Stop Skin Cancer: Before It’s More Than Skin Deep

Skin cancer is the most commonly diagnosed cancer in the U.S., with more than one million new cases each year. Although many cases are curable, others are not. Prevention and early detection are the keys to good outcomes.

I confess: I spent the summers of my adolescence slathered in suntan oil, and in the winter I ski raced, exposing my face and lips to high-altitude sun reflected off of the snow.

Now I’m closing in on 40. In addition to the cosmetic downside of overexposure to the sun, I’m beginning to think seriously about the risk of skin cancer. Skin cancer is the most commonly diagnosed cancer among both men and women in the United States. And although many skin cancers are quite curable, others are not.

My preoccupation with skin cancer likely stems from the fact that I have many of the classic risk factors—I have pale skin, I burn easily, and I have a history of blistering sunburns in childhood. A darker skin tone is no guarantee of protection, however, and we all owe it to ourselves to learn about this very common form of cancer. As is true for many cancers, prevention and early detection are the keys to good outcomes.

Skin Cancer Overview

Each year, more than one million new cases of skin cancer are diagnosed in the United States.[1] Skin cancer is often divided into two broad categories: melanoma and non-melanoma. Non-melanoma skin cancer refers to several different types of skin cancer, but the most common types are basal cell carcinoma and squamous cell carcinoma.

Melanoma is less common than non-melanoma skin cancer, but tends to be much more aggressive. Of the more than one million new diagnoses of skin cancer each year, roughly 62,000 involve melanoma. Close to 8,000 people die of melanoma each year in the U.S.[1]What makes melanoma so dangerous is that it is more likely than other types of skin cancer to spread (metastasize) to other parts of the body. Melanoma can occur anywhere on the body. The first signs of melanoma may be a mole that changes in appearance, bleeds, or has more than one color or an irregular shape.[2]

Basal cell carcinoma accounts for roughly 80 percent of all cases of non-melanoma skin cancer.[3] Basal cell carcinoma most commonly develops on sun-exposed skin, with the head (particularly the nose) and neck being the most common sites. The appearance of basal cell carcinoma varies. It often appears as a raised bump with a smooth, pearly or waxy appearance. It may also look like a firm, flat scar.[4] Basal cell carcinoma very rarely metastasizes (spreads beyond the skin), but it can cause extensive local damage to the skin and surrounding tissues.

Dr. Ken Lee, Director of Dermatologic & Mohs Surgery and Associate Professor of Dermatology at Oregon Health & Science University, explains, “Although basal cell carcinoma is not a deadly cancer, it’s very destructive. If left unchecked it will just continue to get larger and larger. And since it occurs in areas of sun exposure, a lot of these occur on the face. The larger they are, the more that needs to be removed, and the bigger the reconstruction that is needed to repair them. It’s not an insignificant cancer because of where it occurs, and that’s on cosmetically sensitive areas.”

Squamous cell carcinoma accounts for roughly 20 percent of all cases of non-melanoma skin cancer.[5] Squamous cell carcinoma commonly involves the head or neck. The cancer may appear as a red bump or as a rough or scaly area on the skin.4 Squamous cell carcinoma is more likely than basal cell carcinoma to spread to lymph nodes or distant parts of the body, though this happens infrequently.

An alarming trend in both melanoma and nonmelanoma skin cancers is that the frequency of these cancers is increasing—including the frequency in children and young adults.[6],[7] “We are in the midst of a skin cancer epidemic,” says Dr. Lee. “The rate has been rising for all skin cancers. This probably reflects lifestyle changes over the last few decades.”

Risk Factors for Skin Cancer

Although no one is guaranteed of protection from skin cancer, several characteristics or exposures increase the likelihood that you will develop skin cancer:

Personal and Family History: As is the case for several types of cancer, a history of skin cancer in your family or yourself increases your risk of developing the disease.[8]

Skin/Hair/Eye Color:
Having blonde or red hair; blue or green eyes; or light-colored skin makes you more susceptible to skin cancer.[3],[5]“A lot of people think that they are not fair-skinned and tan easily,” says Dr. Lee, “but most Caucasians are fair skinned and burn easily.”

Moles: Having a greater number of moles increases your risk of skin cancer.[8] Atypical moles—also known as dysplastic nevi—may carry a particularly high risk. Atypical moles look different than common moles; they may be larger or have an indistinct or irregular border.9

Actinic keratoses: Actinic keratoses—also known as solar keratoses because of their link with sun exposure—are a type of precancerous change to the skin.[2]They often appear as rough scaly patches on the skin or as a cracked and peeling area on the lower lip. Without treatment, some actinic keratoses will develop into squamous cell carcinoma.

