Care pathway for a skin cancer patient

Surgically removed moles are sent to a pathologist for examination. The majority of mole changes and skin changes are benign, but without a histological examination by a pathologist, a diagnosis cannot be made and appropriate treatment cannot be begun. It is therefore important to see a doctor whenever you notice a suspicious changed mole or some other type of lesion on your skin. 

A helpful checklist of typical features of a suspicious mole is easy to remember by the letters ABCD: 

C = Color: variable, several shades, uneven 
D = Diameter of the area (mole): generally 6+ mm, changes in shape and size 
B = Border: jagged, irregular 
A = Asymmetry: irregular shape 

Further information: Skin cancer patient's guide

The Head Physician or a designated specialist will issue you with instructions based on your referral details, and will also draw up a preliminary plan for examinations and treatment.   

Once your referral has been received at the plastic surgery unit, you will be booked an appointment with a physician or for minor surgery. 

In Uusimaa, treatment is given at Töölö, Jorvi, Hyvinkää, Porvoo and Lohja Hospitals.

Before your appointment, you will receive a medical history form. Please fill this in with care. You can fill in the form in our online service, or you can fill it in on paper and mail it to us in the return envelope provided. Please ensure in particular that your list of medications is up to date. At the appointment, a physician and a nurse will review your medical history and medication with you and will enter your up-to-date details in the information system. Your family is welcome to attend the appointment. 

At the appointment, the physician will prepare a surgery plan with you. You will be informed of the procedure to remove your skin cancer or its scar. You will also be informed if a sentinel node examination is planned for you.    

Generally, the surgical wound can be closed directly, but it may be necessary to employ a skin graft or use a local flap of skin to close the wound, depending on the location and size of the tumor.

The nurse at the visit provides both written and oral information about coming in for the operation.

Surgery to remove the scar left by a skin cancer operation is performed with a wider margin of healthy tissue. The lymph node area corresponding to that area of skin may be examined in connection with this latter surgery. 

Some types of skin cancer may metastasize first only to specific lymph nodes, often those closest to the tissue change, in the neck, armpits or groin. These lymph nodes where metastases first form are called sentinel nodes. 

There may be one or more sentinel nodes. Sentinel node examination yields information about whether and how the disease has spread, and it factors into further treatment choices. 

To find a sentinel node, a small amount of radioactive marker is injected with a thin needle beside the skin tumor or removal scar.  

This substance travels through lymph vessels to the sentinel nodes, which can then be scanned using a camera that detects gamma radiation. The location of the sentinel nodes that show up in the lymphoscintigraphy scan or lymph node map is marked on your skin with a marker pen. You must not wash off these markings. The lymph node map depicts the anatomy of lymph nodes and vessels, not the extent of the cancer tissue. A pathology examination will reveal whether the sentinel nodes are cancerous.  

Before the operation, you will meet the surgeon and a nurse, and the anesthetist if necessary. The purpose of this appointment is to inform you about the operation and to have a discussion about it.

Before coming in for the operation, you will have visited the laboratory for blood tests on the day before the operation or on the morning of the day of the operation.   

A skin cancer operation may be performed as ambulatory surgery, meaning that you will be discharged on the same day, or via inpatient care, meaning that your discharge will depend on the type of operation and your general condition.

On the morning of the day of the operation, a nurse will prepare you for surgery, checking your health by measuring your blood pressure, heart rate, and oxygen saturation, and inspecting your skin condition. You may discuss the operation and postoperative care with the nurse if you wish.   

After the examination, you will change into surgical clothes and receive premedication if you so wish.

Further information: Leikkaukseen.fi

In the operating room, you will be met by the anesthetist and an operating room nurse. They will verify your identity while the nursing staff introduce themselves. The nurse delivering you for the operation will provide your background information and ensure that all the details are in order.   

In preparation, an intravenous catheter (‘drip’) will be inserted in you for administering fluids. Monitoring devices required for general anesthesia and for surgery (e.g. ECG and blood pressure sensors) are also installed. 

