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Health Watch: Skin Cancer: Fighting Back

Surgery and newer pharmaceutical treatments are helping patients battle skin cancer.

By
From the May 2013 issue of Columbus CEO

Mary Brennan enjoyed the outdoors in her youth, and she grew up in an era of blissful unawareness when it came to sun protection. As a result, she suffered several blistering burns when she was younger. Now in her 60s, Brennan is undoing the damage that countless hours of sun exposure left behind. She has had more than half a dozen surgeries to remove small skin cancer lesions.

Brennan certainly isn’t alone. Not too many years ago, slathering on baby oil at poolside was commonplace, and even today, tanning salons are prolific. Meanwhile, the incidence of skin cancer continues to climb.

According to the Skin Cancer Foundation, the disease is the most common form of cancer in the United States. More than 3.5 million cases are diagnosed each year—more than breast, prostate, lung and colon cancers combined.

Treatment of non-melanoma skin cancers increased by nearly 77 percent between 1992 and 2006. At this rate, it is estimated that one in five Americans will develop skin cancer at some point in their lives.

Though there are a number of forms of skin cancer, the most common are basal cell carcinoma, squamous (pronounced SKWAY-muss) cell carcinoma and malignant melanoma. These occur in three different types of cells: the basal cells, the squamous cells and the melanocytes, which are the cells that produce melanin, the chemical that tans our skin in response to sun exposure.

“Malignant melanoma has the highest potential for metastasis, or spreading, and therefore the highest potential for mortality,” says Dr. Michael Conroy, a dermatopathologist with OhioHealth.

As a general rule, sun exposure is thought to be the chief cause of skin cancer, he says. Those with fair skin (particularly redheads) are at highest risk, but anyone can be a victim.

Treatment Options

Basal cell carcinoma is very common, with 2.8 million cases occurring annually. It is relatively easy to treat, doctors say. While surgery is the most common treatment, if the cancer is caught very early and is superficial, a topical cream called Imiquimod can be prescribed. “It uses the immune system to eradicate the cancer,” says Dr. Stephanie Cotell of Northeast Dermatology and Cosmetic Surgery Center, a Mount Carmel Health System affiliate.

Another option is E&C, or electrodesiccation and curettage. In this procedure, the physician numbs the area and uses a curette to scrape away the affected tissue. The procedure is quick and minimally invasive. In most cases, surgery is preferred because cells can be examined microscopically to ensure that all diseased tissue has been removed.

For advanced basal cell carcinoma, doctors may prescribe the vismodegib. “It’s not that common, but sometimes it will be used when patients have had recurrent cancer or cancer that has potentially invaded deeper layers of tissue,” Cotell says. The oral drug may be used in conjunction with surgery, or alone when surgery is not an option.

Squamous cell carcinoma is most often treated with surgery because these techniques are most effective and most measurable. Squamous cell carcinoma tends to have a slightly higher rate of spreading, or metastasizing, than the basal cell variety, Conroy says.

When a lesion is large or located in a delicate place such as the face or neck, doctors often opt for a special procedure called Mohs surgery. The procedure was named for Dr. Frederic Mohs, who developed the technique in 1938. The multistage procedure allows surgeons to remove cancerous cells while leaving as much healthy tissue as possible intact.

Craig Burroughs has undergone several skin cancer procedures. In March, he underwent a Mohs procedure at Northeast Dermatology, after noticing an irritated area on his cheek. The spot was about the size of a pencil point, but it wouldn’t heal. The diagnosis: basal cell carcinoma.

“It was a pretty simple procedure,” Burroughs says. “They numb the area and take a small biopsy, and you wait while they go check it to see if they got all the cells or not.”

Mohs surgery can be used for multiple types of skin cancer, including malignant melanoma. Melanoma, however, doesn’t have the same surgical success rates. The cancer is so invasive that cure rates drop dramatically when it is not detected in the initial stages. “With melanoma, the key is early diagnosis,” Conroy says. “That is why we are so hypervigilant, telling patients to undergo a skin check every six months to a year.”

