An abnormal skin biopsy may seem routine in a dermatology practice, but for the patient receiving that news, it is anything but ordinary. The emotional impact of receiving such results can be overwhelming and substantial.
Cellular dysplasia is a broad and complex concept understood within the dermatologic community as representing a continuum, ranging from mildly atypical aggregations with little potential for harm to poorly differentiated proliferations with high likelihood of lethality. For the patient, however, descriptors such as “precancerous,” “dysplastic,” or “atypical” can be confusing and frightening. Further, a diagnosis of skin cancer can be outright terrifying and potentially have devastating emotional sequelae, including anxiety, depression, and psychosocial dysfunction.1
Cancer is a dreaded word and carries with it a plethora of negative images and associations. It is interpreted and experienced in the context of the affected individual’s personal understanding of the entity, their latest informational inundation from media sources, their family and friends’ perceptions, and perhaps by their own personal experiences with a previous malignancy.
Unfortunately, most patients diagnosed with skin cancer lack the contextual knowledge differentiating basal cell carcinoma, squamous cell carcinoma, melanoma, Merkel cell carcinoma, and other cancer types. Their initial reaction upon hearing about anything abnormal in their test results, therefore, may be images of a cachectic cancer-stricken person slowly deteriorating to a painful and horrific death.
Clearly, a diagnosis of tissue dysplasia does have the potential to induce psychologic dysphoria, a state of unease or general dissatisfaction with life, often associated with depression, anxiety, and agitation.2 The question is, what can clinicians do to optimize not only cellular but also emotional outcomes for these patients?
Typically, when researchers and clinicians investigate treatment outcomes, emphasis is focused on surgical margins, local and distant metastases, scar optimization, end organ function, and skin sensation. While those are all crucial points, optimizing emotional outcomes and decreasing the likelihood of potentially dangerous dysphoria is no less important. By helping our patients better understand their diagnosis and implications for short- and long-term function, quality of life, and longevity, we are providing another vital aspect of patient care.
Simple initial verbalizations can help patients navigate through appropriate medical or surgical treatments and beyond. Ideally, our verbalizations and perspectives can help them achieve a more comfortable cognitive and emotional acceptance and understanding of their diagnosis. As a result, we may increase the likelihood that they will adopt appropriate lifestyle changes to minimize the risk of future skin cancers and concomitantly avoid a “dysphoric slide” into poorer physiologic and psychologic functioning.
The following are suggested therapeutic tips to help patients cognitively and emotionally reframe a terrifying tissue diagnosis into a more acceptable and less ominous one.
Be present and conscious of what nonverbal cues you may be projecting.
A sensitive and caring clinician (you) is aware that a patient undergoing a biopsy or receiving results is likely in a heightened emotional state, and takes care to adopt an appropriate demeanor. Your words, after all, are not the only thing that can affect a patient as you deliver the diagnosis. Appearing disinterested, bored, distracted, or hesitant can create or contribute to a negative impression. Beginning with the skin biopsy, your conversations, attitude, affect, and eye contact can all send messages to your patient. Positive and upbeat conversations, attitude, affect, and confident eye contact ease the anxiety associated with the procedure and fears regarding the biopsy findings. This should continue throughout the process of reviewing biopsy findings and discussing implications and treatment options.
Put the results in context.
Many patients do not realize that tissue dysplasia is not necessarily a harbinger of illness, dysfunction, or death. If a patient has a nonmetastatic, low-grade malignancy, it can be helpful to differentiate localized disease vs metastatic disease. Explain that basal cell carcinoma or squamous cell carcinoma is a localized collection of cells that in all probability have not spread beyond the identified site. In this case, the patient simply has a collection of unhealthy cells that need to be removed or eliminated so they cannot cause trouble in the future.
If the patient has aggressive pathology and/or metastatic disease, on the other hand, make sure they thoroughly understand what that means and the implications. You may want to reference existing and rapidly evolving therapies, or consider the three-group perspective: Group one is “cured” by surgical or immunologic intervention. Group two is “cured” by surgical or immunologic intervention with the addition of radiation therapy or chemotherapy. Group three may be analogized to the “chicken pox group,” the concept that a cure may not be necessary in order to live a healthy life with quiescent disease that may or may not require occasional medical or surgical interventions. Providing reality-based hope is both legitimate and compassionate because statistical prognostications may not accurately apply to your patient.
Offer reassurance that having cancer does not always mean getting and staying ill.
Explaining that cancer makes people sick when it invades and or impairs the functioning of vital organs in the body (for example the liver, lungs, kidney, or brain), may help the patient understand that their skin cancer will not necessarily lead to deterioration or decline in health and wellness. One way to explain this is to introduce the concept that every human body at some point makes abnormal cells, but also has an immune surveillance mechanism whose job it is to be on the lookout for those abnormalities. Much like a police officer on daily patrol, these immune cells actively look for abnormal bacteria, fungus, viruses, and cancer, and destroys them before they can do any harm. Skin cancer simply suggests that the immune system failed to identify this collection of cells, but in all other respects, the patient is probably healthy and well.
