How Prevention and Access Shape Outcomes in Skin Cancer Care

Dr. Maral Kibarian Skelsey discussed how advances in genetics and genomics are reshaping the understanding of skin cancer risk and prevention in a recent interview with CURE. During the conversation, she explained how inherited and environmental factors contribute differently to risk, which patients may benefit from genetic counseling, and how testing can inform screening and prevention strategies.

She also addressed persistent disparities in access to dermatologic care, particularly among underserved populations, and shared practical strategies to help patients overcome real-world barriers to sun protection and long-term prevention.

Skelsey is a skin cancer expert, board-certified dermatologist, and spokesperson for The Skin Cancer Foundation. She is a fellow of the American College of Mohs Surgery, the founder and director of the Dermatologic Surgery Center of Washington, and serves as a clinical associate professor of dermatology at Georgetown University.

CURE: How has progress in genetics and genomics improved our understanding of skin cancer risk, and what practical information should patients take away from this conversation today?

Skelsey: We have really learned so much about why people develop skin cancer and how the risk can vary from one person to another. The new information we are gathering and the progress we have made help us separate inherited risk from environmental risk. We are now able to translate this into practical guidance for patients and families regarding what can be done for prevention, although it does not change the fundamentals of prevention itself. While this has a widespread impact, it doesn't change the basic steps we take to help prevent skin cancer.

There is a lot we know now about inherited gene variants that increase susceptibility to certain skin cancers. For instance, there are mutations such as CDKN2A and others in related genes that are linked to familial melanoma. We also know about genes involved in DNA repair, which can help explain why some people have faulty DNA repair mechanisms. In these inherited genomic syndromes, individuals have an increased risk of skin cancer because their ability to repair or recover from UV damage is diminished. There are also genetic variations affecting pigmentation, such as those predictive of fair skin tone, light hair color, and freckling, which help us understand why some people are more vulnerable to UV damage.

Furthermore, we have learned how UV radiation leaves a characteristic signature in the DNA of skin cells. This gets back to the crux of why the majority of people develop skin cancer, which is an environmental issue; UV exposure is the primary driver. We are learning more through the progress in genetics and genomics and understanding how this accumulated damage over time leads to cancer development.

Which patients might benefit most from testing or counseling, and what can these results mean for prevention or treatment planning?

Most people are not going to need genetic testing, but it can be helpful for a relatively small subset of patients and families. The goal is not to predict exactly who will develop skin cancer or when, but rather to better tailor prevention, screening, and sometimes treatment decisions. Those most likely to benefit from genetic counseling include anyone with a very strong family history, meaning more than two first-degree relatives with melanoma — first-degree relatives being siblings, parents, or children.

Other candidates include those with multiple family members across generations affected by melanoma, people who developed melanoma at a very early age (such as before the age of 40), or individuals with multiple primary melanomas, such as families where members have three or more. We also look for an incidence of cancers that tend to be associated with hereditary syndromes, such as pancreatic cancer. Those people fall into the broad category of those who could benefit.

Others who may benefit are people with abundant dysplastic or highly irregular moles — not just ordinary moles, but those a dermatologist has identified as very atypical — and people whose clinical features or appearance suggest they might have genetic syndromes. If individuals have family members with known genetic syndromes, they could also benefit from testing. However, it is important to have counseling before testing to set the stage and understand the limitations, including what the tests can and cannot do. A result does not necessarily mean someone will get skin cancer, but it provides information that shifts our next steps toward earlier and more frequent full-body skin examinations, total body photography, digital dermoscopy, regular self-exams, and very strict ultraviolet light protection.

We know that UV exposure is still the cause of the majority of skin cancers. Conversely, if a genetic test demonstrates that someone does not have a genetic syndrome, it does not mean they are not at risk, particularly if they have a strong family history. Genetic testing is most useful when there is a definite personal history or family pattern. It helps us determine how closely someone should be monitored by a dermatologist and how aggressively prevention should be emphasized.

Treatment disparities remain a concern within any facet of cancer care, including skin cancer. What inequalities in screening, access to dermatologic care, or treatment outcomes stand out most to you, and what steps could help close these gaps?

That is an important question because the later we diagnose someone due to poor access, the worse the outcomes are. This is very significant in people with skin of color. There are many disparities in terms of skin cancer screening and access to care. Even though melanoma is much less common in people with darker skin, it tends to be diagnosed at a later stage. We need to emphasize education to increase awareness about skin cancers in this population, as well as the different sites where skin cancer may manifest in skin of color. We also need to educate primary care providers on recognizing these more unusual melanomas in less exposed areas. Increasing education for both patients and healthcare providers is vital.

We need to increase access, particularly for patients in rural and underserved areas. There is a real issue right now regarding the cost of preventative care for full-body examinations and covering telemedicine visits for patients in areas with few dermatologists. Additionally, academic centers need to develop more clinical trials for underserved patients to better understand those who develop skin cancers in less typical sites or who are diagnosed very late. We must increase education about what to look for and the importance of full-body exams.

The message we haven't fully gotten across is that UV protection is important for all skin types; this is not a disease limited to those with fair skin. We need to clarify the message about using sunscreen and make it much less confusing, as there is a lot of misinformation in the media about whether sunscreens are safe and how to use them. It requires across-the-board education and increased access.

Adherence to follow-ups, sun protection, and treatment can be difficult for some people. What real-world barriers do you commonly see, and what strategies help improve consistency and safety over time?

People do get tired; there is such a thing as prevention fatigue. They are bombarded with things they should be doing once they receive a diagnosis. Between the shock of the diagnosis and the treatment phase, there is often a sense of medical facility fatigue. It helps if we address that and recognize that people come to these appointments with a great deal of anxiety. It is hard to go every time and wait to find out whether you have skin cancer. We need to address that head-on because it is an emotional and temporal burden.

As we discussed, there are also inconsistent messages regarding sun exposure, sunscreen use, and who needs a full-body exam. Then there is the cost. Most people are facing increasing medical costs; dermatology visits may be an out-of-pocket expense, and sunscreen is an over-the-counter item not covered by insurance. Other costs include transportation and taking time off work. It can also be hard to get appointments in areas with a lot of unmet need. Furthermore, it is not always clear to patients what kind of follow-up they need after treatment or that they have a significantly increased risk. Both physicians and patients need to be concrete about follow-up schedules to prevent gaps. Nobody is perfect, and we should address that; you shouldn't stop going to your dermatologist just because you got a sunburn. It is an ongoing lifestyle choice for our families, ourselves, and our communities.

We need to support the prevention process. Some communities have sunscreen dispensers that are free to the public at hotels, schools, or camps so that everyone is encouraged to use it. Campaigns like Australia’s "Slip, Slop, Slap" — slip on a shirt, slop on sunscreen, and slap on a hat — are very effective. Using simple tools like a smartphone reminder to reapply sunscreen every two hours while at the beach or outdoors can also help. Whether it is boating or golf, putting a reminder on can help patients consistently take the preventative measures that will really help stop this epidemic.

Transcript has been edited for clarity and conciseness.

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