Melanoma begins near the surface of the skin but invades the deeper tissue. Once it moves deeper than one millimeter, Conroy says, it can spread to the lymph nodes and other organs. “At that point, your treatment options become much less desirable,” he says.

Dr. Kari Kendra is a medical oncologist who specializes in skin cancer at the Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute. “If a lesion tests positive for melanoma, the first step is to remove it,” she says. “We do a local excision and sometimes a wide excision, working with a surgeon, a dermatologist and sometimes a plastic surgeon.

“If it is a deeper lesion or ulceration is present, that may warrant further evaluation and systemic adjuvant therapy,” Kendra says. Adjuvant therapy—meaning treatment that works alongside the primary surgical procedure—can cover a range of options.

If doctors suspect that cancerous cells have migrated elsewhere, systemic treatment may be employed. Interferon is a biological therapy that ramps up the body’s ability to recognize and fight the cancer cells. “The drug helps activate the immune system so it can do its surveillance,” Kendra says. While interferon is considered the gold standard, several other such drugs are being tested in clinical trials but are not yet on the market.

Yervoy is a biological agent approved by the U.S. Food and Drug Administration in 2011. Its efficacy against metastatic cancer is being tested in clinical trials now. Two other drugs—Zelboraf and dabrafenib—inhibit the human gene that makes the b-raf protein. This gene mutates in cancerous cells, Kendra says. Dabrafenib, coupled with a substance that inhibits the MEK enzyme (treating cancer cells with an MEK inhibitor can cause them to die off rather than multiply), is now undergoing clinical trials.

Prevention

Although researchers are always looking for new treatments, doctors say the single most important factor is prevention.

“Everyone should do a self-exam once a month,” says Kendra. “Look for anything that looks different on the skin or seems to be changing in shape or color.”

Cotell recommends that patients check their birthday suit on their birthday. “It’s a good way to remember something that is very important,” she says. “Skin cancer is curable in almost all cases when it is caught early.”

Doctors also advise getting an annual skin check by a dermatologist. Conroy says he jokes with patients that because he does so many skin checks, clothing would look abnormal to him in his office. “And this isn’t like going to other doctors’ offices,” he says. “One of the best parts of going to the dermatologist is that we never weigh you here.”

“Skin checks are one of the most common things I do,” Cotell says. “We check everything from the scalp to in between the toes. As we are doing the check, we educate the patient about what we do seemoles, freckles and growths that may appear as we get older.”

Doctors urge patients to follow a few simple guidelines to keep skin healthy. Wear sunscreen every day and reapply after two to three hours, even when not swimming or perspiring. While the body needs vitamin D, experts recommend getting that nutrient through a healthful diet. “We should not seek the sun as a source of vitamin D,” Cotell says.

Dr. Larisa Ravitskiy, founder of the Ohio Skin Cancer Institute, recommends specially designed, lightweight fabrics that protect skin from the sun. The goal is to live safely, she says, not to shun the sun entirely.

“I always recommend that my patients, even those with melanoma, not live under a rock,” Ravitskiy says. Instead, avoid the sun between 10 a.m. and 2 p.m., when the angle of the sun’s rays is most damaging. Wear a hat that covers not just the head but also shades the neck and ears.

Also important are sunglasses that block both UVA and UVB rays. Dark lenses without the right protection can cause the pupil to dilate, exposing the eye to even more of the sun’s damaging radiation. People who spend time on the water, sand or snow must take additional precautions because the sun isn’t hitting them just once, but also reflecting from below. “They must be even more vigilant and wear a protective lip balm with an SPF of at least 20,” Ravitskiy says.

Ravitskiy says many people believe that if they tan and don’t burn, they’re being safe, but it’s not true. Any tan is the body’s response to the sun’s damaging ultraviolet radiation. “If your tan isn’t from a bottle, it’s not healthy, period,” Ravitskiy says.

Kristin Campbell is a freelance writer.