Recognizing Danger: Early Recognition of Melanoma Can Minimize Treatment Needs

CURE, Melanoma Special Issue, Volume 1, Issue 1

By learning how to identify melanoma, patients can seek early diagnoses, potentially minimizing their treatment needs.

As a 34-year-old mother of three, Shannon Lee had a lot to do.

So when a small mole on her inner thigh became uncomfortable, creating a distraction she didn’t need, she made an appointment to have it removed. The mole turned out to be nothing but an annoyance. It also may have saved her life.

During the procedure, Lee’s doctor recommended that he also remove a mole from her other leg and send it out for further testing.

“It was different than my other moles. It was almost black and shaped kind of like a crescent moon,” Lee recalls.

Though she remembers her doctor saying that he “didn’t like the looks of it,” Lee didn’t think anything of it. After all, it never bothered her the way the other one had.

After being diagnosed with melanoma, SHANNON LEE has raised awareness in her community about the dangers of tanning. [PHOTO BY JASON BAFILE]

But the pathology report would reveal something she had never imagined — the oddly shaped mole was melanoma, the most serious form of all skin cancers and a leading cause of death from skin disease.

“I was shocked. I was otherwise totally healthy,” she says.

Unlike the more common — and less dangerous — forms of skin cancer, called basal cell and squamous cell carcinomas, melanoma is more likely to invade nearby tissues and spread to other parts of the body. Once this happens, the disease is more challenging to treat and can be fatal. Fortunately, most cases of melanoma are caught early enough that only surgery is needed to cure the disease. The five-year survival rate of people with melanoma is 91 percent, meaning that this percentage of people are alive five years after their melanoma is diagnosed.

Melanoma develops in melanocytes, the cells that make a pigment called melanin, found in the skin, eyes and hair. When skin is exposed to ultraviolet (UV) rays, melanocytes make more melanin, causing it to tan or develop freckles or moles. UV radiation exposure is considered a major risk factor for melanoma, because it can damage the DNA in melanocytes, causing mutations and affecting how they grow and divide. If the cells are not working properly, they can become cancerous.

Most cases of melanoma are caused by too much exposure to the sun’s UV rays. Exposure can also come from artificial sources, such as sun lamps or tanning beds, which can give off as much as 12 times the amount of UV radiation as that coming from the sun.

“The No. 1 one way to prevent melanoma is to protect yourself from the UV rays — by limiting time outdoors during the peak hours of sunlight and wearing sun-protective clothing and sunscreen,” says Jennifer Y. Lin, a melanoma specialist at the Dana-Farber Cancer Institute/Brigham and Women’s Cancer Center in Boston.

Unfortunately, Lee learned about the risks of tanning too late.

“I knew the sun was bad for my skin. I just didn’t connect tanning with skin cancer,” she says.

She quit tanning the day of her diagnosis and has since spoken out in her community about its dangers. In Rockwood, Pa., Lee says, tanning is widely practiced, especially among teenage girls and young adult women.

Melanoma 101

“I’ve actually convinced some girls who were planning to go tanning in the weeks leading up to prom. They hear my story and realize that, however good tanning makes them look in the dress, it’s just not worth the risk,” she says.Each year in the United States, 42,670 men and 31,200 women are diagnosed with melanoma.

Though most basal and squamous cell skin cancers are found on body parts that get the most exposure to UV radiation, melanomas can occur anywhere on the body. This includes the skin under the finger- and toenails, in the mouth, or on the genitals or even the soles of the feet or palms of the hands. In men, melanomas are most commonly found on the head, neck or on the skin between the shoulders and hips. In women, they are most often found on the skin on the lower legs or between the shoulders and hips.

Like Lee’s, most melanomas are brought to a doctor’s attention because of signs or symptoms discovered by patients themselves. The first sign of melanoma is often a change in the shape, size, color or texture of an existing mole. Melanoma may also appear as a new mole or change in skin. The majority of melanomas are black or brown, but they can also be skin-colored, pink, red, purple, blue or white.

Most melanoma diagnoses are among older adults, but the disease is sometimes found in children and adolescents. In recent years, it has become increasingly common in young women. In fact, a 2012 study by researchers at the Mayo Clinic found that melanoma has increased eightfold for women under 40 since 1970 — a spike that many experts attribute to the use of tanning beds.

