Skin Cancer

Dr. Mowbray encourages every new patient in the office to be screened for skin cancer.

Here are some of the signs of skin cancer that you should look for:

• a new skin lesion that does not heal in one month
• any smooth lesion that is flat or raised and has a red or pink color
• any red lesion that is rough and has scale on the surface
• any lesion that is rapidly growing especially those on sun exposed areas
• a lesion that bleeds after mild trauma such as when you wash the area
• any new mole that is brown or black
• a mole that is changing in color or shape
• any mole on the soles of the feet or on the palms should be evaluated for melanoma
• a pigment streak in a fingernail or a toenail, that starts near the cuticle could be a melanoma

Patients who are at extra risk for skin cancer are as follows:

• you have had a precancerous or a skin cancer treated in the past
• your mother or father have been treated for skin cancer
• you like to suntan either now or in the past
• you are a young woman between the age of 16 and 30 and have been to tanning salons i.e. higher risk for getting a melanoma
• you have a fair complexion with blue eyes and possibly red hair
• you tend to make freckles easily and you always sunburn before you start seeing a tan
• there is a family history of skin cancer, especially if it occurred in your parents or siblings
• you have been told that either you or one of you family members have Atypical Moles or Dysplastic Nevi, as these abnormal moles increase your risk for getting a melanoma
• you grew up in a warm sunny climate or you had recurrent sunburns in a cooler climate
• you had more that two severe sunburns before the age of 12
• you have not worn a sunscreen lotion of SPF 30 or higher each and every day as an adult
• you have been active in outdoor sports such as running and biking and tennis
• your immune system is weakened either by taking transplant drugs or because of HIV infection

NOW IS THE TIME TO GET YOUR SKIN CHECKED FOR SKIN CANCER. PLEASE MAKE AN APPOINTMENT AND MAKE SURE YOUR SKIN IS HEALTHY!

THE THREE TYPES OF SKIN CANCER IN ORDER OF FREQUENCY:

1) BASAL CELL CANCER: the most common form of cancer in the USA

• over one million Americans will develop this cancer each year
• it is common on areas that have been exposed to the sun such as the face, neck and back
• this cancer can appear in many forms, from a flat pink mark to a small ulcer that bleeds with mild trauma
• the most aggressive form is called a sclerosing or inflitrating or morpheaform tumor and may require extensive surgery to remove all of the lesion
• although it usually remains as a localized tumor in the skin, some patients who have delayed getting treatment go on to develop spread of the tumor cells into the lymph nodes or even to more distant sites in the body, that may result in death

Three Examples:

Treatments for Basal Cell Cancer:

A) EDC or Electrodessication and Curettage technique: small basal cell tumors can be cured using an electric needle and a hand held device known as a curette, which scrapes the tumor cells off the normal healthy skin. The wound heals naturally over several weeks, aided by keeping it covered with a bandaid and a topical antibiotic ointment. The resulting scar is usually flat and cosmetically very good although it usually appears whiter than the surrounding skin

B) Imiquimod Prescription Cream: certain basal cell cancers are very thin when viewed with a microscope at the time of skin biopsy. These lesions can be successfully treated with a prescription cream that boosts the immune system in the area of the cancer. The cream known by its chemical name imiquimod. It is applied to the skin cancer by the patient at bedtime, Monday to Friday, for a total of 6 weeks. This gives the patient a good cure rate with minimal scarring. The drawbacks include a rash in the treated area and the fact that there is no surgical proof that all of the cancer cells were eradicated.

C) Surgery: this is also known as excising the tumor. This procedure is performed in the office by Dr. Mowbray using a local anesthetic. Most patients have no discomfort after the procedure is completed. Removing the skin cancer with surgery allows for a higher rate of cure because the surgical specimen will be checked for clear margins by a pathologist.

D) Moh's Surgery and Plastic Surgery: basal cell cancers that have poorly defined margins or show an infiltrating pattern of cancer cells in the biopsy specimen may be candidates for Moh's surgery technique, that utilizes intra-operative microscopic testing to achieve clear tumor margins. Dr. Mowbray will classify the type of skin cancer you have based on its location, its size and the biopsy report. Based on this information that is unique to every patient, Dr. Mowbray will counsel you as to whether he thinks you should be treated with Moh's Surgery or Plastic Surgery.

E) Localized Radiation: superficial radiation can successfully kill the tumor cells without severely damaging the surrounding normal tissue. This is a useful treatment for older patients with cancers on the nose or lip who do not want to go through extensive surgery. Radiation treatments are usually well tolerated and require short daily treatment sessions for 2 to 4 weeks (not on weekends). The cosmetic results are usually excellent. Drawbacks include a cure rate that may not be as favorable as surgery and there is no surgical specimen to send to a pathologist to ensure clear tumor margins.

