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Skin Cancer: What You Need to Know

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You Can Protect Yourself Against Skin Cancer!

Our skin is actually the largest organ of the human body and the health and appearance of our skin often has a profound impact on our quality of life. It plays an extremely important role in protecting our entire body from harmful bacteria, water loss, and serves as a buffer between the outside world and our inner organs, including muscle, bones, etc. Skin also helps control body temperature, protects the rest of the body from ultraviolet (UV) light, and helps the body make Vitamin D. It also plays a key role in creating and maintaining our individual identity, as this protective covering helps create the ‘picture’ of what we see when we look in a mirror. Human beings have long been concerned with their appearance, and therefore have taken an interest in “skin” appearance since the dawn of mankind.

As the largest—and often the most exposed—organ of the body, it should not be surprising that skin cancers are far and above the most common cancer that occurs in humans. Fortunately, the vast majority of these cancers are very treatable, and with timely care, they do little to interfere with our daily lives. The two most common types of skin cancers (Basal Cell and Squamous Cell) occur so often, that they are not even tracked by our national or global Tumor Registries. These are sometimes referred to as non-melanoma skin cancers (NMSC). The American Cancer Society (ASC) estimates that 3.5 million cases of NMSC were diagnosed in 2012 in the United States alone. Most NMSCs are highly curable with timely treatment; however, identifying the problem, seeking treatment, and obtaining timely treatment can still be a challenge for many people. In 2012, more than 75,000 Americans were diagnosed with melanoma, the most serious skin cancer. Most significant is the fact that melanoma incidence rates have been increasing by almost three percent per year in both men and women, according to the National Cancer Institute (NCI) and the ACS. The trauma and losses from delays in treating even the most common skin cancers are very significant. As with all cancers, early diagnosis and timely intervention is vital to good health and even survival. The focus of this report will be on the most serious of skin cancers: melanoma. However, references will be provided for further information on the NMSCs, as they too demand timely attention.

What is Skin Cancer?

Skin cancer develops when skin cells start to grow in an abnormal way. It most often begins on areas of your skin that have had significant exposure to sunlight, but it can also occur in skin cells that would not normally be exposed to sun. Like other cancers, if left alone, the abnormal cells will continue to grow and eventually will push their way into healthy tissues, causing many different types of problems, depending on the type of cancer, the growth rate, and the location. That is why our focus for all skin cancers is (1) Prevention and (2) Early Diagnosis and Treatment.

Types of Skin Cancer

There are three main types of skin cancer: basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. Basal cell and Squamous cell are far more common than melanoma, and fall into the category of NMSC (Non-melanoma skin cancer). However, all of these cancers need early identification and intervention/treatment to minimize the damage to the healthy cells around the abnormal cancer cells.

Melanoma incidence rates have been increasing by almost three percent per year in both men and women (NCI, ACS).

human skin layers

What Does Skin Cancer Look Like?

Basal Cell Carcinoma
basal cell carcinomaBasal cell carcinoma usually presents as a raised, smooth, pearly bump on the sunexposed skin of the head, neck or shoulders. Sometimes small blood vessels can be seen within the tumor. Crusting and bleeding in the center of the tumor frequently develops. It is often mistaken for a sore that does not heal. This form of skin cancer is the least deadly and with proper treatment can be completely eliminated, often without scarring.

Squamous Cell Carcinoma
squamous cellOften a very rapid growing tumor, squamous cell carcinoma (SCC) is commonly a red, scaling, thickened patch on sun-exposed skin. Some are firm hard nodules and dome shaped. Ulceration and bleeding may occur. When SCC is not treated, it may develop into a large mass. Squamous cell is the second most common skin cancer. It is dangerous, but not nearly as dangerous as a melanoma.

Malignant Melanoma
malignant melanomaThe common appearance is an asymmetrical area, with an irregular border, color variation, and often greater than 6 mm diameter (pencil eraser). Most melanomas are brown to black looking lesions; a few melanomas are pink, red or fleshy in color which are called amelanotic melanomas. Unfortunately, these tend to be more aggressive. Warning signs of malignant melanoma include change in the size, shape, color or elevation of a mole. Other signs are the appearance of a new mole during adulthood or new pain, itching, ulceration or bleeding of a mole.

