Skin Cancer - Council for Medical Schemes

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CMScript
Issue 10 of 2016
Member of a medical scheme? Know your guaranteed benefits!
Skin Cancer
South Africa has the second highest incidence of skin cancer in the world after Australia. According to
the Cancer Association of South Africa (CANSA) 2010 statistics, about 20 000 new cases are reported
every year and 700 deaths occur as a result of skin cancer.
by Ronelle Smit - Clinical Analyst
Anatomy of the human skin
The outer layer of the skin is called the epidermis. The skin
helps to control body temperature, stores water and fat, and
gives the skin its colour. The epidermis is a protective layer that contains melanin (pigment) which protects against
heat, sunlight, injury, and infection. The second layer is the
dermis that contains the nerve endings, sweat glands, oil
glands, and hair follicles. Underneath these two layers is a
fatty layer of subcutaneous tissue (subcutaneous meaning
“under the skin”). The picture below shows the different layers of the skin.
from case to case. The image below gives an indication of
the body areas that may be affected by skin cancer.
Aseptic necrosis
Figure 2 & 3: Body areas that may be affected by skin
cancer
Figure 1: A cross section of the skin
Types of skin cancer
Different types of skin cancers exist. The table below gives
information on the different types and the Prescribed MiniDefinition of skin cancer
mum Benefit – Diagnostic Treatment Pair that includes the
Skin cancer is the abnormal growth of skin cells and most
specific type of cancer.
often occurs on the part of the skin exposed to the sun. The
condition affects both men and women. However, the areas
Although all of the types of skin cancer are included in the
of the body where the cancer is more likely to occur differ
PMB Regulations, this article will focus on the most com-
Type of skin cancer
Diagnostic Treatment Pair
Basal cell skin cancer
954J - Cancer of skin, excluding malignant melanoma - treatable
Squamous cell cancer
954J - Cancer of skin, excluding malignant melanoma - treatable
Melanoma
953J -Malignant melanoma of skin - treatable
Merkel cell carcinoma
954J - Cancer of skin, excluding malignant melanoma - treatable
Lymphoma of the skin (cutaneous T-cell
cancer)
901S - Acute leukaemia’s, lymphomas
Kaposi sarcoma
952J - Cancer of soft tissue, including sarcomas and malignancies of the
adnexa - treatable
mon types of skin cancer, i.e. basal cell carcinoma, squamous cell carcinoma and melanoma.
Basal cell cancer
Basal cell cancer is also referred to as basal cell carcinoma
and is usually not life threatening. This type of skin cancer
involves the lowest level of the outer layer of the epidermis.
It is slow growing and seldom invades adjacent areas. It is
the most common type of skin cancer and usually occurs in
areas of the body exposed to the sun. These include areas
such as your neck, face, back, chest and shoulders with the
nose as the most commonly affected area.
signs and symptoms:
• Firm, red nodules
• Flat sores with a scaly crust
• New sore or raised area on an old scar or ulcer
• Rough, scaly patch on your lip that may evolve to an
open sore
• Red sore or rough patch inside your mouth
• Red, raised patch or wart-like sore on or in the anus or
on your genitals
Risk factors that may increase your risk to develop basal
cell or squamous cell carcinoma includes, but are not limited to:
Basal cell carcinoma can be recognised by the following • Chronic sun exposure
• Radiation therapy
signs and symptoms:
• Fair skin
• Red, tender, flat spot that bleeds easily
• Small, fleshy bump with a smooth, pearly appearance, • Gender as men are more likely to develop basal cell
carcinoma than women
often with a depressed centre
• Smooth, shiny bump that may look like a mole or cyst • Age - the majority of basal cell carcinomas occur after
age 50 as it takes years to develop
• Patch of skin, especially on the face, that looks like a
• Personal or family history of skin cancer
scar and is firm to the touch
• Bump that itches, bleeds, crusts over, and then repeats • Immune-suppressing drugs
• Inherited syndromes that cause skin cancer such as
the cycle and has not healed in 3 weeks
certain rare genetic diseases
• Change in the size, shape, or colour of a mole or a skin
growth
Melanoma
Melanoma is the most serious skin cancer. It develops in
the cells (melanocytes) that produce the pigment (melanin)
that gives your skin its colour. Although melanoma most
often develops in areas of the body that had a lot of sun
Squamous cell cancer
As indicated in the name, this type of cancer occurs in the exposure, the exact cause is not known. Melanomas can
squamous cells in the upper layers of the epidermis. Squa- develop anywhere on your body, such as the soles of your
mous cell cancer is usually not life threatening, but can be feet, palms of your hands and fingernail beds. This type of
aggressive in some cases. It can grow to large lesions and melanoma is called hidden melanomas and is more comspread to other parts of the body that can cause serious mon in people with darker skin.
