The most prevalent of all forms of cancer among Americans is skin cancer. More than two million people in the United States are diagnosed with over three and half million incidences of skin cancer in a given year. These numbers exceed those of breast, lung, colon and prostate diagnoses combined, and one in five Americans will develop skin cancer during his or her lifetime.
Early Detection is Key
By Mike Haskew
Skin cancer is common among Americans and indeed occurs regularly around the world. Its most serious form is melanoma. Although the survival rate for melanoma that is detected early – before the cancer has penetrated the skin substantially – is as high as 99 percent, melanoma that is untreated for a prolonged period raises challenges to effective treatment. If melanoma metastasizes into surrounding lymph nodes and into other organs and locations in the body, it can lead to prolonged illness and death.
“There has been a tremendous rise in the incidence of melanoma across the world,” comments Dr. Samuel Banks of the Chattanooga Skin & Cancer Clinic. “Years ago, Dr. Albert Schweitzer said that if you were diagnosed with melanoma you would die from it, but often the disease was not diagnosed until it had penetrated deeply and become invasive. It is fairly aggressive, but as long as it is superficial, it is not as serious. Melanoma is actually quite curable as long as it is localized.”
While the diagnosis of other skin cancers have actually fallen, melanoma continues to be on the rise. The Skin Cancer Foundation reports that 114,900 new cases of the disease were diagnosed in 2010, with 68,130 of these determined to be more seriously advanced and invasive cases. Of these, nearly 8,700 resulted in deaths. Each year melanoma is fatal for males and females at 5,700 and 3,000 respectively.
Types of Melanoma
Melanoma is regularly classified into four major categories: superficial spreading melanoma, lentigo maligna, acral lentiginous melanoma, and nodular melanoma.
Spreading surface melanoma is the most common and accounts for about 70 percent of cases. Often seen in adolescents and young adults, this type involves the top layer of skin for a fairly long period before becoming invasive.
The first sign is the appearance of a flat or slightly raised discolored patch that has irregular borders and is somewhat asymmetrical. The color varies, and you may see areas of tan, brown, black, red, blue or white. This type of melanoma can occur in a previously benign mole. The melanoma can be found almost anywhere on the body, but is most likely to occur on the trunk in men, the legs in women, and the upper back in both.
Lentigo maligna is also superficial for an extended period. Characterized by flat or slightly elevated moles of brown or dark brown color, it is also initially confined to the top layer of skin – a condition referred to as “in situ.” Lentigo maligna is seen routinely among the middle-aged and elderly, whose skin has been exposed to sunlight over a period of years. It may become invasive and is then referred to as lentigo maligna melanoma.
Acral lentiginous melanoma is the most common form of melanoma among African Americans and Asians. It begins superficially and appears as dark discoloration under the skin, often in the nail beds, on the soles of the feet or the palms of the hands. This form of melanoma, though superficial in the beginning, may spread more rapidly than lentigo maligna or superficial spreading melanoma.
Nodular melanoma accounts for about 10 to 15 percent of the melanomas diagnosed. It is invasive at the time it is discovered as a bump on the skin. Primary locations for these cancers are the arms, legs and trunk of the body, often in the elderly, and on the scalp in men. The most aggressive form of melanoma, it usually appears black but may manifest as blue, brown, tan, white, red or even skin tone in color.
Who is at Risk?
Some segments of the general population are at higher risk for developing melanoma and should be on their guard when it comes to prevention and early detection.
“Anything that increases your risk of getting a disease is called a risk factor,” explains Dr. Karin Covi, a Chattanooga dermatologist, praticing in the office of Dr. Rodney Susong. “Having a risk factor does not mean that you will get cancer, and not having risk factors doesn’t mean that you will not get cancer.”
