Abstract
Keywords: Resident, residency, skin cancer, physician-patient communication, shared decision making, patient engagement.
Citation: Nambudiri VE. A resident’s view: eliminating skin cancer — choose your own adventure. J Participat Med. 2012 Feb 29; 4:e4.
Published: February 29, 2012.
Competing Interests: The author has declared that no competing interests exist.
After logging in to the hospital’s online portal from my home laptop, I clicked through a series of targeted news stories that vaguely piqued my interest. The hospital’s annual holiday party with decadent cupcakes and hot cider was coming up the following week; a new study published by researchers who were affiliated with the hospital was receiving widespread media coverage for its novel molecular target for cancer chemotherapy. A reminder flag alerted me that my password would expire in three days. Adding a to-do item to the ever-expanding list, I clicked through the reminder and on to the “Results” screen to follow up on the skin biopsies I had performed earlier in the week. I looked forward to being able to call my patients the next morning to discuss the results with them. Engaging in discussions about the management of benign and complex skin lesions with my patients has taught me more than any reading from the dozens of textbooks or hundreds of articles that laid the foundation for my medical education.
As a resident training in internal medicine and dermatology, I find myself traversing a range of clinical environments, from the outpatient clinics to the inpatient wards, from the intensive care units to the surgical procedure rooms — all in the name of providing care and striving to become the best physician I can be for my present and future patients. I rely heavily on multiple online medical record platforms, several email accounts, and a detailed schedule on my smartphone to juggle my clinical responsibilities.
A critical component of providing care for my patients is diligent followup of laboratory tests and biopsy results that I order, and communicating the results of these procedures to my patients. Learning to follow up on the tests and procedures not only allows me to understand the full scale of clinical care delivery, but also offers me a chance to connect with my patients in a less frenzied environment than the ephemeral 15-minute office visit or rapidly paced morning rounds. While some patients are able to access their blood tests from home via their own secure patient websites, every patient on whom I do a skin biopsy receives a phone call from me with their results, giving me a chance to refine my communication skills, which are increasingly needed for efficient and compassionate care delivery.
My attention turned back to the computer screen as the “Results” page finally loaded. Two blood tests that measure kidney and liver function — performed for monitoring one of my patients who was taking immunosuppressive medications — had returned normal values. I made a note to call the pleasant gentleman in the morning and let him know to continue the current dose of his medications, and that we would see him again in one month for a followup visit.
Scrolling down the list, the next result caught my eye. A pathology report was available from a skin biopsy on a delightful 55-year-old woman, Ms. P, whom I had seen in clinic three days earlier. She presented with a concern about a small spot on her arm that was red, very mildly tender, and had recently bled when she accidentally scraped it. It had been present for the last few months and was not particularly bothersome to her. Using my hand-held dermatoscope, I took a closer look at the pearly red growth on her arm that was barely more than a few millimeters in length. The papule’s distinctive vascular markings and slightly rolled border raised the suspicion in my mind for one particular diagnosis: basal cell carcinoma of the skin.
Basal cell carcinoma is the most common of all cancers diagnosed in the United States each year. Over 1 million new cases of either basal cell or squamous cell skin cancer are expected to occur in 2012.[1] Arising from a particular cell population in the uppermost level of the skin known as the epidermis, basal cell carcinomas are often viewed by dermatologists and other physicians as the “friendliest” of all skin cancers, as their progression to metastatic disease is rare (though it does occasionally occur in the aggressive variants), especially if the initial cancer is caught early.
I had surgically biopsied a small piece of tissue from the spot in question on my patient’s arm and sent it to the pathology lab, awaiting the results that were now available for my review. Looking at the results at hand, I realized I would need to deliver the news to my patient the next morning that in fact, as suspected, she had skin cancer. The pathology report identified the lesion as a superficial basal cell carcinoma without any adverse features such as deep extension or invasion around nerves. As she was an otherwise healthy woman without other risk factors such as immunosuppression or a prior cancer history, I envisioned the management of her skin cancer would be straightforward.
The next morning during our phone call, I first inquired about the site of the biopsy: was there any tenderness or discomfort present at the site? Ms. P stated that her arm was pain-free; the area of the biopsy had formed a small scab that was completely covered by a simple bandage. Our conversation transitioned to a discussion of her biopsy results. I reviewed the pathology report which had identified the spot on her arm as a superficial basal cell carcinoma. As I paused to allow time for her to react and reflect on the diagnosis of skin cancer, she surprised me with her response.
“So it is in fact a basal cell cancer? Great, I’ve read all about them since you mentioned the possibility in clinic. I’d like to discuss the different treatment options — and would like to know which one you would choose to get rid of it if you were faced with the decision.” Her matter-of-fact manner surprised me, her thoughtfulness impressed me, and her desire to weigh my personal input flattered me. As a resident physician at a large academic medical center, I have often seen patients hang on every word uttered by the sage attendings, who are often world experts in their fields. To have a patient earnestly involve me in therapeutic decision making was humbling, but exciting. I wanted to fulfill and surpass her expectations.
