Welcome to ConsultingFootPain articles. Today the focus is cancer and the foot.
by Afni Shah-Hamilton and David R Tollafield
The fifth commonest skin cancer is the melanoma according to the Marsden Hospital (London) but other forms of cancer exist and the foot is as much a target as other parts of the body. The Mayo Clinic in the US suggests only 1% of cancers affect bone. Peeling information off the internet needs interpretation and in reality the foot is a low target for cancer. As a podiatrist I have seen this in skin mainly, but nail beds, the arch of the foot and deeper tissues such as fat, nerves, small blood vessels are prone but not so much in bone or joints. Over 40 years of practice this represents only a tiny percentage of cases. For any self respecting clinician you always have to ask yourself; how many potential cancers have I missed?
Fortunately, working with a multi-disciplinary team, which included a local cancer centre in Birmingham, we saved most feet without amputation and kept people alive for a long time after diagnosis.
Before I qualified as a foot surgeon, and could therefore undertake biopsy to remove tissue for analysis, I relied on others to follow up my clinical observations. Early detection with an ideal rapid referral of a suspicious tumour can increase the chances of recovery for patients. However, specialist centres tend to be distributed widely in the UK making the journey to and from any place for consultation less convenient.
– for those who regularly visit a podiatrist, the regular contact and medical expertise can allow any unusual appearance to be identified more swiftly; and
– once cancer has been diagnosed, the effects of chemotherapy can expose patients to a variety of foot problems.
Foot cancer is rare
This is not intended to be one of those scaremongering articles but sometimes cancer does affect the foot. My most memorable case was where I was sent a nasty foot with mushy ulcer that the patient’s GP thought was a verruca. This was a melanoma. The patient lived 5 years before succumbing to medical complications. The use of dermatoscopes are now used with ever increasing popularity and according to Dr Ivan Bristow, reduce the need for biopsy.
A dermatoscope is a device for magnifying skin lesions to identify characteristics of abnormal change. It raises suspicions and increases the chances of earlier intervention.
The literature tends to talk about other parts of the body rather than the foot being more common and much gets tied in with the lower limb. Foot cancer can lead to an early death but I stress it is not common. Of 367,667 new cancers reported (2015-17) by Cancer Research, under 1/2 died of the disease. While this appears alarming, this statistic does not tell us what type of cancer kills mostly and where that cancer exists.
In the foot and from my experience, survival in the foot is better in most cases. A school friend had foot cancer in the sixties and lived with an amputation and prosthetic leg. Not ideal, but he lived on to marry and doubtless have a family and full life. The link above shows the list and range of cancers all with confusing names. Such names often relate to the type of tissue or location. It is worth looking at the words around cancer to de-mystify terms.
Origins and meaning of words
Remember medicine loves ancient words and in the days when information was distilled for the genteel ear of their patients, doctors used language known only by those who studied the art of medicine embroiled in ancient Latin and Greek.
The word tumour means swelling and is derived from Latin. Tumours may be harmless or harmful, benign or malignant. ‘Onco’ (Greek) is another word which forms oncology. That is the study of tumours and cancers. The Greek physician Galen 130-200AD used ‘onco’ for swelling. Just because something is malignant does not mean that it is a killer. Cancer originally came from Latin meaning ‘crab’, and had its association enshrined with cancer as cancers were seen to have crab like legs. Words associated with these difficult conditions have been around for centuries.
Malignancy implies that the normal cell structure of skin, bone or whatever tissue is infiltrated, appears abnormal under the microscope. The inside of cells alter with their manufacturing rate accelerated or put more technically their metabolic ‘turnover’ increased. The simplest way to think of metabolism is the rate at which we consume energy. If our metabolism is too high we burn energy at a higher and faster rate. The opposite is true if we have a low metabolism. Here we burn less energy. Cancers tend to burn at this high rate so everything grows and divides faster.
Abnormalities can be classified as defective when viewed under the microscope and are stained with special agents to help the laboratory identify the cells that are functioning abnormally. Once the laboratory report goes back to the clinician as to the type of cancer, the oncology doctor can then decide how to treat and give the priority needed; that is treat with chemotherapy, radiation or surgery. A team will deal with each patient from medical consultant, to nurse practitioner or surgeons as required. More than one type of surgeon might be involved as well as other health professionals which can include pyschologists, physiotherapists and podiatrists.
Organs and spread
Breast and ovarian cancer traditionally feature heavily in healthcare with a renewed focus on bowel cancer for older patients with an upswing in prostate and testicular cancers for men.
