Skin Cancer / BBN Flashcards
Breaking Bad News
Open-ended question
D: Hi, my name is ________. I’ll be taking care of you today. How can I help you?
D: Can you tell me what has happened so far?
Assessing Perception
D: Do you know why the investigation was done and what we were looking for?
Warn the Patient
D: I have your results with me today.
D: The results I have are not what we hoped for. OR
D: I have some news that may be upsetting. Is it okay if we talk about it? OR
D: I have bad news today, I wish I had better news, but it is important I share it with you so we can discuss what it means. OR
D: What I’m going to share might be difficult to process, but I’m here to answer your questions and support you through this.
Invitation
D: Do you want anyone to be with you when we discuss the results?
Explain Results
D: Your results show that you have ______ (medical diagnosis), which is a skin cancer.
Patient will start crying once you say cancer
Tissue: Would you like some tissue?
Water: Would you like to have a sip of water?
Offer silence: count to 10
Empathy
If patient is still crying, but you need to discuss the results, ask her: Would you like to discuss this in another day, in another consultation?
Your next patient is a 55 year old man who has come to you today to discuss his results. He is a farmer from central Queensland and had a mole on his forehead which was removed by an excisional biopsy last week.
Results given:
Superficial spreading melanoma, margins are clear, depth is 0.4mm
Tasks:
Explain the results to the patient
Explain your management plan
Open-ended question
D: Hi, my name is ____. I’ll be taking care of you today. Can you tell me what has happened so far?
Assess Perception
D: Did the doctor tell you what we’re looking for and why we wanted to take that sample from the skin lesion?
Warn the patient
D: I have your results with me. It may not be what we hoped for, and this might be difficult to hear, but it is important that I share this so we can discuss what it means and what we can do moving forward.
Invitation
D: Would you want anyone to be with you when I discuss the results?
Explain the Results
D: Your results show a condition called melanoma which is a type of skin cancer.
Emotional component
D: Would you like any tissue?
D: You may have a sip of water.
D: Silence for 10 seconds
D: I’m truly sorry to deliver such difficult news. I can only imagine how challenging this can be. OR I understand the news is overwhelming, we will do everything we can to support you through this. If there’s anything specific you want to ask or discuss, please let me know.
If patient is still crying
D: Would you like to discuss the rest of the details in another consultation?
Explain the condition
A melanoma is an uncontrolled growth and a cancer in a special cell in your skin called the melanocytes.
(Key point)
The most important prognostic factor for the outcome of this cancer is the depth of the mole and the good news is that we have picked up the cancer early and it has not spread too deep into the skin.
Management
Key point 1: Re-excision
Once we make a diagnosis of melanoma, we prefer to do another skin excision to make sure no cancer cells are left behind
The size of the excision depends on the depth of the melanoma. In your case, as the depth is <1mm, we are going to remove a margin of 1cm off your skin
I will refer you to the dermatologist to do the procedure
Key point 2: Sentinel Lymph node
During the excision, the specialist will check the Sentinel lymph node which is the first lymph node close to the area. We check it to make sure that the cancer has not spread.
The specialist injects a dye and takes a sample from the first lymph node that picks up the dye
In case the lymph node is involved and we find cancer cells in it, we may do CT scans from the brain, chest and abdomen or do a PET scan to check for spread
Key point 3: Full Skin check
You will need to do a full skin check as you have had a skin cancer and a melanoma, there is the possibility of having another melanoma or another type of skin cancer
We are going to examine your entire skin, including the head, behind the ears, neck, and other parts (except genitalia unless there is a suspicious lesion there)
Key point 4: Sun protection
Sun exposure is the main risk factor for skin cancers. It is important to wear sunscreen and reapply it every 2 hours. Use a sunscreen with an SPF of at least 30.
Avoid high risk times during the day, usually 12PM - 2PM. You can check the UV index on your phone or on the newspaper to know if it is a risky day for sun exposure
Cover your body with clothes, wear a broad brimmed hat, wear sunglasses, seek shade
Key point 5: Review
Since your lesion is <1mm, I’d like to review you and do skin checks annually
Please notify your first-degree family members to see your GP for a skin check as they have a higher risk for melanomas (four-fold increase)
Key point 6: Red Flags
If you ever notice a skin lesion that is increasing in size, changing in color, is symptomatic (itchy or bleeds when you touch it), come back to me for an examination
Refer: I will refer you to the cancer council and the cancer nurse
Reading material: cancer council.
Your next patient is a 63 year old lady who has come to you to discuss biopsy results. A biopsy was done on a skin lesion on her temporal region last week and results show:
Nodular BCC ,extending to one peripheral margin, no LN involved
Tasks:
Explain results to patient
Discuss the implications and management
Breaking Bad News
Open-ended question
D: Hi, my name is ___. I’ll be taking care of you today. Can you tell me what has happened so far?