Ms. P had read extensively on the matter of basal cell carcinoma from medically oriented websites. She spoke with several of her friends who had seen dermatologists for similar spots in the past, and each seemed to recall a different method for treating them. Indeed, the management options for superficial basal cell carcinoma are quite varied, with several therapeutic modalities available.[2][3] The options available for the treatment of superficial basal cell carcinoma include local surgical excision (with a variety of surgical techniques), staged Mohs micrographic surgery (often reserved for very large lesions or those on the head and neck), cryosurgery (applying liquid nitrogen to the skin to induce a local frostbite-like reaction and kill off the cancer cells), electrodessication and curettage, topical chemotherapy creams (including imiquimod or 5-fluorouracil), photodynamic therapy (applying a topical photosensitizer to the lesion and then shining a fixed wavelength of light to activate and kill the cancer cells), and radiation therapy. The time course for definitive treatment may be seconds to minutes, as in the case of cryosurgery, or take weeks, as with the application of topical chemotherapeutic creams.
As with the removal of virtually any skin growth, multiple factors are considered in weighing therapeutic options; the ultimate goal is to eliminate the basal cell carcinoma and prevent recurrence. A trade-off exists between removing the cancerous cells with a margin of normal tissue and maintaining an acceptable cosmetic appearance during and after treatment. While cryosurgery or electrodessication and curettage may be the fastest treatments, the post-treatment scars and dyspigmentation they leave in their wake are usually much larger than those seen with surgical excisions which remove greater margins of healthy tissue. Topical chemotherapy creams may eliminate the need for an office procedure, but require application multiple times per week for several weeks, which patients may find cumbersome.
I spent several minutes reviewing the range of options with Ms. P and answering her insightful questions. Given the skin cancer’s small size and location, Mohs surgery seemed unnecessary and radiation therapy was not necessary or appropriate.. I proposed topical chemotherapy creams as an attractive option for Ms. P, given her ability to easily reach the spot on her forearm, but she preferred a quicker, more definitive procedure. We collaboratively whittled down the list of acceptable alternatives to surgical excision, the combination of electrodessication and curettage, or cryosurgery. It was then that she again asked me with her kind but direct tone: “Ok, so which of these three would you choose for yourself?”
I paused — would the treatment I chose for myself be the “right” treatment for Ms. P? Was she looking to me to make a decision to alleviate her own angst in picking a therapeutic modality? Would my own desire to further my procedural skills influence the way in which I answered her question? The cure rate from each of the procedures is statistically indistinguishable based on the evidence from past scientific studies. I replied to Ms. P with an honest but guarded response. “I have seen patients do well with all of these treatments. I personally would choose the surgical excision. It takes longer and it requires stitches in place afterwards, but I think it would work well for your particular skin cancer given its location and size.”
Her reply caught me by surprise: “You know, I want to thank you — you’re the first doctor that has ever given me such a straightforward answer! I was leaning towards that option even before you called to tell me the results, and I really appreciate your walking me through all of the choices.” Ms. P’s gratitude continued through the remainder of the conversation, and as I took down her information to schedule a followup visit for the surgery, I returned the compliment. “You know, thank you for asking all of those questions — talking through all of that has really helped make me a better physician and I look forward to helping my next patient through a similar discussion.” I looked forward to seeing her again in clinic the following week to rid her of the small skin growth that had taught us both so much.
In the era of increasing comparative-effectiveness research, cost-effectiveness studies, and calls for value-based health care delivery, the medical field is taking its practice to the next level. Physicians are identifying the superiority of one drug over another for the management of hypertension and the benefits of different screening modalities for various kinds of cancer. Efforts are underway to answer several of these questions for the management of skin cancers, providing ways to better serve our patients and provide them with more definitive answers. As I complete my residency and embark on a medical career at this exciting time, I know the challenges that lay before me are vast — and that my patients will continue to teach me how to thrive and succeed at every step along the way.
References
- National Cancer Institute. Cancer Topics: Skin Cancer. Available at: http://www.cancer.gov/cancertopics/types/skin. Accessed February 1, 2012. ↩
- Cockerell CJ, Tran KT, Carucci J, et al. Basal cell carcinoma. In: Rigel DS,
Robinson JK, Ross M, et al (eds):. Cancer of the Skin, ed 2. St Louis, MO:
Elsevier/Saunders; 2011:99-122. ↩ - Bath-Hextall FJ, Perkins W, Bong J, Williams HC. Interventions for basal cell carcinoma of the skin. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD003412. DOI: 10.1002/14651858.CD003412.pub2. Accessed February 1, 2012. ↩
Copyright: © 2012 Vinod Easwaran Nambudiri. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.