complications. Most squamous cell carcinomas are the result of prolonged exposure to ultraviolet (UV) radiation of First signs and symptoms of melanoma often include:
• A change in an existing mole
the sun or from tanning beds or lamps.
• Development of a new pigmented or unusual-looking
growth on your skin
Squamous cell carcinoma can be recognised by the following
Basal cell carcinoma has an excellent prognosis and can
be cured if identified early and treated correctly.
2
CMScript 10/2016
Identifying the characteristics of unusual moles can be
done by using the letters ABCDE:
• A - Asymmetrical shape. Examine your body for moles
with irregular shapes such as two very different-looking
halves.
• B - Irregular Border. Examine your body for moles with
irregular, notched or scalloped borders.
• C - Changes in Colour. Examine your body for growths
that have more than one colour or an uneven distribution of colour.
• D - Diameter. Examine your body for new growth in a
mole that is larger than about 5 millimetres.
• E - Evolving. Examine your body for changes over
a time period. This includes a mole getting larger or
changing colour or shape, or the development of itchiness or bleeding.
Skin cancer and PMBs
Risk factors that may increase your risk to develop melanoma includes, but are not limited to:
• Fair skin
• History of sunburn as even one or more severe, blistering sunburns can increase your risk of melanoma
• Excessive ultraviolet (UV) light exposure
• Presence of more than 50 ordinary moles or unusual
moles
• Family history of melanoma such as a parent, child or
sibling
• Weakened immune system
The diagnosis of basal cell carcinoma, squamous cell carcinoma and melanoma include:
• The doctor will take a detailed medical history in which
he/she will ask questions relating to your history of previous skin cancer, when you first noticed the lesion,
painfulness of the lesion, sun exposure, as well as family history in relation to the condition.
• A skin examination of the whole body will be done.
• A biopsy (taking of a sample of the lesion). Depending
on the type and size of the lesion a biopsy can be done
under local anesthesia in the doctor’s rooms or under
general anesthesia in the theatre.
Reducing the risk of developing skin cancer
You can reduce the risk of developing of skin cancer by:
• Avoiding the sun between about 10:00 and 16:00.
• Wearing sunscreen even in winter. Use a sunscreen
with a Sun Protection Factor (SPF) of at least 15 and
that protects against all the UV-rays.
• Wearing protective clothing and sun-glasses.
• Avoiding tanning lamps and beds.
• Examining your skin regularly for new skin growths or
changes in existing moles, freckles, bumps and birthmarks.
The Prescribed Minimum Benefits (PMBs) include the diagnosis, treatment and care of all PMB conditions. The PMB
regulations only specify the treatment component of the
conditions. The diagnostic tests required as well as care
that is clinically appropriate must however still be funded by
your medical scheme.
Diagnosis
The PMB diagnostic treatment pair for basal and squamous
cell carcinoma specify that the conditions are only included
if histologically confirmed. The diagnosis must be confirmed
by a positive skin biopsy result. This information is critical
to remember as it may lead to co-payments on accounts or
even unpaid accounts if the test in negative. Histology is the
study of the form of structures seen under a microscope.
The tissue taken during the biopsy will be sent to the pathologist laboratory for the histology. If skin cancer is confirmed
(malignant neoplasm of the skin) and the type of cancer
is determined, the PMB regulations apply and the scheme
must fund all your accounts according to the PMB requirements. If no skin cancer is confirmed all the accounts will
be funded according to your scheme’s rules and limits.
Treatment
Treatment that must be funded as PMB level of care may
not be less than the type of treatment that is available to
state sector patients.
Type of skin cancer
Diagnostic Treatment Pair – Treatment component
Basal cell skin cancer
If histologically confirmed, Medical and surgical management, which includes
radiation therapy.