Who Gets Skin Cancer?

Nearly everyone on earth, if they live long enough, will develop some sort of skin cancer. There are, however, different levels of risk, depending on each person’s exposure to known “risk factors” for skin cancer. A risk factor is anything that affects your chance of developing a problem or disease. Having a known risk factor does not mean you will definitely develop a disease. Also, not having any known risk factors does not mean you will never develop a specific disease. Rather, knowledge about risk factors allows you to evaluate your own personal risk (chance) of developing that disease, and should also teach you how you can minimize your individual risk for any specific disease.

Risk Factors for Skin Cancer

#1 Ultraviolet (UV) radiation exposure. Ultraviolet (UV) radiation is a major risk factor for nearly all skin cancers. UV radiation damages the DNA of skin cells. Skin cancers begin when this damage affects the DNA of genes that control skin cell growth. Sunlight is the main source of UV radiation, which can damage the genes in your skin cells. Tanning lamps and beds are also sources of UV radiation. A tan is your skin’s injury response to excessive UV radiation. In 2012, California became the first state to ban the use of UV indoor tanning beds for all minors under age 18. People with high levels of exposure to light from these sources are at greater risk for skin cancer, including malignant melanoma.

Additional Risk Factors for Developing Skin Cancer
Sources: (Mayo Clinic 2012; Skin Cancer Foundation 2012)

Fair skin. Anyone, regardless of skin color, can get skin cancer. However, having less pigment (melanin) in your skin provides less protection from damaging UV radiation. If you have blond or red hair and light-colored eyes, and you freckle or sunburn easily, you’re much more likely to develop skin cancer than is a person with darker skin.

A history of sunburns. Having had one or more blistering sunburns as a child or teenager increases your risk of developing skin cancer as an adult. Sunburns in adulthood also are a risk factor.

Sunny or high-altitude climates. People who live in sunny, warm climates (closer to the equator) are exposed to more sunlight than are people who live in colder climates. Living at higher elevations, where the sunlight is strongest, also exposes you to more radiation.

Occupations/lifestyles that increase UV light exposure. People who spend the majority of the daylight hours outdoors (agriculture, ranching, forestry, etc.), as well as those who drive for a living.

Moles. People who have many moles or abnormal moles called dysplastic nevi are at increased risk of skin cancer. These abnormal moles—which look irregular and are generally larger than normal moles—are more likely than others to become cancerous. If you have a history of abnormal moles, watch them regularly for changes.

Precancerous skin lesions. Having skin lesions known as actinic keratoses can increase your risk of developing skin cancer. These precancerous skin growths typically appear as rough, scaly patches that range in color from brown to dark pink. They’re most common on the face, head and hands of fair-skinned people whose skin has been sun damaged. They are usually easily removed/treated by your doctor.

A family history of skin cancer. If one of your parents or a sibling has had skin cancer, you may have an increased risk of the disease.

A personal history of skin cancer. If you developed skin cancer once, you’re at risk of developing it again. Even basal cell and squamous cell carcinomas that have been successfully removed can recur.

A weakened immune system. People with weakened immune systems have a greater risk of developing skin cancer. This includes people living with HIV/AIDS or leukemia and those taking immunosuppressant drugs after an organ transplant.

Exposure to radiation. People who received radiation treatment for skin conditions such as eczema and acne may have an increased risk of skin cancer, particularly basal cell carcinoma. Exposure to certain substances. Exposure to certain substances, such as arsenic, may increase your risk of skin cancer.

Age. Although the risk of nearly all cancers increase with age (more time for skin damage), malignant melanoma, the most serious form of skin cancer is one of the most common cancers in people younger than 30. Melanoma that runs in families may occur at a younger age. Additional Risk Factor

Melanoma: The most dangerous type of skin cancer

Definition of Melanoma:

Melanoma is a form of cancer that begins in melanocytes (cells that make the pigment melanin). It may begin in a mole (skin melanoma), but can also begin in other pigmented (colored) tissues, such as in the eye or in the intestines. We do not always know exactly what damages the DNA in skin cells that leads to melanoma. It appears that it is often related to a combination of things, including environmental and genetic factors. Still, doctors believe exposure to ultraviolet (UV) radiation from the sun and from tanning lamps and beds is the leading cause of melanoma.