These are not the only organs affected as the skin, joints and bone are still important human tissues that result in such abnormalities. The spread of cancers, carried through the lymphatics and blood is called metastasis. The original sites of cancer are called Primaries and where there is spread to another location, these are called Secondaries. Often the Secondaries raise suspicions in feet after a bone breaks in the metatarsal bones and this is where a bone or joint cancer may come to be recognised.
Who is at risk?
Abnormal swellings are more prevalent in middle and older aged patients although children can also be affected. Skin cancer not only affects fair skinned or redheads. The pigmented type of tumour melanoma occur in all races and affect all skin types and colours. Everyone is at risk potentially.
How come we miss some cancers?
Specialist podiatrist in cancer care, Afni Shah-Hamilton reports…
‘A misdiagnosis of foot pain was made when this was actually related to the patient having lung cancer. The patient was seen by two physicians and an orthopaedic surgeon who had missed the diagnosis when providing treatment. The cancer sadly was detected too late.’
Pressures on the health system and the process of undertaking tick list approaches to clinical examination can prevent clinicians thinking outside the box. Cost cutting on diagnostic tests can also lead to missing cancers which might otherwise be picked up. The argument for podiatrists undertaking more work on cancer has never been more important and the idea that this should rely on medical doctors alone in an area when the podiatrist is conversant with skin problems seems to miss the opportunity for better screening.
The message is clear. See your doctor if you are concerned, but you can see a specialist podiatrist (1) for an early opinion who can make that referral for you, or can undertake tests. There are many people in healthcare that provide support for all types of cancer. Plastic surgeons to reconstruct anatomy affected. Orthopaedic surgeons who can help deal with bone and joint management. General surgeons and specialist surgeons for different organs as well as physicians. Doctors specialising in stabilising the body are oncologists.
What are the key types of tumour?
Some tumours have a greater affinity for younger patients e.g sarcoma, although middle aged adults typically present with this condition in feet. Presentations can vary between patients. They might simply report pain instead of swelling. Testing for pain or swelling in the local lymph glands is important because the body filters and mops up infections and abnormal cell growths at these sites (arm pit, groin, abdomen, chest and neck).
Tips for assessing lumps and bumps
a) lump size is more than 5cm,
It is important to remember that a swelling is often harmless but you should monitor any changes that take place especially colour changes, bleeding and pain. The toe nail is not an uncommon location for cancer in the foot. The hardened nail can change its appearance. Loss of the nail structure can be replaced with strange shaped skin.
A lady in her 70’s wondered where her nail had gone as it had an unusual appearance. I undertook a biopsy removing a small piece of skin through the nail and found this was a squamous cell carcinoma (2). This was not life threatening by she did have to lose a little bit of toe with her complete nail bed.
Pigments in the nail bed are more than likely due to an old blister turned dark after injury. The pocket of blood changes colour from red to brown. Where there has been no known painful damage then it could be the shoe causing the blood to trap under the nail after a walk for instance. Always check that the pigment is not just a dye stain from the inside of your shoe. It should wipe off. However, where the pigment is dark and spreads, bleeds, maybe is painless, and the nail itself changes, or there is a long thin streak of dark pigment, this maybe a type of cancer called a sub-ungual melanoma. Biopsy or taking a sample of the pigmented cell with normal skin is essential to classify its origin. I have biopsied many nails and nail beds, most are normal, but it is not easy to tell without a laboratory report. Today the newer technique of diagnosing with a dermatoscope can reduce the need for some biopsying and this is certainly to be recommended.
These are all being published APRIL 2020
Topical articles: Five Conditions in feet caused by medication to treat cancers
Supplementary facts and podiatry from Afni Shah-Hamilton
How can podiatry help with peripheral neuropathy?
How can podiatrists help with the toxic effect of medication on nails?
How can podiatrists help with hand-foot syndromes?
How can podiatrists help with Xerosis?
 At present podiatrists undertaking specialist work and known as Extended Scope Practitioners work in the NHS with multidisciplinary teams to triage urgency and offer some tests. Podiatric surgeons might offer biopsy tests depending upon the presenting complaint and over the risk. Referral to specialist centres are more ideal for planning the holistic care of a patient
 A carcinoma forms in the skin or tissue cells that line the body’s internal organs, such as the kidneys and liver. A sarcoma grows in the body’s connective tissue cells, which include fat, blood vessels, nerves, bones, muscles, deep skin tissues and cartilage. This is a simplification but serves differentiate the two common terms used.