 What are the different types of skin cancer?

 We have to begin the conversation of cancer, and what that means. That means, regardless of the organ, you’re talking about uncontrolled growth of abnormal cells. In the case of the skin, most of that abnormality results from genetic alterations or damage to the DNA through ultraviolet light. Then, what type of skin cells are involved is what determines what kind of skin cancer specifically we’re talking about.

The most common skin cancer, and the most common cancer in the United States is basal cell carcinoma. The basal cells are found in the basement membrane, or the bottom most layer of the upper layer of the skin, or the epidermis. An overgrowth of these cells will result in basal cell carcinoma.

The second, what we call a non-melanoma skin cancer, is squamous cell carcinoma. Squamous cell carcinoma cells are found through the epidermis and they happen to be not only the second most common skin cancer, but also the second most common cancer in the United States.

The good news is with these two non-melanoma skin cancers, they have an exceedingly high cure rate when caught early and intervention is performed in early stages.

The third most common type of skin cancer is melanoma. Melanoma arises from the pigment-containing cells, known as melanocytes — they contain pigment or melanin. While these can result in a higher mortality rate, fortunately, in general, when melanoma is also caught early, or what we call in situ (the cells are only on the top layer of the skin or epidermis), they, too, have a similar cure rate to both of the non-melanoma skin cancers.

 What are the major differences between skin cancer and melanoma?

 Melanoma in my mind, since it is derived from a skin cell, is a skin cancer. But we do break them up, in general, between non-melanoma skin cancers and melanoma.

So, the non-melanoma skin cancers, primarily basal cell and squamous cell carcinoma, make up the overwhelming majority of skin cancers. They are the most common. Fortunately, when identified and treated early, they have a high cure rate. Melanoma, similarly, if found early can have a high cure rate; however, if not, it ends up being deadlier than both basal can squamous cell carcinoma. To be sure, if left unchecked, both basal and squamous cell carcinoma can result in mortality as well.

 What are some common causes of the disease?

 We believe almost 90% of all three of these skin cancers are really due to direct sun light, or UV (ultraviolet) damage). Basal cell and squamous cell carcinomas are a result of accrued sun damage over a lifetime. With melanoma, it’s more of (a result from) intermittent exposure or a history of sun burns. However, there is about 10% of individuals who wind up developing skin cancers unrelated to the sun. These are often found in areas that are not sun exposed. I think of these individuals as having some kind of underlying genetic predisposition, or a strong family history, or other underlying reasons as to why they develop these skin cancers.

 In non-melanoma skin cancer, how come these types of skin cancer become so advanced and what patients can look for to be proactive about screening?

As I had mentioned before, the good news is that when these are identified early — I think of prevention, detection, intervention – early intervention is key. Fortunately, when we do intervene as early as possible, the cure rates approach 90% to 100% in three of thede skin cancers. Unfortunately, if for one reason or another – if they’re not identified by the individual and brought to the attention of your dermatologist or they are neglected – they can and will cause both local damage in the case of non-melanoma skin cancer and there is a bigger propensity, for squamous cell particularly, to go outside or beyond the initial area of injury. Melanoma, on the other hand, has a much higher likelihood of spreading beyond the initial lesion. But again, if all three are caught early, cure rates are exceedingly high, approaching 99%.

 What in particular should people look out for?

In the past, we’ve talked about your ABCDE’s of melanoma, which are very important. I like to focus on the E, which is evolution. Really that can translate into identifying anything that is new, unusual or changing. The ABCD’s are:

In general, as I tell of my patients and friends and family, if there is something new on your skin or was already there and it’s changing or your feel as though it’s some sort of an unusual appearance — something about it rubs you the wrong way – it itches, stings or is burning, that warrants you bringing it to the attention of your dermatologist.

 Are there certain individuals at a higher risk for skin cancer?