Sun exposure: Exposure to ultraviolet radiation increases the risk of both non-melanoma skin cancer[3],[5] and melanoma.8 The ultraviolet radiation from the sun that reaches the earth includes both ultraviolet B (UVB) and ultraviolet A (UVA). Exposure to ultraviolet radiation from the sun is greatest at latitudes closer to the equator, at high altitude, and when the sun in highest in the sky.

Tanning beds and sun lamps also provide exposure to ultraviolet radiation, and are believed to increase the risk of skin cancer.[10]

Immune suppression: People who are immunosuppressed, such as those undergoing organ transplantation, have an increased risk of developing skin cancer.[3],[5],[8]

Prevention of Skin Cancer

Sun exposure contributes to both melanoma and non-melanoma skin cancer, and sun protection over the course of a lifetime is the most important aspect of skin cancer prevention. Because much of our sun exposure occurs during childhood, it is important for parents and grandparents to help children develop good sun protection habits.

According to Dr. Lee, sun protection involves more than just sunscreen. “Sunscreen is just one aspect of an overall sun protection program,” he stresses. Optimal sun protection involves avoidance of the sun during peak hours (12 p.m. to 2 p.m.), use of protective clothing such as hats, and then sunscreen. “The problem,” explains Dr. Lee, “is that people negate the effect of the sunscreen because they don’t use common sense. They feel that sunscreen gives them a carte blanche to stay out in the sun.”

Dr. Lee also points out that many people use sunscreen incorrectly, which reduces its effectiveness. “People only put on about 25 to 30 percent of the amount of lotion that is needed to actually get the SPF on the label. And then they don’t put it on evenly.” Reapplying sunscreen regularly is also important. “You need to reapply at least every two hours, if not every hour, because you probably didn’t put enough on in the first place,” says Dr. Lee, who recommends using a sunscreen with an SPF of at least 30. Choosing a sunscreen that feels good on your skin may motivate you to put enough on and to reapply regularly.

Finally, Dr. Lee recommends choosing a broad spectrum sunscreen that protects against UVB and UVA. Ingredients such as titanium dioxide, zinc oxide, and avobenzone (Parsol 1789) indicate broad spectrum protection. In addition, a sunscreen approved by the U.S. Food and Drug Administration in 2006—Anthelios SX —may offer improved protection against UVA along with protection against UVB. Anthelios SX contains ecamsule (Mexoryl™), avobenzone, and octocrylene.[11]

Early Detection of Skin Cancer

Because skin cancer affects people of all ages, it’s important that we all learn to recognize the signs of skin cancer. Dr. Lee, who treats many young people with skin cancer, points out that melanoma is the second most commonly occurring cancer (after breast cancer) in women between the ages of 30 and 35, and the most common cancer in women between the ages of 25 and 29.

As a general rule, Dr. Lee recommends watching for “anything that’s changing, anything that’s bleeding or not healing, or anything new.” For melanoma, specifically, using the “ABCD” guidelines can help you recognize suspicious skin changes. “A” refers to asymmetry, “B” refers to border, “C” refers to color, and “D” refers to diameter. A skin lesion (typically a mole) may be a cause for concern if it is asymmetric (one half is different than the other half), has an irregular or jagged border, has more than one color, or is larger in diameter than a pencil eraser.

While these criteria can help you recognize melanoma, it’s important to remember that it’s possible for a melanoma not to have any of these characteristics, and it’s also possible for a noncancerous skin change to have all of these characteristics.

In addition to monitoring your own skin, you may also benefit from regular skin exams by a physician. “If you have a family history or personal history of skin cancer, you really need to be seen by a dermatologist once a year,” says Dr. Lee. If you don’t have a family or personal history of skin cancer but have other risk factors for skin cancer, you may want to see a dermatologist for a baseline skin exam.

Treatment of Skin Cancer

Surgery is the mainstay of treatment for non-melanoma skin cancer, and several different types of surgery are available. Depending on the type, extent, and location of non-melanoma skin cancer, the cancer may be removed by electrodessication and curettage (a technique that involves scraping and burning the abnormal area); surgical excision (use of a scalpel to remove the cancer and some surrounding normal tissue); laser surgery; cryosurgery (freezing); or a technique known as Mohs micrographic surgery. Mohs micrographic surgery is complicated and requires expertise, but is often recommended for the treatment of high-risk basal cell carcinoma or squamous cell carcinoma.[12] In this procedure a doctor removes thin layers of skin one at a time and evaluates them for cancer while the patient waits. The doctor keeps removing layers of skin until he or she reaches a layer that is cancer-free. This procedure removes the least amount of normal tissue, and also has the highest cure rates for both primary and recurrent cancers.

