Bryan C. Schultz, M.D. - Affiliates in Diseases and Surgery of the Skin, S.C.    
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Skin Cancer FAQs: Detection and Prevention

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"Skin cancers don't go away, but continue to grow larger. Detect cancers when they are small. To prevent cancer, develop smart sun protection habits and check all your skin monthly. Patients with light skin or those with a history of skin cancer or pre-cancer should also have regular exams by their dermatologist."

INCREASED CANCER MORTALITY WITH HISTORY OF NONMELANOMA SKIN CANCER

Data from a study of 1.1 million adults showed patients with nonmelanoma skin cancer (basal cell and squamous cell) have a 20%-30% increased cancer mortality risk for other cancers. For both men and women risk was increased for melanoma, cancer of the pharynx, lung and non-Hodgkin lym-phoma. Breast cancer mortality in women only was increased 34%. For men only, risk was increased for salivary glands, prostate, testes, urinary bladder and leukemia. All cause mortality was only slightly increased (3% for men and 4% for women). Mean age at diagnosis of other cancer was 52 years old.

Regular check-ups with their primary physician would be prudent for patients with this history. For your physician's reference, this data is reported in JAMA 9-9-98 pp. 910-912.

1. WHAT CAUSES SKIN CANCER?

The association of sun exposure with skin cancer is well established. People with lighter skin (especially those who don't tan) are more susceptible to skin cancer. Skin wrinkling and skin cancer relate to total sun exposure over one's entire life.

2. WON'T I HAVE EARLY WARNING SIGNS?

Even patients who never sunbathe receive thousands of hours of lifetime exposure. Unfortunately, when the total dosage reaches a critical point, patients start noticing precancerous and cancerous lesions. These may appear in large numbers and at frequent intervals. A patient may have had smooth skin until age 30, 40, or 50 and suddenly begins to develop precancerous or cancerous lesions several times a year. They cannot undo the sun damage now. They can decrease further radiation damage by wearing sunscreen lotions regularly. This will not, however, keep radiation damage at zero. Patients will even develop lesions in winter. X-ray treatment in the past also predisposes to skin cancer. We should know of any such previous treatment.

3. WHAT IS THE MOST COMMON TYPE OF SKIN CANCER?

Basal cell carcinoma is the most common cancer in the United States. Approximately 500,000 new cases occur each year. We treat this kind of skin cancer many times daily in our office.

It usually appears as a pimple-like spot that does not seem to go away. Almost all patients thought it was a pimple at first. They tend to pick at it, believing this is the reason the lesion persists. Any pimple should be gone within 1-2 months. If a pimple is still on the face after a 2 month period, make sure we check it.

This cancer does not usually metastasize (one study reported one in 3000 spread to other organs) and, therefore, it is rarely fatal, except in persons who neglect it. It does grow locally in the area in which it develops with the potential of destroying adjacent structures (for example nose, cheek, eyelid, etc.) and must, therefore, be treated to prevent this.

4. HOW IS BASAL CELL CARCINOMA TREATED?

I use surgical excision with suturing, laser excision, or curettage and electrodesiccation (using a sharp surgical curette to remove the tumor and for biopsy while making sure the entire tumor is gone, and subsequent burning with an electric needle). I find cure rates with any of these methods to be well over 95%.

The surgical procedures described above should be completely painless, with the patient feeling only the slightest prick with a local anesthetic.

Another method reserved for the most difficult skin cancers, in my opinion, is called Moh's chemosurgery. This method may leave larger defects that can take a significant period of time to heal. It is, therefore, not usually my initial therapeutic choice. This method involves taking small pieces of skin and checking them to ensure complete removal of a large tumor or difficult recurrent tumors.

We may occasionally use cryosurgery (freezing) or x-ray to treat some skin cancers.

In some carcinomas, large size or difficult location may lead me to suggest that our plastic surgeon excise the cancer. This would be recommended if indicated; however, most lesions can be treated quite simply in the office.

5. WHAT IS APPROPRIATE FOLLOW-UP CARE FOR EARLY DETECTION AND TREATMENT?

Patients who have had a skin cancer will be prone for life to develop others, just as a patient with cavities will be so predisposed. Studies have shown a 35-50% incidence of an additional skin cancer (basal and squa-mous cell types) within 3 years after treatment of the first cancer.

A small percentage of cases may recur but are usually detected at an early stage when patients are followed routinely. Every 3 months (for 1 year) after removal of any cancer and every 6 months lifelong are current recommendations. Patients who follow this routine rarely have significant problems because lesions are found when they are small.

Some areas, such as the forehead and nose, may develop several skin cancers. Former President Reagan developed one skin cancer on his nose and had another one develop on the nose shortly thereafter, and a recurrence, according to reports. This is another reason for frequent lifetime check-ups by any patient having basal cell carcinoma.

6. WHAT SHOULD I LOOK FOR?

The face, neck, tops of the hands and arms are most frequently exposed to ultraviolet light from the sun. 90% of all skin cancers (except melanoma) occur in these areas. These are the areas that patients should watch most carefully, although all skin should be checked monthly at home. The following signs of skin cancer (basal and squamous cell) should be closely looked for:

1. An open sore or pimple that bleeds, oozes or crusts and remains for one month or more. A persistent nonhealing pimple should be checked. Almost all patients (including former President Reagan) call skin cancer a pimple that they usually pick at. They invariably think this is the reason it is still present.

2. A reddish patch or irritated area, especially on sun exposed skin. It may or may not be symptomatic. Most skin cancers do not cause the patient any discomfort. Many skin cancers will also never bleed.