 Just like with most cancers and most diseases, there are populations of individuals who are at greater risk. We talked about sun exposure. Fair skinned individuals, light hair, light eyes who are more prone to sun burn because we do know individuals who have a history of sun burn, especially five or more over the course of their life, have a higher incidence of skin cancer, especially if they have those sun burns at a younger age.

Also, as I mentioned, individuals with a genetic predisposition. There are these diseases that, unfortunately, people can be born with where they are unable to repair damage to their DNA that is caused by ultraviolet light.

Another population is those who are immuno-compromised. So, those who have organ transplants and are required to be on immuno-suppressant medications tend to have a higher chance of developing these non-melanoma skin cancers and skin cancers in general.

 Most people think that skin cancer occurs in older adults, but can it happen in children, adolescents and young adults?

We just talked about who is more likely to develop skin cancer, but the truth of the matter is anyone and everyone can develop skin cancer. If you have skin and you have cells in your skin that can go awry with an abnormal collection of cells, then you can develop skin cancer. Obviously, certain individuals are at greater risk.

That does include children. Fortunately, it’s not a common thing to see skin cancer in children. Populations that we specifically want to make sure we follow more closely are individuals who have a family history, specifically a history of melanoma that increases you risk of developing melanoma significantly. Otherwise, if they are a pediatric oncology patient, or they require transplants, these are the individuals who we want to keep a close eye on.

In general, the pediatric population doesn’t develop many skin cancers.

 What is your biggest piece of advice for someone who is newly diagnosed with skin cancer?

Jeremy Brauer: My rule of three is early prevention, early detection and early intervention. If you see something new or unusual or changing. If someone has developed a skin cancer, it is taking that next step of getting all of the information you can. The best way to do that is to schedule an appointment with your board-certified dermatologist, discuss what the diagnosis means and what the expectations of the diagnosis are, and really review and identify the risks, benefits and alternative treatment options are for skin cancer.

Learning Types of Skin Cancer and Who Is At Risk

Why is early detection so key in skin cancer?

 Early detection is so key because these skin cancers have a very high cure rate when identified and treated early. If these are caught in the earliest of stages and removed and treated appropriately at early stages, the cure rates can approach 99%.

 How often should people be visiting a dermatologist?

 I like to tell individuals you should feel more than comfortable to see a dermatologist as often as you feel is necessary. Specifically, for total body skin examinations, everyone after a certain age should have an annual skin check, where the dermatologist has the opportunity to evaluate your skin from head to toe, front to back. That should be in conjunction with the monthly self-exam, which you would perform by yourself and/or with someone at home that can help you, usually with a handheld mirror, a blow dryer and a full-length mirror. That helps you to get a full look at your body to try to identify anything new, changing or unusual.

Once you have a diagnosis of skin cancer, in particular non-melanoma skin cancer, I like to have individuals come back for at least twice or a bi-annual skin check. With patients with melanoma, on the initial diagnosis in the beginning, I prefer to bring them in every three to four months a year, and then we transition over to twice a year.

One caveat to that, if there are individuals with a large number of nevi, or moles, or funny-looking lesions on the skin, or there is a strong family history for melanoma, that may also cause a dermatologist to increase the frequency from a once-a-year skin check to twice a year.

What are some of the warning signs associated with the different types of skin cancer?

 There are different types of skin cancer — basal cell carcinoma, squamous cell carcinoma, melanoma – and they do, in general, have different appearances, but the more general response is that anything on the skin that is new, unusual or changing warrants bringing it to the attention of your dermatologist.

In general, basal cell carcinomas, looking for pink or translucent bumps on the skin; they can be skin-colored or speckled. You can actually have what is called pigmented-cell carcinomas. These are generalities and these can take any shape, size or form for all skin cancers, which is why it is important to identify something that doesn’t seem right — that E in the ABCDE’s.

With squamous cell carcinoma, we tend to describe these as red and scaly or rough. They can be raised; they can be warty.