Certain patients with non-melanoma skin cancer may be candidates for non-surgical treatments, such as radiation therapy, topical therapy (application of medications to the skin), or photodynamic therapy. Photodynamic therapy involves the uses of an agent that collects in cancer cells and makes them sensitive to light. Light is then applied to the area in order to destroy the cancer cells.

Surgery is also the primary treatment for melanoma, but melanoma patients—particularly those with more advanced disease—may undergo additional procedures and treatments as well. These procedures and treatments may include removal and evaluation of nearby lymph nodes; delivery of chemotherapy to the affected limb (isolated limb perfusion); whole body (systemic) treatment with a chemotherapy or immunotherapy drug; or radiation therapy.[13]

For patients with melanoma that has spread to distant sites in the body, the available treatments have limited effectiveness and survival remains poor.[1] The poor prognosis of metastatic melanoma highlights the importance of early detection. Patients with melanoma that has spread to distant sites in the body may wish to consider participating in clinical trials of new treatment approaches. Two sources of information about ongoing clinical trials are the National Cancer Institute (www.cancer.gov) and eCancerTrials (www.ecancertrials.com).

Getting Older and Getting Smarter

I still love the sun and the outdoors, but I’ve gotten smarter about my skin.

I try to remember to wear a hat when I’m out in the sun, I wear sunglasses to protect my eyes, and I dutifully apply high-SPF sunscreen to any exposed skin. In spite of their protests, I cover my kids with hats and sunscreen as well. I keep an eye on my many moles and make it a point to have my skin looked at during my annual exam. I may not be able to completely undo the damage I did when I was younger, but I can avoid making it worse.

References:

[1] American Cancer Society. Cancer Facts and Figures 2006. Available at http://www.cancer.org/docroot/STT/stt_0.asp. Accessed April 17, 2006.
[2] National Cancer Institute. Melanoma (PDQ®): Treatment. Patient Version. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/melanoma/patient. Accessed November 6, 2006.
[3] Rubin AI, Chen EH, Ratner D. Basal-Cell Carcinoma. New England Journal of Medicine. 2005;353:2262-2269.
[4] National Cancer Institute. Skin Cancer (PDQ®): Treatment. Patient Version. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/skin/patient. Accessed April 17, 2006.
[5] Alam M, Ratner D. Cutaneous Squamous-Cell Carcinoma. New England Journal of Medicine. 2001;344:975-983.
[6] Christenson LJ, Borrowman TA, Vachon CM et al. Incidence of Basal Cell and Squamous Cell Carcinomas in a Population Younger Than 40 Years. JAMA. 2005;294:681-690.
[7]Strouse J, Fears T, Tucker M, Wayne A. Pediatric Melanoma: Risk Factor and Survival Analysis of the Surveillance, Epidemiology and End Results Database. Journal of Clinical Oncology. 2005; 23: 4735-4741.
[8] Miller AJ, Mihm MC. Mechanisms of Disease: Melanoma. New England Journal of Medicine. 2006;355:51-56.
[9] National Cancer Institute. What You Need to Know About™ Moles and Dysplastic Nevi. NIH Publication 99-3133. Revised June, 1999. Available at: http://www.cancer.gov/cancertopics/wyntk/moles-and-dysplastic-nevi. Accessed December 7, 2006.
[10] World Health Organization. Sunbeds, Tanning, and UV Exposure. Fact Sheet No. 287. March 2005. Available at http://www.who.int/mediacentre/factsheets/fs287/en/print.html. Accessed April 17, 2006.
[11] U.S. Food and Drug Administration. FDA News. FDA Approves a New Over-the-Counter Sunscreen Product. July 24, 2006. Available at: http://www.fda.gov/bbs/topics/NEWS/2006/NEW01417.html. Accessed January 9, 2007.
[12] National Cancer Institute. Skin Cancer (PDQ®): Treatment. Health Professional Version. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/skin/HealthProfessional. Accessed April 17, 2006.
[13]National Comprehensive Cancer Network. Melanoma: Treatment Guidelines for Patients. Version III/September 2005. Available at: http://www.nccn.org/patients/patient_gls/_english/_melanoma/contents.asp. Accessed December 13, 2006.
[14]National Cancer Institute. What You Need to Know About™ Skin Cancer. NIH Publication 05-1564. Revised June, 2005. Available at: http://www.cancer.gov/cancertopics/wyntk/skin. Accessed December 7, 2006.
[15] Cormier JN, Xing Y, Ding M et al. Ethnic Differences among Patients with Cutaneous Melanoma. Archives of Internal Medicine. 2006;166:1907-1914.
[16] Morton DL, Thompson JF, Cochran AJ et al. Sentinel-Node Biopsy or Nodal Observation in Melanoma. New England Journal of Medicine. 2006;355:1307-17.

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