The risk of melanoma seems to be increasing in people under 40, especially women. (Mayo Clinic) Knowing the warning signs of skin cancer can help ensure that cancerous changes are detected and treated before the cancer has spread. Melanoma can be treated successfully if it is detected early.

Signs and Symptoms

Melanomas can develop anywhere on your body. They most often develop in areas that have had exposure to the sun, such as your back, legs, arms and face. Melanomas can also occur in areas that don’t receive much sun exposure, such as the soles of your feet, palms of your hands and fingernail beds. These hidden melanomas are more common in people with darker skin.

The first melanoma signs and symptoms often are:

• A change in an existing mole
• The development of a new pigmented or unusual-looking growth on your skin
• Melanoma doesn’t always begin as a mole. It can also occur on otherwise normal-appearing skin.

Estimated new cases and deaths from melanoma in the United States in 2012 (NCI): New cases: 76,250 • Deaths: 9,180

Normal Moles

Normal moles are generally a uniform color, such as tan, brown or black, with a distinct border separating the mole from your surrounding skin. They're oval or round and usually smaller than 1/4 inch (about 6 millimeters) in diameter—the size of a pencil eraser. Most people have between 10 and 45 moles. Many of these develop by age 40, although moles may change in appearance over time and some may even disappear with age.

Often the first sign of melanoma is a change in the shape, color, size, or feel of an existing mole. Melanoma may also appear as a new mole. Thinking of “ABCDE” can help you remember what to look for:
Asymmetry: The shape of one half does not match the other half.
Border that is irregular: The edges are often ragged, notched, or blurred in outline. The pigment may spread into the surrounding skin.
Color that is uneven: Shades of black, brown, and tan may be present. Areas of white, gray, red, pink, or blue may also be seen.
Diameter: There is a change in size, usually an increase. Melanomas can be tiny, but most are larger than the size of a pea (larger than 6 millimeters or about 1/4 inch).

Evolving: The mole has changed over the past few weeks or months; the mole is new.


Incidence (How Often it Occurs)

Melanoma does not occur as often as the non-melanoma skin cancers (3.5 million/year), but due to the potentially deadly results, it is considered a serious cancer. Based on rates from 2007-2009, 2 percent of men and women born today will be diagnosed with melanoma of the skin at some time during their lifetime. This number can also be expressed as one in every 50 men and women will be diagnosed with melanoma of the skin during their lifetime. As noted within risk factors, people with fair skin and hair have the highest risk of developing melanoma. This is reflected in the U.S. incidence rates by race in the chart below (Source: NCI). These rates are based on cases diagnosed in 2005-2009 from 18 SEER geographic areas (nationwide data).

melanoma incidence rates

Diagnosing Melanoma (and other Skin Cancers)

If you have a change on your skin, your doctor must find out whether or not the problem is from cancer. You may need to see a dermatologist, a doctor who has special training in the diagnosis and treatment of skin problems. The dermatologist will check the skin all over your body to see if other unusual growths are present.

If your doctor suspects that a spot on the skin is cancer, you may need a biopsy. For a biopsy, your doctor may remove all or part of the skin that does not look normal. The sample then goes to a lab. A pathologist checks the sample under a microscope, looking for changes in the skin tissue cells. Sometimes it’s helpful for more than one pathologist to check the tissue for cancer cells. You may have the biopsy in a doctor’s office or as an outpatient in a clinic or hospital. You will probably have a local anesthetic before the biopsy is taken. (Source: NCI)

There are four common types of skin biopsies:

Shave biopsy: The doctor uses a thin, sharp blade to shave off the abnormal growth

Punch biopsy: The doctor uses a sharp, hollow tool to remove a circle of tissue from the abnormal area