A good number of melanomas will be what we call de novo, they are going to rise independent of an existing mole. However, a change in an existing mole, so your ABC’s — it’s asymmetric, the borders are irregular, the color has changed, there is a large diameter, and the evolution of that lesion. To be fair, there are melanomas that are what we call amelanotic melanomas that have no pigment at all and may looks like a basal or squamous cell carcinoma, where it is a pink blemish on the skin.

Additionally, lesions that are bleeding, or ulcerating, so it’s a sore and not healing. A very common story is a non-healing pimple. If someone has a pimple on their nose, they’ve treated as though it were a pimple or acne, and it persists for weeks to months at a time, that is something you should bring to the attention of your dermatologist and perhaps have it biopsied.

 What exactly can be new, changing or unusual that people should be looking out for?

 Most people will and can develop new moles into their 30s, and in some cases their 40s, but it’s less common. At that point, when you are in your 30s and 40s and you start to get new lesions, take that very seriously. You should always take development of new lesions seriously if they are unusual to you in any way or they are changing in any way. The good news is that, as your life goes on, will get new spots on your skin and most of the time those will be benign. And please, we’d much prefer you go into your dermatologist and let us evaluate the lesion and tell you don’t worry about it, than to neglect it. If you identify, detect and intervene early, these things have a very high cure rate.

 What does a thorough self-exam consist of?

 A thorough self-examination consists of really taking that time once a month, sitting in front of a full-length mirror or taking a handheld mirror, and if you have a hair dryer or blower, those are the only tools you need in addition to your own eyes. If you have the benefit of a second pair of eyes, either a loved one or significant other or someone you’re comfortable helping to examine you.

It’s then taking a look from top to bottom. Use the hair blower to look through your scalp. Look in front and behind your ears. Look at the tip of your nose, your fingertips, your palms, your soles. Look at the genitalia. Really look everywhere you have skin because the truth of the matter is: Where there is skin, you can develop skin cancer. Yes, 90% of skin cancer will occur because of the sun and will occur on those exposed areas. However, there are absolutely areas where you can develop melanoma or other skin cancers where, as we say, “the sun don’t shine.”

Specifically, for men and woman, you should look everywhere on the body, but melanoma tends to be on the legs of women and on the back of men. So, backs of legs or the back are not areas easily seen by an individual, so all the more reason to have that second mirror or second individual help you during those exams.

 The Skin Cancer Foundation has a campaign called the Big See, can you talk about this?

 The Big See is a fantastic campaign. It was launched last year. It’s multimodal — there are television commercials, it’s on the internet, print media. It goes back to what we’ve been talking about. We can speak hours on the characteristics of what certain skin cancers look like and how best to detect them. But the truth is that we should simplify the message to help individuals understand what warrants the alarm bells going off and what warrants you making the phone call to visit a dermatologist.

It’s three simple things: something that is new, unusual or changing. That is really the primary message. Any of those, one or more, that describes a skin lesion you have, pick up the phone and make that appointment.

New, Unusual or Changing: How to Detect Skin Cancer

 What is the current standard of care for skin cancer?

 We initially have to start with identifying something as new, unusual or changing. In general, once you’ve taken the step of seeing your board-certified dermatologist, if it does warrant a biopsy, that’s going to be your initial step. For most, what a biopsy involves is an administration of local anesthesia, a little needle stick to numb the area. They take a piece of skin, and in general, just Aquafor or vasoline is all you’ll need, depending on the concern for the lesion, maybe a few stitches can be put in.

Then, once we diagnose and determine what kind of skin cancer it is, where it is on the body and take into account other factors of the individual (age, any other underlying medical conditions, what medications they take, where on the body the skin cancer is located), we’ll have a conversation about the risks, benefits and alternatives to various treatment options.

 What is the best way for patients to learn more about their options?

 First and foremost, an honest and direct conversation with your dermatologist who can, in detail, discuss the diagnosis and expectations. The Skin Cancer Foundation is a fantastic resource. We always caution use of the internet to gather information, but the Skin Cancer Foundation, the major organizations across dermatology are other great resources. Primarily, a good, thorough conversation with your board-certified dermatologist should help you direct which way you want to go with your treatment.

