SKIN CANCER

    There are many types of skin cancer.  They vary in terms of how common they are and how much of a threat they are to your health.  Skin cancers overall are the most common form of cancer. 

    The skin contains many types of cells including the keratinocyte (common skin cells, those that contribute over 99% of the cells of the epidermis, the outside layer of the skin, the cells that mature and shed off) and the melanocyte (the pigment cells, they provide pigment to overlying keratinocytes giving us our natural skin color or our tan, everyone has the same number of melanocytes they just vary in how effectively they produce and hand off pigment).  In general, skin cancers dervied from keratinocytes (basal cell carcinoma, squamous cell carcinoma) are much more common but much less likely to kill you.  Melanoma, the skin cancer derived from melanocytes, is less common but results in the vast majority of lethal cases of skin cancer.

    The great preponderance of skin cancers result from the effects of ultraviolet (UV) radiation on the skin.  Melanoma appears to be more related to sun exposure before age 18 and we have scientific proof that sunscreen and other sun-protective strategies when used in children decreases the rate of  melanoma later on in life; a direct result of this evidence was the regulation of tanning booth use in New York State for those under age 18.  On the contrary, keratinocyte-derived skin cancers appear most associated with chronic sun exposure over a lifetime and similarly we have proof that consistent sunscreen and other sun-protective strategies in aduthood decreases the rate of these cancers.  So whether you are a child or an adult, THE USE OF SUNSCREENS AND OTHE SUN-PROTECTIVE STRATEGIES HAVE BEEN SHOWN TO REDUCE THE RISK OF SKIN CANCER.

    Basal Cell Carcinoma (BCC)--accounts for roughly 3.5 million cases of skin cancer a year and essentially no deaths because spread to other tissues like lymph nodes or distant organs (metastasis) is rare.  As such this type of cancer is more of annoyance in most cases but when left untreated can result in local destruction especially when near vital organs such as the eyes or other areas of the face.  Because in general it does not threaten life, there are several options to treat BCC ranging from the least invasive/lowest cure rate such as cryotherap with liquid nitrogen or topical chemotherapeutics such as 5-fluorouracil to the most invasive/highest cure rate treatment which is Mohs micrographic surgery.  Factors that are involved in choosing the right treatment for you depends upon factors that affect cure rates for the various procedures--in general for smaller lesions the cure rates go up and for larger lesions the cure rates go down, for superficial non-aggressive forms the cure rate goes up, for deeper more aggressive forms the cure rate goes down; other factors include the location with locations on the face usually pushing towards the highest cure rate procedures that spare tissue and those on the trunk and extremities pushing towards treatments where tissue sparing is not an issue.

    Squamous Cell Carcinoma (SCC)--accounts for 2.2 million cases of skin cancer a year and about 2,000 deaths (0.1% of cases).  SCC is most common in fair-skinned individuals with a lifetime of sun exposure--farmers, boaters, golfers, construction workers.  SCC is unique in that it has pre-malignant lesions including actinic keratoses (AKs) found in chronically sun exposed areas of the face, neck, upper trunk, dorsal forearms and hands.  The rate of transformation of actinic keratoses to full blown SCC is generally low, roughly 1 in 4,000 per year, but many factors can influence this rate: i) immune status is critically important with those having compromised immune systems such as transplant recipients having a 50X higher rate of AKs turning into SCCs (as well as a 100-200X higher rate of dying from SCC), other conditions that can affect immune status include having lymphoma/leukemia, being on chemotherapy or other immunosuppressive drugs, and AIDS, ii) continued sun exposure results in both increased risk for UV-induced mutations taking the AK the next step toward becoming an SCC but UV light also suppresses the immune system in the skin (this is why we use UV light to treat skin conditions such as psoriasis that are immune-mediated), and iii) some individuals probably already have some built-in mutations in them that facilitate the transformation of AKs to SCC, it is not uncommon to have some individuals with as many as 50 SCCs in a lifetime while others have had many AKs but no SCCs.  To reduce the risk of SCCs, treatment is directed at education regarding the importance of sun-protection as well as treatment of AKs which is a large part of annual skin exams in fair-skinned individuals over age 50.  Individual AKs are often treated with liquid nitrogen cryotherapy; large areas with numerous AKs can be treated with topical chemotherapy agents such as 5-fluorouracil, topical immune system enhancers such as imiquimod, or by photodynamic therapy (Blu-U) which utilizes a chemical photosensitizer that accumulates in rapidly dividing cells making those cells susceptible to absorption of blue light creating heat and destruction of the premalignant cells.  SCC themselves are treated by many of the same therapies that are used to treat BCC with the understanding that these lesions have potential to metastasize and kill; risk stratification being based upon the degree of differentiation of the cells in the tumor (differentiation is how much the cells mature and shed like normal skin cells), the immune status of the patient, and the size and location of the lesion (scalp and lips being at higher risk for metastasis).  In circumstances of poorly differentiated SCCs of the head and neck, it will sometimes be necessary to refer these patients to surgeons at an oncology center who can better assess the chance of spread to lymph nodes.

    Melanoma--accounts for about 80,000 cases a year and nearly 15,000 deaths.  Melanoma is most common on the back especially the upper back and houlders and the legs especially in women but it can appear anywhere.  It most commonly affects fair individuals but these individuals only have about a 20% increased risk compared to those who can tan, and while people of darker skin types have lower rates, it is of note that the legendary reggae musician Bob Marley died from melanoma of the toe at age 36.  The vast majority of melanomas begin where they are 100% curable and you can see them, thus monthly self skin exams are very helpful at decreasing the risk of an individual dying from melanoma (some studies suggest a decrease of as much as 90%).  This tells you that these early treatable melanomas are easy to spot if you make the effort to look.  The classic guide for identifying a lesion that is potentially melanoma is to look for the ABCDEs of melanoma--Asymmetry, Border irregularities, Color variation, Diameter >6mm (size of a standard pencil eraser), and Evolution (the changing "mole").  These characteristics relate to an enlarging tumor where growth is not regulated thus leading to more growth, spread or color in one area vs another hence asymmetry and color variation.  Most melanomas appear de novo (no preexisting mole was present) with only about 15% arising from an existing mole (so if a mole has been the same for 30 years and now suddenly out of nowhere it seems to be changing especially in an asymmetric fashion that would be highly suspicious).  New lesions suspicious for melanoma may have many of the ABCDE characteristics but the critical factor in identifying these lesions is to find them when they are flat as flat lesions equal early curable lesions!!  Do not hesitate when a lesion shows any of the ABCDE features, individuals get in trouble with melanomas not because they didn't see them but because they didn't get them looked at by a dermatologist early enough.  Early melanomas can be treated in our clinic by simple excision; later lesions will need to be referred to oncology surgeons who can assess lymph nodes and consider advanced treatments such as immune therapy.

    Other types of skin cancers--less common skin cancers can arise from other cell types in the skin including blood vessels, hair follicles, glandular structures, and connective tissues and so it is imperative that individuals identifying any unordinary skin lesion that is not going away bring themselves to qualified dermatology professionals for an examination--a 10 minute examination can save your life!!

     

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