Incisional biopsy: The doctor uses a scalpel to remove part of the growth

Excisional biopsy: The doctor uses a scalpel to remove the entire growth and some tissue around it; this type of biopsy is most commonly used for growths that appear to be melanoma

Staging Melanoma

If the biopsy shows that the skin change is melanoma (or any other cancer), then further testing may be required to determine the “stage” of this particular cancer. Staging is a critical step in determining your future plan of care. To assign a stage to your melanoma, your doctor will:

Determine the thickness. The thickness of a melanoma is determined by carefully examining the melanoma under a microscope and measuring it with a special tool called a micrometer. The thickness of a melanoma helps doctors decide on a treatment plan. In general, the thicker the tumor, the more serious the disease. (Mayo Clinic)

See if the melanoma has spread. To determine whether your melanoma has spread to nearby lymph nodes, your surgeon may use a procedure known as a sentinel node biopsy. During a sentinel node biopsy, a dye is injected in the area where your melanoma was removed. The dye flows to the nearby lymph nodes. The first lymph nodes to take up the dye are removed and tested for cancer cells. If these first lymph nodes (sentinel lymph nodes) are cancer-free, there’s a good chance that the melanoma has not spread beyond the area where it was first discovered. Cancer can still recur or spread, even if the sentinel lymph nodes are free of cancer. (Mayo Clinic)

Order a more comprehensive work up if there is any evidence that the melanoma has spread. This may include a number of diagnostic scans, depending on the location of the melanoma, and other factors. Your doctor may recommend a CT scan, an MRI, and/or a PET scan to help determine if and where there might be additional melanoma cell clusters.

Melanoma is staged using the Roman numerals I through IV. A stage I melanoma is small and has a very successful treatment rate. But the higher the numeral, the lower the chances of a full recovery. By stage IV, the cancer has spread beyond your skin to other organs, such as your lungs or liver. These are the primary stages of melanoma (Source NCI):

• Stage 0: The melanoma involves only the top layer of skin. It is called melanoma in situ.

• Stage I: The tumor is no more than 1 millimeter thick (about the width of the tip of a sharpened pencil.) The surface may appear broken down. Or, the tumor is between 1 and 2 millimeters thick, and the surface is not broken down.

• Stage II: The tumor is between 1 and 2 millimeters thick, and the surface appears broken down. Or, the thickness of the tumor is more than 2 millimeters, and the surface may appear broken down.

• Stage III: The melanoma cells have spread to at least one nearby lymph node. Or, the melanoma cells have spread from the original tumor to tissues nearby.

• Stage IV: Cancer cells have spread to the lung or other organs, skin areas, or lymph nodes far away from the original growth. Melanoma commonly spreads to other parts of the skin, tissue under the skin, lymph nodes, and lungs. It can also spread to the liver, brain, bones, and other organs.

Treatment Options for Melanoma Patients

Treating early-stage melanomas: Treatment for early-stage melanomas usually includes surgery to remove the melanoma. A very thin melanoma may be removed entirely during the biopsy and require no further treatment. If there are any melanoma cells seen at the edges (border) of the biopsy, then your surgeon will remove the cancer as well as a small border of normal skin and a layer of tissue beneath the skin. For people with earlystage melanomas, this may be the only treatment needed.

Treating melanomas that have spread beyond the skin: Your doctors will discuss a variety of options and choices available to you, if you need treatment beyond the initial surgery. You may have a team of specialists to help plan your treatment. Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat skin cancer include dermatologists and surgeons. Some people may also need a reconstructive or plastic surgeon. People with advanced skin cancer may be referred to a medical oncologist or radiation oncologist. Your health care team may also include an oncology nurse, a social worker, and a registered dietitian. Because skin cancer treatment may damage healthy cells and tissues, unwanted side effects sometimes occur. Side effects depend mainly on the type, location, and extent of the treatments and are unique for each person. Before treatment starts, your health care team will tell you about possible side effects and suggest ways to help you manage them.

Recent years of research have opened up new hope for patients that have a melanoma that has spread beyond the skin. Treatment options may include:

• Surgery to remove affected lymph nodes. If melanoma has spread to nearby lymph nodes, your surgeon may remove the affected nodes. Additional treatments before or after surgery may also be recommended.

