Skin CancerWhat to look for and how to prevent it

Emily Louise Keimig MS MDClinical InstructorDepartment of Dermatology

ObjectivesIdentify risk factors for skin cancerDiscuss the three most common types of skin cancerDiscuss preventionVitamin D

General Statistics

• More than 3.5 million non-melanoma skin cancers in more than 2 million people• 137,990 new cases of melanoma

• Current estimates 1:5 Americans will develop skin cancer in their lifetime• By 2015, 1:50 Americans will develop melanoma in their lifetime

Structure of the Skin

Basal Cell Carcinoma

Basal Cell Carcinoma

• Most common form of skin cancer• >2 million cases diagnosed in the US every year• Areas of sun exposure most common areas to develop

- Head and neck, face• Can develop on any part of the body• Caused by ultraviolet (UV) rays from the sun or tanning beds

- Rays damage the DNA in the cells of the skin• Develops after years of sun exposure

- Risk increases after age of 50- BUT <50 years also develop BCC• Often women who have or continue to use tanning beds

• Grows slowly• Rarely spreads to other parts of the body

BCC

Basal Cell Carcinoma

Dome-shaped growth•Visible blood vessels•Pink or skin colored•May have flecks of brown or black•May flatten in the center•Bleeds easily•Crusting and oozing

Patch •Shiny pink or red•May have slight scale•Common on trunk•Grows slowly•May be mistaken for a patch of eczema

Signs and Symptoms

Basal Cell Carcinoma

Scar•Waxy feeling•Hard•Pale-white to yellow color•Looks like a scar•Difficult to see the edges

Non-Healing Sore•Bleeds easily•Won’t heal or heals and then returns•Oozing and crusting•Sunken center•Visible blood vessels

Signs and Symptoms

Basal Cell Carcinoma

• Physical traits- Light-colored or freckled skin- Light eyes and light hair- Inability to tan

• Sun history- Outdoor exposure without protection- Tanning beds

• Medical history- Personal history of BCC• Risk of developing a second BCC increases by 40%

- Close blood relative with BCC- Medications that depress the immune system- Exposure to X-rays (acne in the 1940s)

Risk Factors

Basal Cell Carcinoma

• Skin evaluation by dermatologist• Biopsy of suspicious lesions• Excision• Electrodessication and curettage• Mohs surgery• Photodynamic therapy (PDT) for early BCC• Medicated creams for early BCC• Pills

- Vismodegib for advanced disease or BCC that has spread• Radiation

- For BCC that cannot be cut out

Detection and Treatment

Actinic Keratosis

Actinic Keratosis

• Caused by ultraviolet (UV) exposure from sun or indoor tanning• Usually develop after age 40• Have higher risk of developing skin cancer in general• Most people develop more than one AK• Very common• Most people develop more actinic keratoses throughout lifetime• Pre-cancerous

- May develop into squamous cell carcinoma (SCC)• Goal is to treat before they turn into skin cancer

AK

Actinic Keratosis

Rough patch on the skin•May be painful when rubbed•May itch or burn

Persistently dry lips•AKA actinic cheilitis

Signs and Symptoms

Actinic Keratosis

May grow quickly and look like a horn May have a tan or brown color

Signs and Symptoms

Actinic Keratosis

• Physical Features- Fair skin- Light hair and eyes- Skin that burns easily

• Medical History- Weakened immune system- Medical condition making skin very sensitive to the sun

• Exposures- Polycyclic aromatic hydrocarbons (PAH)• Roofers

- Ultraviolet light exposure- Some medications

Risk Factors

Actinic Keratosis

• Evaluation by dermatologist for any suspicious lesions• Cryotherapy or liquid nitrogen therapy• Field treatment

- Medicated creams• Imiquimod• 5-Fluorouracil• Diclofenac

- Photodynamic therapy (PDT)

Detection and Treatment

Squamous Cell Carcinoma

Squamous Cell Carcinoma

• 700,000 new cases diagnosed annually in the United States• Most are caused by ultraviolet (UV) light exposure• Most common in areas of chronic sun exposure