2) SQUAMOUS CELL CANCER: the second most common type of skin cancer

• this cancer is less frequent than basal cell cancer but it can be more agressive, spreading in the body causing metastatic tumors that may result in death
• it some cases it has a rough or scaly appearance that may resemble a wart
• it is usually seen on sun exposed areas such as the ears, hands, arms, legs and the scalp, especially in men who have thinning hair
• the lesions may grow slowly and develop within a precancerous actinic keratosis or they can develop very rapidly and look like a "horn" or a "volcano"
• they usually do not cause any symptoms such as pain or bleeding
• this cancer is associated with excessive sun exposure so it is seen quite commonly in Arizona
• it is more aggressive in those with weakened immune systems, such as those taking organ transplant drugs or in patients who have been infected with the HIV virus

Three Examples:

Treatment for Squamous Cell Cancer

A) Surgery: the best treatment remains surgical excision of the lesion. Some patients with more advanced tumors may require Moh's Surgery or Plastic Surgery (also see sections D and E under Basal Cell Cancer above).

PRE-SQUAMOUS CELL CANCER LESIONS:

These are lesions that on skin biopsy show damage to the squamous cells in the epidermis but invasion into the dermis has not yet occurred so they are not malignant yet. This type of skin growth is also from prior sun exposure and goes by the names of Actinic Keratosis or Bowen's Disease or Squamous Cell Cancer In Situ. These lesions are also treated in the dermatology office with either Liquid Nitrogen to freeze the lesion or EDC using an electric needle and a curette (see above section A under treatment of Basal Cell Cancer). Prescription creams such Efudex, Imiquimod, Zyclara or Solaraze are sometimes used depending on the results of the skin biopsy and the clinical appearance of the lesion. Dr. Mowbray will give educate you about your treatment options so you can make an informed decision.

3) MALIGNANT MELANOMA: the most serious type of skin cancer

• this is the most serious form of skin cancer that causes about 9000 deaths in the USA each year
• it starts in the epidermis within the pigment cells known as melanocytes, so the lesion usually has one or colors of pink to brown to black
• it is more common in those with fair skin, blond or red hair, blue eyes and freckles
• patients with a higher number of moles are at greater risk for getting a melanoma
• more melanomas develop in patients with atypical or dysplastic moles i.e. their moles are not all round or uniform in color
• in some cases melanoma can start in areas that have not had been exposed to a lot of sun exposure, such as the buttocks or palms or soles
• melanoma can occur in all ages although dermatologists are concerned about the large number of new cases that are developing in young women who have have repeatedly suntanned or have gone to tanning salons
• there is an increased risk in certain families that pass on a gene that predisposes them to melanoma and in some cases to pancreatic cancer. There is now a genetic test for this gene and it may be appropriate for a patient to be screened for the gene if other members in your family have had a melanoma
• more advanced cases of melanoma are seen in older patients, especially men
• people of all skin type including african americans may develop melanoma in areas protected from the sun such as inside the mouth, on the palms and soles or in the back of the eye i.e. all of these areas have pigment cells that can become malignant
• a melanoma beneath the nail may appear as a pigmented band or stripe of brown color that extends from the cuticle to the end of the nail

Treatments for Melanoma:

A) Surgery: this remains the cornerstone of treatment for melanoma. The lesion and surrounding skin are removed so that the cancer will not recur at that site in the future. This may cure the melanoma if it is is diagnosed early and the tumor has not spread beyond the skin around the melanoma

B) Staging of the Melanoma: tumors that are found on initial biopsy or excision to be greater than 1 mm in thickness have a higher risk of spread in the body, either locally to the nearby lymph nodes or in some cases the cancer may be detected at more distant sites at the time of initial diagnosis. In order to better estimate the patient's prognosis, a sampling of the nearby lymph nodes may be advised if there is no evidence of more distant spread of the cancer. This procedure is known as a Sentinel Lymph Node Biopsy. This is not a therapeutic surgery but it usually identifies those patients that have had spread of the melanoma cells to the nearby lymph nodes. These patients are identified as having Stage III metastatic disease and they may benefit from a year of interferon therapy.

C) Treatments for more advanced melanoma: patients with distant spread of the melanoma cells to other parts of the body are thoroughly evaluated by a medical oncologist. Treatments include biologic or immune agents, radiation or chemotherapy. Selected patients may temporarily benefit from more surgery in the future if new metastatic deposits of tumor are identified with a PET scan or a CT Scan and the cancer is localized in one area.

KEY MESSAGE: the best way to beat skin cancer and melanoma is by:

• decreasing your risk factors and use a protective sunscreen lotion of SPF 30 each morning
• not suntanning and avoid direct sun exposure between the hours of 10AM and 4PM
• reapply your sunscreen lotion SPF 30 or higher every 2 hours if you are active outdoors in the direct sun
• regularly perform a self examination of your skin every month so that any new or changing skin lesions can be evaluated by your doctor or dermatologist
• seeing your dermatologist for a skin cancer screening exam
• learning about your family history and whether anyone in your family has had an abnormal mole, also called an Atypical or Dysplastic Mole (also called a Nevus)
• taking notice of any suspicious change in your pigmented lesions and report this to your doctor. A biopsy should be performed on all lesions that are suspicious for skin cancer and especially if you notice a new or changing mole