 How has immunotherapy changed treatment for patients with skin cancer?

 Immunotherapy, these days, we consider as a treatment option for melanoma. It’s been a game changer for a certain period of time of survival in advanced cancers. That has definitely prolonged the life of many individuals who unfortunately otherwise would not have fared as well prior to the onset of immunotherapies.

In addition to melanoma, another interesting and promising area is targeted therapy. Here, what we’re looking at is the identification within the tumor of a mutation, specifically in a gene or pathway, and then targeting that specific gene or pathway in the tumor, which has also led to increased survival rates and has really allowed for a change in the way we approach some of the more advanced tumors.

 What is available for these types of cancers?

 Immunotherapy definitely has its role in the armamentarium of skin cancers, most importantly advanced skin cancers. However, that said, early intervention is key. Once we’ve detected these skin cancers, early intervention results in very high cure rates and hopefully prevents some of these local tumors from becoming metastatic or advanced tumors.

The intervention with the highest cure rate for surgical procedures is Mohs micrographic surgery. This is ideal for non-melanoma skin cancers specifically, but there is a growing interest and use in certain melanomas as well. The idea here is, depending upon the skin cancer but also the location, as long as we deem the tumors appropriate to use this technique, it is similar to the initial biopsy where you numb the area, take a small piece of skin. I liken it to a waiting game. Unlike leaving the office and waiting a week for your results, everything is done on site in real time. We process the tissue and a mohs also functions as the pathologist to read the slides and is able to map out where the tumor is or isn’t. It’s a staged excision, so we only approach it from a targeted perspective. We are not taking large circles or measuring out large margins, it’s a much more targeted approach. The benefit of this is it allows for tissue conservations, thinking about the tip of the nose and ears. Also, it has a higher cure rate with good cosmetic outcome because you are tissue sparing.

Another surgical intervention is a standard surgical excision. I mentioned margins, depending upon the location of the tumor as well as the tumor characteristics, you take a standard margin of skin…those vary. You excise, take a big piece of skin and put stitches in just like you would with mohs, but it’s not a staged procedure. In general, it’s just one procedure.

Some other non-surgical treatments include electrodesiccation and curettage. This tends to be reserved for individuals who have a superficial basal cell carcinoma or what we call in situ squamous cell carcinoma, where the lesion is very superficial and is on the upper most part of the skin. Here, what we are doing is using a tool called a curette, which is a sharp tool, to scrape the area of involvement but also with electrodesiccation where we are burning the surrounding skin. This is often repeated in series a few times to remove the majority, if not all, of the tumor. The downside to this is that we are not going to have any histologic confirmation, meaning no pathology. The goal here is to avoid having to cut and sew. The drawback is that you can’t evaluate the tissue under the microscope because you’re scraping and burning the remaining tumor cells.

Another non-surgical option is radiation therapy. This is sometimes used in conjunction with surgical treatment if it is determined that the subtype of skin cancer warrants it. We talk about something called a perineural invasion. If you find during the course of mohs surgery or if we get the specimen back after incision and we find involvement of the nerves, we would then refer the individual to receive concurrent radiation therapy. Radiation therapy is also good for non-surgical cancer. There are reasons, not just the tumor but also the individual may dictate the best approach to removal of the skin cancer. In certain instances, maybe the individual is not able to tolerate the procedure or they decline the procedure. So, radiation therapy is appropriate for these individuals. Similarly, there are certain tumors that don’t heal well that may be a better candidate for a non-surgical option.

 What is the most exciting treatment option out there right now?

 I really do believe immunotherapy and targeted therapies for metastatic disease really have been a game changer. I think we will see a continued attempt to move towards minimally invasive treatments and cures for all tumors and all diseases. So, I would group skin cancer in there as well. I’m looking forward to what comes out on the horizon.