3. A shiny bump that can be a pearly color or pinkish-red color.


7. WHAT ARE PRE-CANCERS AND SQUAMOUS CELL CARCINOMA?

Actinic keratoses (pre-cancers) usually present as small reddish patches that may have a slight brownish tinge. They may be slightly scaly and occasionally bleed. One usually notices it as a small patch that will scale or is rough and looks slightly different than the surrounding skin. One key in differentiating this from a benign area is that these areas will still be there one or two months later. Any persistently different area of skin should be checked by a dermatologist.

These keratoses will lead to a somewhat more difficult skin cancer, squamous cell carcinoma, if not treated. They usually grow slowly and may take several years before turning into a squamous cell carcinoma; however, patients should not delay in treatment, as some may develop into squamous cell carcinoma rather rapidly. Although squamous cell carcinoma of the sun-exposed skin does not frequently spread to other organs (metastasize), this is possible (approximately 5-10% reported in different studies) and, therefore, should be treated early. As these develop into squamous cell carcinoma, the scale may become thicker and the lesion may grow deeper.

These premalignant keratoses can be easily treated with superficial therapy, such as freezing with liquid nitrogen. This causes a scab or blister and heals usually within 1 or 2 weeks. This method removes the diseased top layer of the skin. Presidents Clinton and Bush have had several actinic keratoses treated with this method. A topical chemical, 5-fluorouracil, may be used, but may cause too much irritation of the skin for some patients. It is used mostly for patients with large numbers of actinic keratoses.

Although actinic keratoses are precursors of squa-mous cell carcinoma and therefore can be detected in a premalignant phase, basal cell carcinoma does not have any precursor lesion. Basal cell carcinoma develops from the very beginning as a basal cell carcinoma.

8. WHAT IS MELANOMA?

Malignant melanoma is the most serious form of skin cancer, since it will spread to other organs if not detected at an early phase. It is not as prevalent as basal cell carcinoma, premalignant actinic keratoses and squamous cell carcinomas. This form of skin cancer will be fatal if not treated early, so any suspicious moles or other spots should be checked or removed immediately. Those individuals with a family history of multiple moles have an increased incidence of developing melanoma and should be checked at least yearly. There is a much higher incidence of malignant melanoma in light-skinned individuals who have had excessive sun exposure and especially a severe sunburn. Current thinking indicates that a serious sunburn early in life may predispose an individual to the development of malignant melanoma. This is another important reason for judicious uses of sunscreens and avoidance of sunburn.

Please refer to our pamphlet on moles for a more thorough discussion of moles and precursors of malignant melanoma.

9. HOW SHOULD I USE SUNSCREEN?

If you have light skin or have had one of the lesions mentioned above, avoidance of excess sun exposure by using hats, protective clothing and sunscreen should become a lifelong habit. Sunscreen lotions with a sun protection factor (SPF) of 30 or greater should be used. Apply to the skin regularly about 15-30 minutes before and 15-30 minutes after exposure, after swimming and every 2 hours or so if out for a prolonged period of time. Even products that are supposedly water proof should be reapplied to the skin after being in water. New research finds markedly better results with 2 closely-spaced applications to ensure adequate amounts are applied and skipped areas are covered.

Even five and ten minutes of sun continues to add to the total lifetime dosage. It does not require a sunburn to develop chronic sun damage. During the very sunny seasons or when in sunnier climates, daily morning use of sunscreen is advised. Those with very light skin or skin cancer are urged to use sunscreen daily year round.

11. WHAT ABOUT SUNSCREEN ALLERGY?

Some people, especially those allergic to sulfa, may be sensitive to the main ingredient in many sunscreens: PABA. PABA also has the disadvantage of discoloring clothing and other materials. For such individuals we have an excellent non-PABA product. Some sunscreens have a creamy base that may aggravate acne or pimples. In such cases we have an alcohol-based product. We have PABA-free or "chemical free" (micronized titanium dioxide) sunscreen for allergic patients. If sunscreen stings the eyes, wear a hat and apply sunscreen below it to avoid dripping into the eyes. We will suggest a good sunscreen for you, or simply ask us.


12. ARE SELF TANNING AGENTS ACCEPTABLE?

These agents are usually just skin dyes or bronzing agents that are acceptable for most patients. The color does not protect skin like natural tanning, so they should not be used as sunscreens.

13. WHAT EFFECT DOES THE THINNING OZONE LAYER HAVE?

It means you will get more dangerous ultraviolet radiation daily, but self-protection with hats, sunglasses (with ultraviolet protection), tight-weave clothing and high SPF sunscreens can lower your risk more than the thinning ozone layer increases it.
Data released by NASA in 1992 indicated that we have the potential of developing decreased ozone over the northern latitudes similar to that which has already developed seasonally over Antarctica (but not as severe).

I am closely following such data and receive reports from NASA, etc. Please ask if you are interested in an update on the scientific data.

I have also lobbied Congress for acceleration of steps to protect the environment through the Montreal Protocol. That accelerated schedule has been ordered by the president and American business indicates they will make a concerted effort to comply.

14. WHAT'S NEW?

A. Smoking increases the risk for skin aging (wrinkles) and perhaps for squamous cell skin cancer.

B. Pre-cancerous actinic keratoses are less prevalent while on a consistent low-fat diet (fat as 21 % of calories vs. 40% for controls).

C. The National Weather Service started a new ultraviolet index similar to my 20-year sunburn meter program (but not as detailed for time of day). The EPA and the National Weather Service consulted with me while developing this program, and I support its efforts to increase awareness of ultraviolet intensity.

15. WHY SHOULD I WORRY ABOUT ALL THIS?

You shouldn't! Properly informed and protected people are probably at less risk than their predecessors.

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