- Head and neck, back of the hands- Lower legs in women

• Can occur anywhere- Lips, inside of the mouth, genitals

• Tanning beds increase risk- Much higher risk- SCC earlier in life

• Can spread to other parts of the body• Highly curable with early detection and treatment

SCC

Squamous Cell Carcinoma

Rough bump or lump on the skin Dome shaped crusted bump

Signs and Symptoms

Squamous Cell Carcinoma

Sore that doesn’t heal•Or heals and then returns

Bowen’s Disease •Squamous Cell Carcinoma in situ•Flat•Reddish•Scaly patch•Grows slowly

Signs and Symptoms

Squamous Cell Carcinoma

Involving the nail Involving the lip

Signs and Symptoms

Squamous Cell Carcinoma

• Physical traits- Light skin, eyes, hair- Inability to tan

• Exposures- Ultraviolet exposure- Arsenic, PAHs, tobacco, heat

• Medical history- Diagnosed with actinic keratosis• 40-60% of SCC may come from an actinic keratosis

- Ulcer or sore that has been present for years- Suppressed immune system- Papillomavirus (HPV) infection- X-rays for acne

Risk Factors

Squamous Cell Carcinoma

• Evaluation by dermatologist and biopsy of suspicious lesions• Dependant on how deep the cancer is and if it has spread• With treatment, most are cured• Excision• Mohs Surgery• Electrodessication and Curettage for early SCC• Photodynamic Therapy for early lesions• Chemotherapy Cream

- 5-Fluorouracil cream for earliest stages• Radiation

Diagnosis and Treatment

Melanoma

Melanoma

• The most serious form of skin cancer• Roughly 75% of skin cancer deaths are from melanoma• Can spread to other parts of the body (metastasize)• Can spread quickly• Can be deadly

• Incidence rates increasing over past 30 years• Rate increased by 2.8% per year

• Caucasians and men >50 years are at higher risk• Before age 40, incidence rates twice as high in women than in men• Most common form of cancer for young adults 25-29 years old• Increasing faster in females 15-29 years old than in males of same age• In women <44 years, incidence rate increased 6.1% annually• May be due to indoor tanning practices

Statistics

Melanoma

• Anyone can develop melanoma• Look for the ABCDEs of melanoma• Asymmetry• Border• Color• Diameter• Evolving

Signs and Symptoms

Melanoma

Melanoma•One half is unlike the other half•Two sides should be mirror images of one another•May be different in shape or color

Normal Mole

Asymmetry

http://www.health.com/health/gallery/0,,20723732_6,00.html

MelanomaAsymmetry

Melanoma

Melanoma•Irregular•Scalloped•Poorly defined

Normal Mole•Regular•Smooth•Discrete

Border

http://skincancer.dermis.net/content/index_eng.html

MelanomaBorder

http://skincancer.dermis.net/content/index_eng.html

Melanoma

Melanoma•Varied•Multiple colors•Tan, brown or black•White, red, or blue

Normal Mole•One color

Color

http://skincancer.dermis.net/content/index_eng.html

MelanomaColor

http://skincancer.dermis.net/content/index_eng.html

Melanoma

Melanoma•Usually larger than 6mm in diameter•Can be smaller!•May have other features mentioned earlier in addition to size

Normal Mole•Can be over 6mm•Should have all other features of a normal mole

Diameter

http://skincancer.dermis.net/content/index_eng.html

Melanoma

Melanoma•Looks different from other moles• “ugly duckling”•Changing in size•Changing in shape•Changing in color

Normal Mole•Stable over time

Evolving

MelanomaUnder the Nail

http://www.skindermatologists.com/p/nail.html

MelanomaMouth

http://www.oralcancerfoundation.org/facts/rare/om/

MelanomaHands and Feet

http://imaging.ubmmedica.com/cancernetwork/journals/oncology/images/unwinding/200408-1192-6.gif

Melanoma

• Skin- Fair skin- Sun-sensitive skin- >50 moles, large moles, unusual-looking moles- Tanning• Sun, tanning beds, sun lamps• Indoor tanning increases melanoma risk by 75%

• Family/Medical history- Melanoma in a family member• Parent, child, sibling, cousin, aunt, uncle

- Personal history of another skin cancer• Especially melanoma• Melanoma survivors have a roughly 9-fold increased risk of developing another melanoma