But it’s not just routine recreational tanning that ups your chances of getting melanoma. A few bad sunburns in childhood and adolescence can significantly raise your risk of skin cancer, according to a study published in Cancer, Epidemiology, Biomarkers & Prevention in 2014.

“There is really no amount of sun that is healthy. If you have to be in the sun, protect yourself and your loved ones with sunscreen with high SPF (sun-protection factor) and wear protective clothing,” Lee says.

Though sun exposure is the biggest risk factor for melanoma, there are others. People with many moles or unusual moles called dysplastic nevi — flat, large moles that have irregular color and shape — have a higher risk of developing melanoma. So, too, do people with fair skin, blue or green eyes, and blonde or red hair. People with a family history of melanoma are also at increased risk. “Looking back, I see that I actually had more than one risk factor — the tanning, my complexion and the fact that I have a lot of moles. But hindsight is 20/20,” Lee says.

Treating Early-Stage Melanoma

Though melanoma is a relatively rare form of skin cancer — it accounts for less than 2 percent of all skin cancer cases in the U.S. — it causes most of skin cancer deaths. This is because it is more likely to advance and spread to other parts of the body. Though melanoma can spread to almost anywhere, the most common places are the lymph nodes, lungs, liver, brain, bones and abdomen.After a suspicious-looking mole is detected, by either the patient or the primary-care physician, the next step is to see a dermatologist. If the dermatologist suspects melanoma after an exam, he or she will take a small sample (biopsy) of skin from the suspicious area and send it to a laboratory for a histological examination under the microscope by a pathologist. Further testing on the tissue may be needed to confirm the diagnosis. The doctor may also take biopsies from other areas. A surgeon will often perform a wider excision to make sure all the tumor cells are taken and may also remove nearby lymph nodes to see if they show any signs of cancer.

If melanoma is detected, the doctor will perform additional tests — such as blood tests and imaging tests like X-rays or CT scans — to learn the stage of the disease. The stage is based on how deeply the melanoma penetrates the skin and whether or where it has spread:

  • Stage 0: The melanoma involves only the top layer of skin.
  • Stage 1 (a or b): The melanoma is no more than 1 millimeter thick. The surface may appear broken down. Or, the tumor is between 1 and 2 millimeters thick and its surface is not broken down.
  • Stage 2 (a through c): The melanoma is between 1 and 2 millimeters thick, and the surface appears broken down. Or, the thickness of the tumor is between 2 and 4 millimeters, and the surface may appear broken down. Alternatively, the lesion is more than 4 millimeters thick, and the surface is either broken down or not broken down.
  • Stage 3 (a through c): Melanoma cells have spread to at least one nearby lymph node. Or, the melanoma cells have spread from the original tumor to tissues beyond the node, but nearby.
  • Stage 4: Melanoma cells have spread to the lungs or other organs, skin areas or lymph nodes far away from the original growth.

Knowing the stage will help determine what treatment is needed. As the disease becomes more advanced, so do its treatments. Because Lee’s melanoma was caught in its earliest stage, surgery was the only treatment required. But some people may require additional treatment depending on the stage at diagnosis. Other treatment may include radiation or medicines such as immunotherapies, targeted therapies or chemotherapy.

“A millimeter can make all the difference. Once the disease penetrates the skin and metastasizes into the lymph nodes and beyond, it is difficult to treat and can be fatal,” says Lin.

Even after successful treatment, melanomas do sometimes come back — even those caught early when initially diagnosed. The cancer may come back in the same place (a local recurrence), nearby (a regional recurrence) or in another part of the body (a distant recurrence).

So far, Lee has had several recurrences — each one surgically removed. To ensure that any new melanomas, should they develop, are caught early, when they are easiest to treat, Lee continues to be monitored by a doctor specializing in melanoma.

A typical follow-up schedule for people with early-stage melanomas that were removed completely calls for physical exams every six to 12 months for several years. For thicker melanomas or those that had spread beyond the skin, a typical schedule might include physical exams every three to six months for two years, then every three to 12 months for the next few years.

Lee also performs a full body exam each month, tracking every mark on her body and bringing any changes to her doctor’s attention.

“I’m a freak about moles now. I have to be,” she says.

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She knows that vigilance could very well save her life.