A skin cancer operation can be performed under general anesthetic or local anesthetic.   

A skin cancer operation begins with removal of the tumor or of the scar left in a removal operation. The relevant sentinel nodes are located using a surgical radiation sensor.  

The removed tumor or scar and sentinel nodes are sent to a pathologist for examination. The pathologist examines the sentinel node thoroughly, returning an answer a few weeks after the operation. 

A skin cancer operation lasts 1 to 4 hours.  The duration depends on a number of things: the extent of the tumor or its scar to be removed, the number of sentinel nodes to be removed, and the technique used to close the surgical wound.  

In most cases, you will be able to get out of bed and use the bathroom by the evening of the day of the operation.  You will be allowed to ingest fluids when you arrive on the ward. You will also be given solid food in the evening of the day of the operation. If you feel nauseous, you can be given nausea medication.   

If you can get mobile soon after the operation, you will have a better chance of a speedy recovery and less of a risk of blood clots. Nurses and ward physiotherapists will help you get up and support you in moving around and will help you in using assistive devices. 

Your general condition will be closely monitored on the ward with measurements of your blood pressure, heart rate and body temperature. Blood samples will be taken if necessary.  

Pain management is especially important, because pain impedes recovery. You will be given painkillers regularly to alleviate the pain.  

The anesthesiologist and surgeon will plan the postoperative pain management regime. Medication planning is informed by your underlying conditions and allergies, the extent of the operation, and your own requests and previous experiences of pain management. 

On the ward, painkillers are usually administered by mouth. Preparations from several drug classes are typically used to ensure sufficient pain management. You will be administered painkillers on an as-needed basis. Pain rating scales are used for estimating perceived pain. 

Further information: Kivuhallintatalo.fi

If necessary, a physiotherapist will coach you on mobility after the operation according to instructions given by the physician. Your need for an assistive device will be assessed at the same time.  

The purpose of postoperative physiotherapy is to restore your normal functional capacity. Physiotherapy focuses on the mobility of joints near the operated region. If necessary, the physiotherapist will provide you with instructions for mobility exercises. 

It is important to remember to exercise your upper limb and strain it gently against the tightness of the wound, little by little each day. Upper limb exercises are important after a sentinel node examination of lymph nodes in the armpit region in order to regain full mobility of the upper limbs and to prevent permanent tissue tightness. 

If you note any tightness or functional restrictions in the operated area, you may contact the ward physiotherapist for an evaluation of the need for further rehabilitation. 

Any swelling presenting after lymph node surgery is treated with positioning and compression fabrics.

You will be given oral and written instructions for your rehabilitation. 

Further information: Kuntoutumistalo.fi

Your monitoring will be individually planned at one of the weekly multidiscipline skin tumor meetings. These are attended by professionals who treat skin cancers: plastic surgeon, pathologist, dermatologist, oncologist, and skin tumor nurse.  
 
All the information needed for the decision will have been collected before the meeting: a tissue sample from the original tumor for the pathologist’s examination, any imaging and radiology examinations, and other patient details.  You do not need to contribute to the collecting of these samples and information.

The multidiscipline skin tumor meeting will make a customized recommendation on surgical treatment of skin cancer, on monitoring, and on other treatments such as radiation therapy or chemotherapy. The recommendation will be entered in your patient records. 

At your next appointment, the physician will inform you of the treatment plan and discuss further action and monitoring with you.  You will also be given information on how to prevent and treat scar formation. 

Monitoring will be undertaken in outpatient health care, at a plastic surgery unit, or at a dermatology unit. Some patients will be referred to treatment and monitoring at the Oncology Unit.

At monitoring appointments, the physician will examine and palpate your skin and lymph node regions. Imaging examinations may be performed if deemed necessary in your monitoring plan.

You yourself must examine your scar, lymph node regions, and skin regularly. If you note any suspicious changes, contact the unit responsible for your treatment or monitoring. 

The risk of developing skin cancer is 10 times higher for a patient who has already had skin cancer than for the rest of the population.