Skin cancer: it’s the tiger in the jungle waiting to pounce – the tiger that could kill your patients quickly… it’s the tiger that you can’t afford to miss.
As primary care clinicians, optometrists will regularly encounter patients with skin cancer on the face, ears and scalp. You have a role to play in the detection and referral management of this disease. This role confers legal obligations.
Australia and New Zealand have the highest prevalence of skin cancer in the world. Skin cancer rates increase with age, and this rate increase coincides with presbyopia. In Australia every year, 48 out of every 100,000 people will be diagnosed with melanoma.1 In New Zealand, it’s 50 per 100,000.1 The numbers of people dying from melanoma are also increasing.1
Skin Cancer Encounters in Practice
The Australianpopulation has a strong representation by light skin types. Chronic sun exposure is the main driver for rising skin cancer rates. The combination of light skin and excessive chronic sun exposure has resulted in elevated skin cancer rates over recent decades. By age 70, one in three Australians with fair skin will have had at least one skin cancer. The vast majority of these skin cancers are basal cell carcinoma (BCC) followed by squamous cell carcinoma (SCC). With prolonged neglect, SCC can result in distant spread and eventual death. High risk sites for aggressive SCC with a worse prognosis include the ears, lip and other central facial sites. Melanoma can behave in a more aggressive manner than SCC. The scalp, ears and other facial sites are also high risk sites for melanoma.
there is a responsibility within the optometry profession to recognise something that could be skin cancer
Skin cancer specialist Dr. John Pyne says optometrists are well placed to notice possible skin cancers during a consultation and refer the patient on for medical assessment. Importantly, he says, as healthcare professionals, they have a legal obligation to do so.
“I use the analogy of dentists. Dentists don’t just examine and manage teeth – they have a duty of care to examine the oral cavity and around the mouth. If a patient presents to a dentist with a potential cancer on the lip, tongue, or other area in the oral cavity, the dentist has a duty of care to recognise a lesion as suspicious for cancer and refer the patient for medical assessment,” said Dr. Pyne.
“In a similar way, the role of optometrists in primary health care is not just examining eyeballs, optics and vision. It is expected that an optometrist should recognise an atypical skin lesion and consider if skin cancer is in the differential diagnosis. If most optometrists refer these skin lesions, this creates a legal obligation for the optometry profession as a whole to conduct such referrals.
“During a consultation, an optometrist can examine a patient’s central facial features with slitlamp magnification. When optometrists fit spectacle frames to the ears, they are looking at the patient’s ears and often, pulling them back. When a patient sits in the chair, the optometrist is quite typically, standing up and can look down to view the patient’s face and scalp.
“These actions offer opportunities to identify suspicious skin lesions. Obviously, the role of the optometrist is not to diagnose skin cancer and treat it. However, there is a responsibility within the optometry profession to recognise something that could be skin cancer, then refer the patient on,” he said.
Clues to Common Skin Cancer Presentations
Dr. Pyne explained that as with most malignancy, growth and change in appearance are common skin cancer presentations. “Any new or changing lesion with growth over weeks to months should be viewed with suspicion. Malignancy has a higher metabolic demand compared to background skin. Increased local blood supply presents as pink. Acquired or persistent pink is suspicious. Tumour associated blood vessel morphologies typically appear different to background blood vessels. Tumours can expand and split the epidermis creating ulceration. Persistent ulceration at a site not exposed to trauma is a common clue to malignancy. Disturbed or altered skin surface morphology, even without ulceration, is another common clue to skin cancer,” said Dr. Pyne.
Sample Images of Skin Cancers
Images of skin cancer cases included in this article display some common presentation features. Figure 1 is a basal cell carcinoma. Note the changed blood vessel morphologies. Figure 2 is another basal cell carcinoma displaying altered surface morphology compared to the adjacent background skin. Figure 3 is a squamous cell carcinoma with tumour associated blood vessels highlighted by white keratin. Figure 4 is another squamous cell carcinoma case showing exophytic growth and ulceration. Figure 5 is an invasive melanoma with atypical blood vessel morphologies and altered brown pigment.
Aside from saving lives and reducing morbidity from late presentation, taking the time to look for skin cancer can make good business sense. The opportunity to recognise a skin cancer at an early stage and refer on is a great practice building strategy – one that will ensure patient loyalty (and possible longevity) and enhance your professional reputation for being thorough. Conversely, not recognising or referring a patient on to have a potential skin cancer checked has the potential to compromise your professional reputation.
Recognising something that could be a skin cancer and referring it on is not a particularly arduous job. If you do detect something potentially dangerous, and initiate the process of diagnosis and treatment, the patient’s life may be saved… and your reputation enhanced.
Skin cancers are a common encounter in routine optometric practice. Optometrists should be mindful of skin lesions which may be skin cancers and refer relevant cases for medical review. A vigilant optometrist who initiates a referral, which leads to skin cancer diagnosis and treatment, may save the patient’s life.
Dr. John Pyne: From Optometrist to Skin Cancer Specialist
|Dr. John Pyne never intended to be a skin cancer specialist. He finished his studies in optometry and toyed with the idea of studying medicine. “I wasn’t quite sure what I wanted to do… but I decided to throw my hat in the ring and applied to University of Sydney. I forgot about the application until I received a letter of acceptance. I had to make a decision within three days. I was in my 20s and didn’t have kids, so I decided, why not?
Dr. Pyne’s intention was to study ophthalmology however at that time, the University of Sydney’s teaching college was focused on melanoma and so as a medical undergraduate he received extensive exposure to melanoma patients. “I was being taught general surgery as an undergraduate, in the melanoma unit by Professor Bill McCarthy. He was a really good mentor and teacher and I became increasingly interested in the area.”
Both Dr. Pyne’s mother and father had had skin cancer, and having enjoyed an outdoor lifestyle growing up in the Sutherland Shire, he knew his own skin was at high risk. Dr. Pyne’s past, combined with his studies, directed his future and before he knew it, he was practising in melanoma skin cancer and working as an academic. “I built the world’s first Master of Medicine (skin cancer) degree at the University of Queensland – there’s still nowhere else you can study it at this level, and I completed a PhD looking at the correlation between dermatoscopy – or the optical image – and the histopathology of skin cancer.”
Today Dr. Pyne, MBBS BOptom (Hons 1) MMed PhD FSCCA is an Associate Professor of Skin Cancer Medicine at The University of New South Wales. He has a well-established practice in Sydney’s Sutherland Shire, and continues his work at the University of Queensland, as Program Director and Course Co-ordinator for the Master of Medicine (skin cancer) course. He is a Senior Lecturer of optometry students at the UNSW SOVs, and he delivers lectures to colleges, associations and medical practitioners around the world, among numerous other roles.
Passing on the Knowledge
As Dr. Pyne sees it, he has reached a stage in his career, when it is increasingly important to ensure knowledge about skin cancers is shared and well understood.
“If you’re confronted with a common disease that kills a large number of people, there’s an obligation on you, as a teacher, to gather the knowledge and pass it on. So having students in my clinic, and taking the time to teach them; taking the time to research and write papers, have them formatted, peer reviewed and published in scientific journals, is what has been driving me for the last 10 years.
“I’m 100 per cent focused on skin cancer and nothing else. I liken it to the tiger in the jungle waiting to pounce – the tiger that could kill your patients quickly… the tiger that we, as health care professionals, can’t afford to miss.
“What I’m really interested in is making sure people don’t die prematurely. And to be able to do that – to save lives – is a privilege.”