R: I had this mole on my forehead. The doctor told me that I had to cut it off. He made this big cut that made this big scar on my forehead, and I’m here for the results today.
Perception
D: I’m so sorry that you have a scar in the forehead. But did the doctor explain why he had to make that cut and what he was looking for?
R: No doctor, he didn’t tell me what he was looking for. He just told me that we had to take it off.
Warn the patient
D: I have you results with me today. Unfortunately the news I have for you is not that good. Is there anyone that you’d like to be with you when I discuss your results?
R: No, please tell me.
D: Your results show basal cell carcinoma, which is a type of skin cancer.
R: Oh my god, I have cancer. she starts crying
D: Give tissue I’m so sorry to give you this news. I wish I had better news. Do you want a glass of water? Do empathy things Do you want some time to maybe discuss this in another consultation?
R: No doctor, please continue.
Explain results to patient
D: Your results show basal cell carcinoma, which is a skin cancer in the lower part of the epidermis, which is the outer layer of the skin. It is the most common type of skin cancer and the good point about this cancer is it grows slowly and does not spread to other parts of your body. We usually try to remove the entire lesion on the first skin excision, but your report shows that there are some skin cancer cells extending to one margin of the cuts we made during the first excision, which means that there are some skin cancer cells remaining on your skin.
D: Key point 1: I will need to refer you to the dermatologist/skin surgeon. We have some options: The best option is to remove the rest of the cancer with another skin excision & surgery
R: No, I don’t want another surgery
D: May I know why you don’t want another surgery?
R: I already have a big scar
D: I understand that you have concerns about a scar, but in these cases, the specialist can use a special technique called MOHS surgery which minimizes the scar and the amount of skin that we remove. In this method, the specialist will remove small pieces of skin and check it at the same time to make sure they have clear margins and to make sure that the entire cancer has been removed. With this method, we will be removing minimal skin, and this minimizes the scar
R: No, I don’t want any surgery.
D: I understand that you don’t want any surgery. If you’re not happy with the surgical option, there are other options that we can try, but these have side effects and have a risk of failing to treat the remaining cancer completely. We can try:
Cryotherapy - we use liquid nitrogen, spray it on the area and we freeze and kill the cancer cells
Topical medications - we can use a cream called imiquimod. You have to apply it on the area a few times, but it can cause some skin irritations
Photodynamic therapy - you apply a cream on the area which makes the skin sensitive to light and then we shine a special light to the area to kill the cancer cells
Radiotherapy - we can use radiation to kill the cancer cells, but it can damage the surrounding tissues too
D: I will give you some reading materials about the options, and I will also ask the specialist to discuss the options with you so you can make an informed decision about this. I can arrange for a family meeting and a joint meeting with the specialist to have a chat about this.
D: Key point 2: As we have diagnosed a skin cancer, I’ll arrange for you to come back to do a full skin check, to make sure that you don’t have other areas of cancer.
D: Key point 3: Sun protection
D: I want to review you, depending on the option that you choose. If you see any lesion that is changing in color, is itchy, is growing, please come back to me
D: Referrals: cancer nurse, psychologist; reading material from cancer council
Your next patient is a 63 year old lady who has come to you to discuss her biopsy results. A biopsy was done on a skin lesion on her temporal region last week and results show:
Squamous cell carcinoma, margins are clear
Tasks:
Explain results
Discuss your immediate and long-term management
Open-ended question
D: Hi, my name is ____. I’ll be taking care of you today. Can you tell me what has happened so far?
Assess Perception
D: Did the doctor tell you what we’re looking for and why we wanted to take that sample from the skin lesion?
Warn the patient
D: I have your results with me. It may not be what we hoped for, and this might be difficult to hear, but it is important that I share this so we can discuss what it means and what we can do moving forward.
Invitation
D: Would you want anyone to be with you when I discuss the results?
Explain the Results
D: Your results show a condition called squamous cell carcinoma which is a type of skin cancer.
Emotional component
D: Would you like any tissue?
D: You may have a sip of water.
D: Silence for 10 seconds
D: I’m truly sorry to deliver such difficult news. I can only imagine how challenging this can be. OR I understand the news is overwhelming, we will do everything we can to support you through this. If there’s anything specific you want to ask or discuss, please let me know.
If patient is still crying
D: Would you like to discuss the rest of the details in another consultation?
Explain the condition
A squamous cell carcinoma is a type of cancer in a special cell in your skin called the squamous cells.
The good news is that we have been able to remove the entire cancer with a safe margin.
Key point 1: Examine lymph nodes
I will examine your lymph nodes and glands to make sure that the cancer has not spread. Sometimes, the specialist may decide to do further scans to make sure that it has not spread to other areas of the body.
