Transcript Northwestern Medicine

Skin Cancer
What to look for and how to prevent it
Emily Louise Keimig MS MD
Clinical Instructor
Department of Dermatology
Objectives
Identify risk factors for skin cancer
Discuss the three most common types of
skin cancer
Discuss prevention
Vitamin 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
BCC
• 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
Basal Cell Carcinoma
Signs and Symptoms
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
Basal Cell Carcinoma
Signs and Symptoms
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
Basal Cell Carcinoma
Risk Factors
• 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)
Basal Cell Carcinoma
Detection and Treatment
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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
Actinic Keratosis
Actinic Keratosis
AK
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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
Actinic Keratosis
Signs and Symptoms
Rough patch on the skin
•May be painful when rubbed
•May itch or burn
Persistently dry lips
•AKA actinic cheilitis
Actinic Keratosis
Signs and Symptoms
May grow quickly and look like a horn
May have a tan or brown color
Actinic Keratosis
Risk Factors
• 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
Actinic Keratosis
Detection and Treatment
• Evaluation by dermatologist for any suspicious lesions
• Cryotherapy or liquid nitrogen therapy
• Field treatment
 Medicated creams
• Imiquimod
• 5-Fluorouracil
• Diclofenac
 Photodynamic therapy (PDT)
Squamous Cell Carcinoma
Squamous Cell Carcinoma
SCC
• 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
Squamous Cell Carcinoma
Signs and Symptoms
Rough bump or lump on the skin
Dome shaped crusted bump
Squamous Cell Carcinoma
Signs and Symptoms
Sore that doesn’t heal
•Or heals and then returns
Bowen’s Disease
•Squamous Cell Carcinoma in situ
•Flat
•Reddish
•Scaly patch
•Grows slowly
Squamous Cell Carcinoma
Signs and Symptoms
Involving the nail
Involving the lip
Squamous Cell Carcinoma
Risk Factors
• 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
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Ulcer or sore that has been present for years
Suppressed immune system
Papillomavirus (HPV) infection
X-rays for acne
Squamous Cell Carcinoma
Diagnosis and Treatment
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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
Melanoma
Melanoma
Statistics
• 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
Melanoma
Signs and Symptoms
• Anyone can develop melanoma
• Look for the ABCDEs of melanoma
• Asymmetry
• Border
• Color
• Diameter
• Evolving
Melanoma
Asymmetry
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
http://www.health.com/health/galle
ry/0,,20723732_6,00.html
Melanoma
Asymmetry
Melanoma
Border
Melanoma
•Irregular
•Scalloped
•Poorly defined
Normal Mole
•Regular
•Smooth
•Discrete
http://skincancer.dermis.net/content/index_en
g.html
Melanoma
Border
http://skincancer.dermis.net/content/index_en
g.html
Melanoma
Color
Melanoma
•Varied
•Multiple colors
•Tan, brown or black
•White, red, or blue
Normal Mole
•One color
http://skincancer.dermis.net/content/index_en
g.html
Melanoma
Color
http://skincancer.dermis.net/content/index_en
g.html
Melanoma
Diameter
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
http://skincancer.dermis.net/content/index_en
g.html
Melanoma
Evolving
Melanoma
•Looks different from other moles
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“ugly duckling”
•Changing in size
•Changing in shape
•Changing in color
Normal Mole
•Stable over time
Melanoma
Under the Nail
http://www.skindermatologists.com/p/nail.ht
ml
Melanoma
Mouth
http://www.oralcancerfoundation.org/facts/ra
re/om/
Melanoma
Hands and Feet
http://imaging.ubmmedica.com/cancernetwor
k/journals/oncology/images/unwinding/20040
8-1192-6.gif
Melanoma
Risk Factors
• 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
Melanoma
Diagnosis and Treatment
• 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
Melanoma
Prognosis
• 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
How to Prevent Skin Cancer
Sun avoidance
Sunscreen use
Sun 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
General Facts
• 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
Sunscreen
What to look for and how to apply
• 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
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
Risks
• 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
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