Empathize with them.
Skin care experts uniquely understand that skin cancer can feel like being betrayed by a trusted friend. For many individuals, sunlight represents a consistent source of pleasure. The feeling of sunlight on their skin creates pleasurable sensations, and some studies have even suggested that internal opioid (endorphin) release occurs in some individuals, creating a true chemical addiction to the sun.3
Often, sunlight exposure is experienced in places of relaxation and recreation accompanied by sights, sounds, smells, and other tactile stimulations which can intensify the experience. Cultural images of suntanned celebrities further cement and validate the yearning to seek sunlight and achieve bronzed beauty status.
A diagnosis of a dysplastic nevus, actinic keratosis, basal cell carcinoma, squamous cell carcinoma, or malignant melanoma shatters this perception. Their trusted friend that delivered so much pleasure suddenly has become a feared enemy. Those sensations of warmth felt minutes after sun exposure that elicited such wonderful feelings now elicit feelings of anxiety and trepidation as they wonder whether the sun exposure is causing another dysplastic or cancerous growth.
Conversely, a patient who has regularly used sunscreen may feel defeated by their diagnosis, or guilty about not having done enough to prevent it. For these patients, you can explain that sunscreen and some protective clothing do not completely block UV activation in the skin.
In the wake of a skin cancer diagnosis, a patient’s family, friends, and even medical professionals are prone to unsolicited medical advice about their condition. It can be infuriating and depressing for patients to constantly hear about what they cannot or should not do. In contrast, “You can and here’s how,” is more palatable.
One approach is to advise that this diagnosis may be an opportunity for the patient to reevaluate their relationship with the sun. Explain that they do not need to completely avoid outdoor activities and sunlight, but may want to step up their sun protective behaviors when doing so; for instance, wearing and reapplying sunscreen, using protective clothing, seeking shade or choosing to limit outdoor activities to non-peak sunlight hours.
It is been suggested that UV-filtered sunlight produces pleasant sensations of heat in the skin that may elicit similar feelings of warmth, relaxation, and tactile pleasantry.
There are many confusing messages about sunscreen, from recent chemical sunscreen controversies to the promulgated notion that sunscreen eliminates any potential benefits from UV exposure, such as vitamin D3 or immune system activation. Make sure your patient has the correct information and can ask any questions they may have.
Provide information on utilization of some protective clothing, physical sunscreens, moderate use of chemical sunscreens, and limiting outdoor exposures during peak UV hours. Help the patient understand that a balance between complete avoidance of the sun and tanning with baby oil, iodide, and a sun reflector is possible (and likely the best solution).
Confront denial, if present, in a gentle and supportive manner.
A sometimes-encountered coping strategy employed consciously or subconsciously by patients after a skin cancer diagnosis is “factual denial.” They may minimize or disregard evidence-based data supporting the contention that sun exposure prematurely ages the skin and increases the risk of skin cancer. Work with the patient to formulate a safe, mutually acceptable plan of action. If, for example, they are concerned about getting enough vitamin D, you might suggest vitamin D rich foods or a D3 supplement. Smart, safe, and moderate sun exposure is a winning plan.
The Final Word
The goal of minimizing psychologic dysphoria may be best achieved by providers who seek to provide perspective, empowerment, hope, and control for patients diagnosed with tissue dysplasias. This stated goal is not simply to provide compassion in order that our patients feel better; it serves a more profound purpose by recognizing that dysphoric individuals tend to make poorer health choices and are less likely to adhere to treatment recommendations.
Given this reality, failure by physicians to make attempts to diminish or avoid psychologic dysphoria may compromise an otherwise great clinical outcome. Anxiety, depression, and psychosocial impairment are comorbidities that can have a siginificant impact on patients with skin cancer.4
Dr Fried is a board-certified dermatologist, clinical psychologist, and author of Healing Adult Acne. He practices at Yardley Dermatology Associates in Yardley, PA, and is a member of The Dermatologist’s editorial advisory board.
Disclosure: The author reports no relevant financial relationships.
1. Beutel ME, Fischbeck S, Binder H, et al. Depression, anxiety and quality of life in long-term survivors of malignant melanoma: a register-based cohort study. PLoS One. 2015; 10(1):e0116440. doi:10.1371/journal.pone.0116440
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
3. Robinson KC, Fisher, DE. Tanning as a substance abuse. Commun Integr Biol. 2014;7(5): e9715.doi:10.4161/cib29890
4. Pinquart M, Duberstein PR. Depression and cancer mortality: a meta-analysis. Psychol Med. 2010;40(11):1797-1810. doi:10.1017/S0033291709992285