination or the emotional conflict between self-perception and physical anatomy (Gatos, 2018). Gender and sexual minority persons are a vulnerable group because people with low income, long travel distances to cancer screening sites, or who lack health insurance or paid medical leave are less likely to be treated according to cancer care guidelines (National Institutes of Health, 2021).
The World Health Organization reports that 300,000 melanoma skin cancers occur globally each year, and rates are increasing. It is the 19th most commonly occurring cancer in men and women. One in every three cancers that are diagnosed in the world are skin cancers. The global incidence of melanoma skin cancer is 2.6 per 100,000 females per year and 2.5 per 100,000 males per year. The incidence is 15 times higher in developed than in developing regions, a statistic that may be related to recreational exposure to the sun. The highest rates are in Australia, New Zealand, Norway, and Denmark.
PLANNING AND IMPLEMENTATION
Collaborative
After diagnostic testing, the cancer is staged. Because the thinner the melanoma, the better the prognosis, the Clark level of a melanoma may be used. This system uses a scale of 1 to 5 to describe which layers of skin are involved. The higher the number, the deeper is the melanoma.
The primary treatment for melanoma is surgical resection. Excision of the cancerous lesion with a 2- to 5-cm margin is recommended when feasible. The width of the surrounding margin should be wider for larger primary lesions. Generally, the margin of the excision should be 10 times as wide as the depth of the tumor. For example, if the penetration of the melanoma is 2.5 mm, the margin should be 2.5 cm around the lesion. When the melanoma is on a finger or toe, surgical treatment is to amputate as much of the finger or toe as is necessary. Elective regional lymph node removal is controversial. While completion lymph node dissection may help control the disease, it does not increase survival. Proponents believe that this procedure decreases the possibility of distal metastases.
The prognosis for metastatic melanoma is poor; it is highly resistant to currently available chemotherapeutic agents. In later stages adjuvant therapy and immunotherapy are used as well as intralesional therapy and chemotherapy. Radiation is not often used to treat the original melanoma but is rather used for symptom management as a palliative measure if the cancer has spread to the brain.
General Comments: Cytokines may cause side effects such as chills, aches, fever, severe fatigue, and swelling. Malignant melanoma is relatively resistant to chemotherapy, but several regimens have shown some activity against the cancer.
| Medication or Drug Class | Dosage | Description | Rationale |
|---|
| Chemotherapeutic agents | Varies with drug | Dartmouth regimen: dacarbazine (DTIC), carmustine, cisplatin, and tamoxifen; other: carboplatin, paclitaxel | Decrease replication of malignant cells and kill them |
| Immunotherapy (adjuvant immunotherapy with cytokines), immunomodulation | Varies with drug | Interferon-alpha; interleukin-2; dabrafenib, trametinib, pembrolizumab | Enhances immune system to recognize and destroy cancer cells; shrinks metastatic melanomas (effective in 10%–20% of patients) |
Independent
Patient and family education is the most important nursing responsibility in preventing, recognizing, and treating the disorder. Educational materials and teaching aids are available from various community and national organizations and the local or state branches of the American Cancer Society (https://www.cancer.org) and the National Cancer Institute (https://www.cancer.gov). Nursing care of patients who have had surgery is focused on patient education because most of these patients are treated in an ambulatory or short-term stay setting. Instruct patients to protect the site and inspect the incision and graft sites for bleeding or signs of infection. Immobilize recipient graft sites to promote engraftment. Evaluate limbs that have surgical incisions or local isolated chemotherapy to prevent edema.
Reactions to skin disfigurement that occur with some treatments may vary widely. Determine what the cancer experience means to the patient and how it affects the patient's perception of body image. Help the patient achieve the best possible grooming as treatment progresses. Suggest a support group, or if the patient is coping ineffectively, refer for counseling. If the patient is at a late stage of the disease, discuss with the patient and family if a referral to palliative care is appropriate.
Evidence-Based Practice and Health Policy
Restrepo, D., Huayllani, M., Boczar, D., Sisti, A., Gabriel, E., Lemini, R., Spaulding, A., Bagaria, S., Manrique, O., & Forte, A. (2019). Biopsy type disparities in patients with melanoma: Who receives the standard of care? Anticancer Research, 39, 6359–6363.
- The authors aimed to determine whether patient demographics and institutional demographics cause inequality in the type of biopsy performed for people with skin melanoma. They used the National Cancer Database and included all people with cutaneous melanoma and malignant melanoma. They included excisional, punch, shave, or incisional biopsies. Excisional biopsy is the standard of care for lesions that are suspicious for melanoma.
- They found that the likelihood of undergoing an excisional biopsy decreased in patients who were Hispanic, non-White, and older than 80 years of age. And those who were treated at community rather than academic/research cancer treatment centers were less likely to receive excisional biopsies. These groups did not receive standard of care, leading to health disparities.