 What is on the horizon for patients with skin cancer?

 Patients have a lot to look forward to. Medicine, technology and innovation are all moving at a very fast pace. Immunotherapy and targeted therapies, more of these are going to be made available to individuals with metastatic melanoma as well as advanced squamous cell carcinoma. Also, the non- and minimally-invasive biopsy techniques. Right now, a bopsy is invasive. There is numbing and taking a blade to the skin…there are other imaging techniques and the better and greater the ability becomes to detect skin cancer, whether they are benign or malignant tumors, we’ll begin to see more non-invasive biopsy techniques moving forward.

 How can patients become empowered to become their own best advocates for treatment decisions?

Jeremy Brauer: It starts with education. Knowledge is power. A great resource is your board-certified dermatologist, and also the resources available on reputable web sites like the Skin Cancer Foundation and all of the literature they have available. Within dermatology, there is the American Academy of Dermatology and other societies that are great resources. I do believe it begins with education.

Going back to prevention, a lot of what people need to understand is that skin cancer is serious. You can die from skin cancer. That is a known misconception. But, the good news is that these are preventable tumors and cancers. You have to take action and prevent it. How do you do that? Appropriate use of UVA or UVB spectrum sun screen, sun protected behaviors when you are outdoors, screening — not just coming to your dermatologist once a year, but also monthly self-skin examinations…Look for something new, unusual or changing and bring that to the attention of your dermatologist. Early detection results in early intervention which results in very high cure rates. 

What's on the Horizon in Skin Cancer Treatment

 Skin cancer is the most common cancer in the country, but there is still a lack of awareness. Why do you think that is?

 There are a lot of wonderful campaigns out there, a lot of education that talk about sunscreen. But, nonetheless, we see patients in the office who come in for skin exams or individuals who even have a history of skin cancer, and there still seems to be this general lack of awareness of specific types of skin cancers. The fact that, even though when treated early have a very high cure rate, when left alone and untreated can lead to death.

Last year, the Skin Cancer Foundation commissioned a survey to gauge awareness of the disease in the United States. Can you talk about this?

 The general lack of awareness and understanding regarding skin cancer in general prompted this study. The Skin Cancer Foundation, along with Regeneron and Sanofi, commissioned an online survey, which was conducted by the Harris Poll with roughly 2,000 adults (aged 18 years and older) in the United States.

They evaluated overall understanding and awareness of skin cancers in general. (They) also specifically asked questions about squamous cell carcinoma basal cell carcinoma and melanoma. A lot of the interesting findings revolved around cutaneous squamous cell carcinoma. The one thing that I found very interesting was almost three-quarters of those that were surveyed, were generally unaware of cutaneous squamous cell carcinoma. Just over 40% of those had never even heard of cutaneous squamous cell carcinoma. To put that inti perspective with melanoma, that same 40% were somewhat unaware of melanoma, but only, I believe, around 10% had never heard of melanoma before.

 Why are individuals less aware of cutaneous squamous cell carcinoma compared with melanoma?

 There are a lot of theories behind this. There is no dedicated cancer registry for squamous cell carcinoma compared to melanomas. In general, most individuals do not consider squamous cell carcinoma or even non-melanoma skin cancers as deadly, whereas, melanoma we know is deadly. We hear about it in the news of celebrities and famous politicians who are diagnosed and have passed from the disease. The more recent in treatment have revolved around metastatic melanoma. I think they are all important. They all raise awareness for skin cancer, specifically for melanoma, but to some degree, people look at the non-melanoma skin cancers as “good cancer.” In truth, there is no good skin cancer. These skin cancers if left alone, while they might not metastasize, can cause invasive damage locally and cause death that way as well.

 What is the number one thing we need to be raising awareness on right now?