Key point 2: Full skin check
Key point 3: Sun protection advice
Key point 4: Review
I would like to follow you up every 3-6 months for the first 2 years then every 6-12 months to do a full skin check and a full lymph node examination
Key point 5: Red flags: lumps and bumps in the body, losing weight, etc
Refer: I will refer you to the cancer council and the cancer nurse
Reading material: cancer council
Version 2:
Margins are not clear - patient concerned of the scar
We have been able to remove the major part of the cancer, but the margins are not clear. We need to go back for a re-excision.
R: No, I don’t want another surgery
D: May I know why you don’t want another surgery?
R: I already have a big scar
D: I understand that you have concerns about a scar, but in these cases, the specialist can use a special technique called MOHS surgery which minimizes the scar and the amount of skin that we remove. In this method, the specialist will remove small pieces of skin and check it at the same time to make sure they have clear margins and to make sure that the entire cancer has been removed. With this method, we will be removing minimal skin, and this minimizes the scar
R: No, I don’t want any surgery.
D: I understand that you don’t want any surgery. If you’re not happy with the surgical option, there are other options that we can try, but these have side effects and have a risk of failing to treat the remaining cancer completely. We can try:
Cryotherapy - we use liquid nitrogen, spray it on the area and we freeze and kill the cancer cells
Topical medications - we can use a cream called imiquimod. You have to apply it on the area a few times, but it can cause some skin irritations
Photodynamic therapy - you apply a cream on the area which makes the skin sensitive to light and then we shine a special light to the area to kill the cancer cells
Radiotherapy - we can use radiation to kill the cancer cells, but it can damage the surrounding tissues too
However, since squamous cell carcinoma has a potential for metastasis or spread, our preferred method is still a surgical excision.
D: I will give you some reading materials about the options, and I will also ask the specialist to discuss the options with you so you can make an informed decision about this. I can arrange for a family meeting and a joint meeting with the specialist to have a chat about this.
Version 3:
Confirmed SCC in situ, margins are clear, but it’s 0.8mm
We have been able to remove the cancer completely from your skin. As a squamous cell carcinoma has the potential to spread to the surrounding skin, we prefer to have at least 1mm of cancer-free skin around it to be safe. In your case, the cancer-free margin is 0.8mm. For this reason, I will refer you to the dermatologist to discuss the options with you.
We prefer a surgical removal, we can do it with a MOHs surgery.
Occasionally, we can do radiotherapy, or topical treatment but since squamous cell carcinoma has a potential for metastasis or spread, our preferred method is still a surgical excision.
Your next patient is a 55 year old man who initially presented to your GP with frequency, urgency, and pain on passing urine. On DRE, you found a large prostate and referred him to the urologist. The urologist has investigated the prostate and results are:
PSA 6 (<4 normal, 4-6 intermediate, >10 high)
Core biopsy shows adenocarcinoma, Gleason score of 7 (intermediately aggressive)
Cystoscopy did not reveal bladder neck obstruction
Whole body isotope scan revealed no metastasis
CT pelvis and spine normal and no cancer outside of prostate capsule
Tasks:
Explain results and implications
Discuss treatment options with the patient
Open-ended question
D: Hi, my name is ____. I’ll be taking care of you today. Can you tell me what has happened so far?
R: Please explain the results, when I saw the word cancer, everything became a blur.
Warn the patient
D: Yes, I have your results with me. It may not be what we hoped for, and this might be difficult to hear, but it is important that I share this so we can discuss what it means and what we can do moving forward.
Invitation
D: Would you want anyone to be with you when I discuss the results?
Explain the Results
D: Your results show that you have a prostate cancer.
Emotional component
D: Would you like any tissue?
D: You may have a sip of water.
D: Silence for 10 seconds
D: I’m truly sorry to deliver such difficult news. I can only imagine how challenging this can be. OR I understand the news is overwhelming, we will do everything we can to support you through this. If there’s anything specific you want to ask or discuss, please let me know.
If patient is still crying
D: Would you like to discuss the rest of the details in another consultation?
Explain the condition
The prostate is a walnut-shaped gland which is located below your bladder which secretes some fluid in the semen.
We have found a type of cancer called adenocarcinoma, which is a cancer in the gland cells of the prostate.
We look at the characteristics of the cells to calculate a score called the Gleason score which tells us how aggressive the tumor is and what the possibility is of the cancer spreading.
Your score is 7, which means that we have an intermediate risk of spread and it is not a high risk of spread.
We have done a blood test called the prostate specific antigen, which we check for prostate cancer. Usually in a cancer, it is elevated, but we are concerned if the level is above 10. In your case, it is mildly elevated and is 6.
The good news is that we have checked for spread of the cancer, and all of your scans are normal and clear of any spread.