• Chemotherapy. Chemotherapy uses drugs to destroy cancer cells. Chemotherapy can be given intravenously, in pill form or both so that it travels throughout your body.

• Radiation therapy. This treatment uses high-powered energy beams, such as X-rays, to kill cancer cells. It’s sometimes used to help relieve symptoms of melanoma that has spread to another organ. Fatigue is a common side effect of radiation therapy, but your energy usually returns once the treatment is complete.

• Biological therapy. Biological therapy boosts your immune system to help your body fight cancer. These treatments are made of substances produced by the body or similar substances produced in a laboratory. Biological therapies used to treat melanoma include interferon and interleukin-2. Side effects of these treatments are similar to those of the flu, including chills, fatigue, fever, headache and muscle aches. Ipilimumab (Yervoy) is another drug that uses your immune system to fight melanoma. Ipilimumab is used to treat advanced melanoma that has spread beyond its original location.

• Targeted therapy. Targeted therapy uses medications designed to target specific vulnerabilities in cancer cells. Vemurafenib (Zelboraf) is a targeted therapy approved to treat advanced melanoma that can’t be treated with surgery or melanoma that has spread through the body. Vemurafenib only treats melanoma that has a certain genetic mutation. Cells from your melanoma can be tested to see whether this treatment may be an option for you.

Experimental Melanoma Treatments

Clinical trials are studies of new treatments for melanoma. Doctors use clinical trials to determine whether a treatment is safe and effective. People who enroll in clinical trials have a chance to try evolving therapies, but a cure isn’t guaranteed. And sometimes the potential side effects aren’t known. Some melanoma treatments being studied in clinical trials include:

New combinations of treatments. Researchers are testing whether combining treatments may increase the effectiveness of melanoma treatment. For instance, different combinations of chemotherapy, biological therapy, targeted therapy and radiation have been proposed. However, combining treatments can make severe side effects more likely.

New targeted therapies. Researchers are testing new targeted medications in people with advanced melanoma. For instance, targeted drugs designed to stop melanoma from attracting blood vessels have shown some success. Blood vessels carry nutrients to the melanoma, and blood vessels help spread cancer cells throughout the body. A drug that stops this process could cause a melanoma to remain small and localized.

Vaccine treatment. Vaccines for treating cancer are different from vaccines used to prevent diseases. Vaccine treatment for melanoma might involve injecting altered cancer cells into the body to draw the attention of the immune system and hopefully stimulate it to develop defensive cells.

Prevention and Early Diagnosis is Vital

As noted throughout this report, there is an enormous survival advantage for those that are able to be diagnosed earlier with melanoma (before it has spread to other areas). An even greater advantage would be if we could prevent the melanoma (or other skin cancers) from developing in the first place. This is why (1) Prevention and (2) Early Diagnosis is what we shout within the cancer care community! Since we believe that the majority of UV radiation that contributes to skin cancer starts years before the visible evidence of the skin damage/cancer shows up, we now realize how critical it is to protect our skin from the day we are born. Here are a few proactive steps each of us can take in our daily life to reduce our personal risk.

Preventive Measures

Avoid midday sun. Avoid the sun when its rays are the strongest. For most places, this is between about 10:00 a.m. and 4:00 p.m. Because the sun’s rays are strongest during this period, try to schedule outdoor activities for other times of the day, even in winter or when the sky is cloudy. You absorb UV radiation year-round, and clouds offer little protection from damaging rays. Seek the shade when you can.

Protect yourself from “reflected” sun. UV light is reflected by sand, water, snow, ice, and pavement. The sun’s rays can go through light clothing, windshields, windows, and clouds.

Wear sunscreen year-round, every day. Use a broad-spectrum (UVA and UVB) sunscreen with a sun protection factor (SPF) of at least 15. (Some doctors will suggest using a lotion with an SPF of at least 30). For extended outdoor activity, use a water-resistant, broad spectrum product with an SPF of 30 or higher. Apply sunscreen generously, and reapply every two hours—or more often if you’re swimming or perspiring. Use a generous amount of sunscreen on all exposed skin, including your lips, the tips of your ears, and the backs of your hands and neck.