 People need to understand that there is no such thing as a “good skin cancer.” It is a cancer, regardless of the organ. Squamous cell carcinoma, there are more cases of that diagnosed every year than breast, prostate and lung cancers combined. Two of the top three cancers in Americans are skin cancers. Number one being basal cell carcinoma and number two being squamous cell carcinoma. It is very prevalent.

The good news is, if we are aware of these carcinomas and we pay attention and we prevent them, those numbers can drop significantly. Additionally, if you are diagnosed with a skin cancer or you do notice something new, unusual or changing, early detection and intervention results in a 99% cure rate. I think it’s very important that individuals are aware of what to look for or even once they do notice something, they are aware of what to do and who to call. That is how we are going to get these numbers down.

 How can someone determine if a product is sun safe?

 The Skin Cancer Foundation has done a lot of great work with this, working with federal government and industry. As mentioned earlier, the most important thing when looking at a sunscreen label is looking at whether it has both UVA and UVB protection. For a long time, we focused on the ultraviolet B, which everyone more commonly knows as SPF (sun protection factor). While UVB is the one that causes not just skin cancer but sun burns, UVA also can cause skin cancer in addition to more of the aging of the skin. That is why it’s very important that we are protecting against both UVA and UVB.

In general, though, we should look at the number of SPF. While most will say a minimum of 15, I tend to tell my patients a minimum SPF of 30, applied appropriately. This depends on what level of activity you plan, applying appropriately throughout the day is the best way to determine which sunscreen you should use.

 The Foundation has Destination Healthy Skin. Can you talk about that?

 I was fortunate enough to be a part of it. Destination Healthy Skin is a fantastic program. It’s a mobile education and detection RV that drives around the country. I think they accumulated over 10,000 miles this most recent summer. You have the ability to sign up and come in and get a toal body skin evaluation by a board-certified dermatologist. I was fortunate enough to do this in mid-town Manhattan.

It also educates individuals, those who maybe weren’t interested in getting a skin check, there is lots of materials available outside of the RV. We had the opportunity to speak with individuals and answer questions. It’s a really great program.

 The foundation has also lobbied, can you talk about some of these areas?

 The Skin Cancer Foundation, in addition to the Big See Campaign and the mobile unit, they work tirelessly with local and federal government to raise awareness, look toward methods of prevention and detection. In some of these more specifically, we’re talking about tanning beds. We talk about prevention and we know history of use of tanning beds before the age of 35 significantly increases your risk of developing skin cancer. So, they’ve made great strides and worked tirelessly to institute bans in underage tanning, reduction in use overall and changing a lot of the laws both locally and nationally. That was a really wonderful accomplishment.

Also with the sunscreen, there has been a lot of focus on sunscreen, both at the national and international level looking at specific ingredients. The Skin Cancer Foundation has been involved in that conversation since the very beginning. They also have their own seals that they along with industry have been placing on labels to make it more user-friendly for consumers to understand what is considered a safe SPF. If a sunscreen has that seal of approval, is it active, is it appropriate to use if you know you’re going to spend countless hours outside or a daily use seal for going to and from work. They’ve also worked with the FDA, who has approved physical blockers, mainly zinc and titanium dioxide that are safe and effective and are to be used in sunscreen. And they’re looking to gain more information with the chemical sunscreens. The Skin Cancer Foundation has been right there applauding that effort and aiding in any way that they can.

 What is the best way for others to get involved to raise awareness?

 We live in the day and age of social media. It’s a much more interconnected world and I think any time individuals educate others and speak about their own experiences, it only empowers others. If you are someone who has survived or was diagnosed with skin cancer and took the appropriate steps of seeing your board-certified dermatologist and getting the appropriate treatment — speak out about it if you’re comfortable. Let others know that this is an experience that might sound crazy upfront, but at the end of the day, your skin cancer was cured by the actions you took.

Similarly, I think raising awareness through education, the Skin Cancer Foudnation website and the resources they provide are fantastic. All of these things are great ways to continue to educate and raise awareness around skin cancer.

Raising Awareness Around Skin Cancer

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