Skin Cancer of the Feet: To Biopsy or Not to Biopsy?

As a podiatrist, you have no doubt seen patients with wounds, masses, or lesions on their lower extremities. If these wounds, masses, or lesions are later found to be skin cancer, the treating podiatrist is at risk of a lawsuit. A common allegation in these cases is a delay in diagnoses and treatment of cancer resulting in harm to the patient. Skin cancer developing on the lower extremities is not uncommon and podiatric medical physicians are in a unique position to detect these types of cancers on their patients.

The most common skin cancers that affect the feet include:

• Malignant melanoma
• Basal cell carcinoma
• Squamous cell carcinoma

Possible Signs of Skin Cancer
While not all wounds, masses, or lesions need to be biopsied, but there is a time when a biopsy should be considered. If, based upon your clinical evaluation, the wound, mass, or lesion is suspicious of cancer, performing a biopsy in a timely manner or referring the patient to a specialist for further evaluation is critical to improve the clinical outcome for the patient and reduce professional liability risk.

Signs of potential cancer include:

• Ulceration in non-weight bearing areas
• No signs of improvement or healing after appropriate treatment
• Worsening of the lesion
• Ulceration in the presence of good circulation and neuro-sensory status
• No apparent inciting event for the lesion
• Multiple physician involvement with no resolution

While squamous cell carcinoma is the most common form of skin cancer on feet, malignant melanoma poses a significant concern within the scope of podiatry and creates the need for podiatric medical physicians to be aware and vigilant of this issue. Given the intricate anatomy and varied presentations of lesions in the lower extremities, the detection of melanoma can be difficult; however, since this is one of the deadliest forms of skin cancer, early detection and prompt intervention are extremely important.

Risk Reduction Strategies

1. Document a thorough history of the wound, mass, or lesion including the date of onset, any prior home remedies, and any treatment by other healthcare providers.
2. Carefully document your initial clinical findings including the location of the lesion and a description of the size, color, odor, discharge, and any other observations of the lesion.
3. Re-evaluate the patient at appropriate intervals and document your clinical findings. Is the wound improving, static, or worsening? Biopsy should be considered as soon as there is any clinical suspicion of cancer or there is no resolution or change in the wound within three to four months.
4. Document your decision-making process. Document why you are performing a biopsy or referring the patient for further evaluation and treatment. If you decide not to perform a biopsy on a wound, document why you are not doing so.
5. If you are performing the biopsy, ensure that you are proficient in determining the appropriate biopsy method, and obtaining an appropriate tissue sample.
6. Don’t let the patient “fall through the cracks.” Consider flagging your EMR to remind you to consider performing a biopsy after three months. Ensure that the patient keeps all referral and consultation appointments by keeping a log of the date of the referral, the healthcare provider referred to, the date of the appointment, the date you received a report from the healthcare provider, the date you reviewed the report, the date you notified the patient of the results, and any follow-up actions that need to be made.
7. If a patient reports that a biopsy was previously performed by another provider revealing no significant findings, document when the biopsy occurred and obtain a copy of the biopsy report prior to performing a biopsy or other surgical intervention.
8. If you transition the care of a patient to another healthcare provider, document the transition of care in the patient’s medical record, confirm that the new provider has agreed to assume the care and treatment of the patient, and confirm that the patient understands the new provider will be assuming care.

Podiatric medical physicians play a crucial role in identifying skin cancers of the lower extremities by conducting comprehensive skin examinations during routine foot care visits and being adept at recognizing suspicious lesions. Podiatrists can contribute to timely diagnosis, helping to ensure optimal outcomes for patients.

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The information contained on the PICA Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. All information contained on the blog is subject to change.