(compared to the general population)

- Weakened immune system

Risk Factors

Melanoma

• Skin examination by a dermatologist• Removal or biopsy of any abnormal pigmented lesions/spots• Type of treatment depends on a few factors

- How deeply the melanoma has grown into the skin- Whether it has spread to other parts of the body- Patient’s overall health

• Surgery• Immunotherapy

- Help’s patient’s immune system to fight the cancer• Chemotherapy• Radiation therapy• Clinical trials

Diagnosis and Treatment

Melanoma

• Dependant on depth and whether the melanoma has spread• 98% survival at 5-years for patients whose melanoma was detected and

treated before spread to the lymph nodes• 62% survival at 5-years for patients whose melanoma has spread regionally• 15% survival at 5-years for patients whose melanoma has spread distantly• Early detection• Early treatment• Close follow up with your dermatologist

- Every 3 months for 2 years- Every 6 months for 2 years- At least annually after 2 years

Prognosis

How to Prevent Skin CancerSun avoidanceSunscreen useSun protective clothing

Sun Avoidance

• Avoid peak times- Before 10 am- After 2 pm

• Wear sunscreen• Wear sun protective clothing• Even when wearing sunscreen and sun protective clothing, shade should be

sought• Never use tanning beds or sun lamps

Sunscreen

• 2010: daily sunscreen use cut incidence of melanoma in ½ • Everyone should wear

- All skin types develop skin cancer• Every day if going to be outside

- 80% of rays can penetrate the skin on cloudy days• Snow, sand, and water reflect the sun’s rays

General Facts

Sunscreen

• Broad spectrum - Ultraviolet A and Ultraviolet B (UVA & UVB)

• Sun Protection Factor (SPF) of at least 30• Water and sweat resistant products• Don’t forget lips, ears and scalp• Apply enough of it!

- Most people only apply 25-50% of recommended amount- 1 ounce or enough to fill a shot glass• May need more depending on surface exposed

• Apply BEFORE going outdoors- 15 minutes

• Re-apply sunscreen- Every two hours- After swimming or sweating heavily

What to look for and how to apply

Sun Protective Clothing

• Ultraviolet Protection Factor- UPF- Fibers may be treated with reflective components

• Tighter woven clothing- If you can see through it, the sun can get through it

• Hats- Wide brimmed- Protect neck and tops of ears

Indoor Tanning

Indoor Tanning

• More than 1 million people tan DAILY in the United States• 2010 estimated revenue 2.6 billion dollars• Nearly 28 million people tan indoors in the US annually

- 2.3 million are teenagers• Nearly 70% of tanning patrons are Caucasian girls and women

- Primarily aged 16-29 years of age

Indoor Tanning

• US DHHS and WHO declared UV light from sun and artificial sources as carcinogens• Equipment emits UVA and UVB, may be stronger than the sun• 59% increase in the risk of melanoma in those exposed to UV radiation due

to indoor tanning- Increases with EACH use

• Multiple studies associate indoor tanning with increased skin cancer risk- All types of skin cancer- Cancers in younger patients

• Frequent exposure may lead to addiction• Should not be used as a source of Vitamin D• Illinois prohibits minors under age 18 from indoor tanning• No such thing as a “base tan”• Try sunless tanners as an alternative

Risks

A Word About Vitamin D

Vitamin D

• Required for bone health• Evidence linking Vitamin D with other health benefits (such as cancer and

cancer survival) have been inconsistent, inconclusive, and insufficient• Obtained from diet and sun

- Diet: available year round- No increased risk of skin cancer- Fortified mild, cheeses, yogurt, cereals- Oily fish: salmon and tune

• Amount from sun is inconsistent AND increases the risk of skin cancer• American Academy of Dermatology recommendations

- Sun NOT a recommended source of vitamin D- Talk to your doctor about diet and supplements• 600IU ages 1-70 years• 800IU ages >71 years

Additional Resources

• American Academy of Dermatology- www.aad.org

• Skin Cancer Foundation- www.skincancer.org

• National Cancer Institute- www.cancer.gov

• American Cancer Society- www.cancer.org

• American Melanoma Foundation- www.melanomafoundation.org

Questions?

Thank You