Squamous cell cancer
If histologically confirmed, Medical and surgical management, which includes
radiation therapy.
Melanoma
Medical and surgical management, which includes radiation therapy.
CMScript 10/2016
3
Basal and Squamous cell carcinoma
The following treatment qualifies as PMB level of care:
• Curettage and cryotherapy - involves removing the surface of the skin with a scraping instrument (curet) and
then freezing (cryotherapy) the base and edges of the
biopsy site with liquid nitrogen
• Freezing - involves freezing cancer cells with liquid nitrogen (cryosurgery). This is usually done for superficial skin lesions.
• Medicated creams or lotions.
• Simple excision - the cancerous tissue and a surrounding margin are cut out. Your doctor may recommend
removing additional normal skin around the tumor in
some cases (wide excision).
• Mohs surgery – involves removal of the cancer layer
by layer and examining each layer under a microscope
until no abnormal cells remain.
• Radiation therapy.
Other treatment options that do not qualify for PMB cover
are available. It is important to know that your scheme may
fund them from your day-to-day benefits or medical savings
account but the medical scheme may also deny authorisation and funding completely.
• Electrodessication (drying up of tissue using a high-frequency electric current applied with a needle-shaped
electrode) and curettage (ED and C).
• Laser therapy.
• Photodynamic therapy.
Melanoma
The following treatment qualifies as PMB level of care for
early stage melanoma:
• Surgical removal of the melanoma – involves removal
of a very thin melanoma during a biopsy or removal
of the cancer, the border of normal skin and a layer of
normal tissue underneath the skin.
The following treatment qualifies as PMB level of care for
melanomas that have spread beyond the skin:
• Surgical removal of the melanoma and affected lymph
nodes.
• Chemotherapy
• Radiation therapy
• Biological therapy namely interferon treatment.
This article does not discuss metastatic melanoma. It
is therefore important to clarify your benefits for treatment of metastatic melanoma with your treating doctor
and medical scheme.
References:
1. Figure 1: http://www.enchantedlearning.com/subjects/
anatomy/skin/
2. Figure 2 & 3 : https://www.skinhealthuk.com/skin-cancer-information
3. Melanoma. http://www.mayoclinic.org/diseases-conditions/melanoma/basics/definition/con-20026009 [Accessed 24 November 2016]
4. Basal cell carcinoma. http://www.mayoclinic.org/diseases-conditions/basal-cell-carcinoma/home/ovc20251803 [Accessed 24 November 2016]
5. Squamous cell carcinoma of the skin. http://www.mayoclinic.org/diseases-conditions/squamous-cell-carcinoma/home/ovc-20204362 [Accessed 24 November
2016]
6. Skin Cancer: © 2016 American Cancer Society, Inc. All
rights reserved. http://www.cancer.org/cancer/skincancer/ [Accessed 24 November 2016]
7. Fact Sheet – Skin Cancer 2010. http://www.cansa.
org.za/files/2012/05/SKIN_CANCER_Leaflet-2010.pdf
[Accessed 24 November 2016]
WHAT ARE PRESCRIBED MINIMUM BENEFITS?
Prescribed Minimum Benefits (PMBs) are defined by law. They are
the minimum level of diagnosis,treatment, and care that your medical scheme must cover – and it must pay for your PMB condition/s
from its risk pool and in full. There are medical interventions available over and above those prescribed for PMB conditions but your
scheme may choose not to pay for them. A designated service
provider (DSP) is a healthcare provider (e.g. doctor, pharmacist,
hospital) that is your medical scheme’s first choice when you need
treatment or care for a PMB condition. You can use a non-DSP voluntarily or involuntarily but be aware that when you choose to use a
non-DSP, you may have to pay a portion of the bill as a co-payment.
PMBs include 270 serious health conditions, any emergency condition, and 25 chronic diseases; they can be found on our website
Contact information:
[email protected]
Hotline: 0861 123 267
Fax: 012 430 7644
The clinical information furnished in this article is intended for information purposes only and professional medical advice must be
sought in all instances where you believe that you may be suffering
from a medical condition. The Council for Medical Schemes is not
liable for any prejudice in the event of any person choosing to act
or rely solely on any information published in CMScript without
having sought the necessary professional medical advice.
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