We have also checked the bladder, and the prostate is not causing any narrowing of the outlet of your bladder.
Management
Overall, prostate cancer is a slow-growing cancer and it takes many years for it to grow and possibly spread. This is the reason that it gives us some options to treat it. I will be explaining each option and the pros and the cons of each option for you to make an informed decision.
Active surveillance or a wait-and-watch approach
Usually we prefer to do this in old men above the age of 60 or 70. But we can only do it in low to moderate grade tumors, which have a PSA level of less than 10, and Gleason score of 7, where we can wait and continue monitoring the tumor. The reason we can do this is the slow speed of growth in this specific cancer which gives us time to monitor for any changes. An advantage of this is that the other treatment options usually have some complications like erectile dysfunction, and we can avoid this complication for some time. The cons of this are:
There is still a possibility of the cancer growing and spreading
You will need to do PSA every 3 months, DRE every 6 months, and biopsy every 6-12 months and every 2-3 years
Surgery
We can remove the prostate gland with a surgery. It can be done in an open surgery where we make a cut on your abdomen and remove the prostate, or a keyhole surgery where we make 3 small cuts on your abdomen, insert tubes to remove the prostate; or the new method of a robotic methods.
The advantage of this is, as we remove the cancer completely, we won’t have to worry about the spread of the cancer. But the disadvantage of this is, it can have some complications like erectile dysfunction, urinary incontinence, infection, bleeding
Radiotherapy
In this method, we try to kill the cancer cells using radiation
We have 2 options:
We will shine radiation to the area of the prostate. But the disadvantage of this is you may have urinary symptoms like frequency and urgency, pain and blood during urination, or bowel symptoms like diarrhea or painful bowel motions
Brachytherapy: we will insert a small radioactive seed in the prostate and that will kill the cancer cells
Hormonal treatments
We can use some medications to suppress the androgen hormones which trigger the growth of the cancer.
Medication by injections: Zoladex
Sometimes, we can remove the testes to reduce the androgens in the body
I’ll give you some reading materials from Cancer council. You can think about all the options. We can have a joint meeting with your family and the urologist to discuss the options, and you can decide which option that you prefer.
Red flags: urinary retention, bone pain
Review regularly
Refer to cancer nurse
You are working in the general surgery clinic. A 27 year old lady comes to you for the results of an FNA of thyroid nodule. The results show microcalcifications from a 1.5cm nodule on the right lobe of the thyroid and cytology is positive for papillary thyroid carcinoma.
Tasks:
Explain results
Explain next steps in management
Explain the consequences of management
Open-ended question
D: Hi, my name is ____. I’ll be taking care of you today. Can you tell me what has happened so far?
R: Please explain the results, when I saw the word cancer, everything became a blur.
Warn the patient
D: Yes, I have your results with me. It may not be what we hoped for, and this might be difficult to hear, but it is important that I share this so we can discuss what it means and what we can do moving forward.
Invitation
D: Would you want anyone to be with you when I discuss the results?
Explain the Results
D: Your results show that you have a papillary thyroid cancer.
Emotional component
D: Would you like any tissue?
D: You may have a sip of water.
D: Silence for 10 seconds
D: I’m truly sorry to deliver such difficult news. I can only imagine how challenging this can be. OR I understand the news is overwhelming, we will do everything we can to support you through this. If there’s anything specific you want to ask or discuss, please let me know.
If patient is still crying
D: Would you like to discuss the rest of the details in another consultation?
Explain the condition
D: Your results show papillary thyroid cancer. It is a cancer in a butterfly-shaped gland in your neck. This is the most common type of thyroid cancer.
Management
Step 1 is we need to examine your neck for lymph nodes and also do an ultrasound to assess the possibility of the cancer spreading. This will help us grade the cancer features and characteristics.
First line of treatment is surgical removal. We have two options:
Total thyroidectomy: we remove the entire gland
Lobectomy: in this method, we remove part of the gland
The final decision depends on your lymph node results, the grading of the cancer, and the surgeon will involve you in the decision making.
After surgery, we use a treatment technique called radioactive iodine. By giving this, any possible cancer cells which were left behind will pick up the iodine and this will destroy the cancer cells.
We will follow-up with regular blood tests and we’ll do a test called thyroglobin (TG). If thyroglobin stays high, this means that there are cancer cells remaining in the body and in that case, we will send you for a radioiodine uptake scan to find the remaining cancer cells.
Explain consequences
During a thyroid surgery, there is a risk of damage to a nerve called the recurrent laryngeal nerve, which is a nerve that goes to the voicebox. If injured, it can affect your voice.
Upon removing the entire thyroid gland, we need to prescribe you with thyroid hormones/thyroxine for the rest of your life.
Sometimes after surgery, you may develop a low calcium (hypoparathyroidism).