Wear protective clothing. Sunscreens don’t provide complete protection from UV rays, so wear tightly woven clothing that covers your arms and legs and a broad-brimmed hat, which provides more protection than a baseball cap or visor does. Some companies also sell photoprotective clothing; your dermatologist can recommend an appropriate brand.

Don’t forget sunglasses. Look for those that block both types of UV radiation—UVA and UVB rays.

Avoid tanning beds. Tanning beds emit UV radiation, which can increase the risk of skin cancer.

Keep newborns out of the sun. Sunscreens should be used on babies over the age of six months.

Become familiar with your skin so you’ll notice changes. Examine your skin monthly, so that you become familiar with what your skin normally looks like. This way, you may be more likely to notice any skin changes. With the help of mirrors, check your face, neck, ears and scalp. Examine your chest and trunk and the tops and undersides of your arms and hands. Examine both the front and back of your legs and your feet, including the soles and the spaces between your toes. Also check your genital area and between your buttocks. If you notice anything unusual, point it out to your doctor at your next appointment.

Teen Tanners: The New Faces of Melanoma

Women ages 18 to 39 are now eight times more likely to be diagnosed with this potentially deadly skin cancer than they were just 40 years ago.

Limit the Sun, Not the Fun!

If there’s any good news about melanoma, it’s this: You have the power to substantially lower your risk of getting it. All it will cost you is a little extra time spent protecting yourself from the sun and paying attention to the moles on your skin. Developing protective habits as children and teens can be life-saving in later years. All skin types (fair, medium and dark skin) and people of all ages need protection from UVA and UVB rays. Everyone should protect their skin: use sunscreen properly, wear a hat, cover up! (Please see pages 16-17 for more suggestions.)

The Dangers of UV Indoor Tanning Beds

While it’s no secret that the number of people developing melanoma has long been climbing, one group has had a disproportionately meteoric rise. Women ages 18 to 39 are now eight times more likely to be diagnosed with this potentially deadly skin cancer than they were just 40 years ago. This is significant because the years of potential life lost due to melanoma are higher than for other cancers. An American dying from melanoma loses about 20 years of life.

This rise in skin cancer rates happens to coincide with the growth of indoor tanning. Young women are by far the most frequent users of tanning machines: 71 percent of tanning salon patrons are girls and women aged 16-29. However, people who tan indoors are 74 percent more likely to develop melanoma, 2.5 times more likely to develop squamous cell carcinoma, and 1.5 times more likely to develop basal cell carcinoma than non-tanners.

Melanoma is a potentially deadly form of skin cancer that is on the rise in teens.

San Luis Obispo County has the highest rate of new melanoma diagnoses in the state: 106 percent above the national average.

Ninety percent of childhood melanoma cases occur in girls aged 10-19, and in those cases 40 percent of the time the diagnoses and treatment are delayed.

About two Californians die of melanoma each day, for a total of more than 800 deaths from melanoma every day.

Indoor ultraviolet (UV) tanners are 74 percent more likely to develop melanoma than those who have not tanned. Melanoma is a potentially deadly form of skin cancer that is on the rise in teens.

Did you know? Due to the harmful effects of tanning beds, California has banned the use of UV indoor tanning beds for all minors under 18.

Questions to Ask Your Doctor Before Treatment

What is the stage of the disease?

Has the cancer spread?

Do any lymph nodes or other organs show signs of cancer?

What are my treatment choices? Which do you suggest for me? Why?

Is this something that can be treated locally, or should I seek care from a university setting, in a major city?

What are the expected benefits of each kind of treatment?

What can I do to prepare for treatment?

Will I need to stay in the hospital? If so, for how long?

What are the risks and possible side effects of each treatment?

How can side effects be managed?

Will there be a scar? Will I need a skin graft or plastic surgery?

What is the treatment likely to cost?

Will my insurance cover it?

How will treatment affect my normal activities?

Would a research study (clinical trial) be a good choice for me? How often should I have checkups?