Risk factors for melanoma include the following:
• Having a fair complexion – fair skin that freckles and burns easily, does not tan or tans poorly; blue, green or other light-colored eyes; and red or blond hair
• Being exposed to natural or artificial sunlight over long periods of time
• Having a history of blistering sunburns as a child
• Having several large or numerous small moles
• A family history of unusual moles
• A family or personal history of melanoma
• Being white and male
Statistics indicate that one in 39 Caucasian men and one in 58 Caucasian women will develop melanoma during their lifetimes, while the majority of those diagnosed with melanoma are white males aged 50 or over. Risk for melanoma doubles if a person has sustained more than five sunburns. Roughly 65 percent of all melanoma cases are caused by exposure to ultraviolet radiation emitted from the sun.
“The sun is like an x-ray with different wavelengths of radiation,” remarks Dr. Banks, “and it will damage exposed areas. You don’t undo that damage. Melanocytes are pigments that tan our skin, and skin doesn’t tan unless it is trying to protect itself from damage. A tan looks nice, but it means the skin has been damaged and activated those pigment cells. So there is no such thing as a healthy tan.”
Prevention is a key element in the defense against melanoma, and nothing is more important than protecting the skin against long-term exposure to the sun. If an individual is consistently using tanning beds, sun lamps or tanning in outdoor sunlight, the best advice is to stop. Research indicates that indoor tanning increases the likelihood of melanoma by 75 percent. Schedule outdoor activities before 10 a.m. and after 4 p.m. when the sun’s rays are less intense.
The idea of getting a base tan before going on a beach vacation is a popular myth. Tanning only increases the possibility of developing melanoma. Sunscreen with an SPF (sun protection factor) of at least 30 should be worn every day, applied initially 30 minutes before going outside, and then reapplied every two hours.
Another line of defense is an awareness of what to look for on the surface of the skin, performing periodic self examinations, and visiting your healthcare professional on a regular basis. “A doctor should be consulted if one of the following problems occur,” advises Dr. Covi. “They include a mole that changes in size, shape or color, one that has irregular edges or borders, is more than one color, is asymmetrical so that when it is divided in half the two halves are different in size and shape, or is itchy, oozes, bleeds or is ulcerated. Other signs include changes in pigmented skin and satellite moles which are new moles growing near an existing mole.”
Basic awareness can help with early detection and perhaps save a life. The ABCDEs of melanoma are well worth remembering. They include the following:
• Asymmetry – halves not matching
• Border – uneven, scalloped or notched edges
• Color – multiple or varied shades of brown, tan, black, red, blue or some other color
• Diameter – usually larger than the size of a pencil eraser
• Evolving – includes changes in shape or color, crusting, itching or bleeding
A skin examination by a doctor or other healthcare professional is a first step in assessing the nature of a mole, pigmented area or birthmark that may appear suspicious. If warranted, a biopsy may be performed with the removal of much of the mole or lesion and its close examination by a pathologist to determine the presence or absence of cancer cells.
According to Dr. Banks, progress in the ability to diagnose melanoma in recent years has resulted in greater potential for positive outcomes. “We use a polarized light instrument called a dermatoscope to see the structure of some pigmented cells under the skin,” he relates. “The instrument has been around for about seven years, and over time you learn the patterns that are more suspicious and you possibly biopsy less. If a patient needs surgery, then that treatment can begin sooner.”
In addition, a database of thousands of images of melanomas is available to physicians. The images are utilized in comparing a patient’s mole or lesion to others that are known to be malignant and then determining the best course of action.
When melanoma is detected, the next step in treatment is to determine its severity, or stage. While Stages I and II are localized and classified as early, Stages III and IV are more advanced and have metastasized. Stage III generally involves lymph nodes close to the original site, and Stage IV has progressed to nodes which are distant from it. In 2010, an updated staging system was introduced, gauging more accurately the thickness, depth of penetration and possible spread of the disease.
Although a limited number of melanomas may respond to treatment with creams or be eradicated with cryosurgery (using extreme cold to treat tumors), the most effective treatment remains surgery. When the cancer is in situ, it is often possible for the doctor to remove a melanoma during an office visit. A procedure called a wide local excision involves removal of the melanoma and some healthy skin surrounding it. A pathologist reviews the surrounding cells, and the process of removing layers is continued until a clear margin is determined.
Treatments for advanced melanoma include surgery to remove diseased lymph nodes, the use of immunotherapy to support the body’s own immune system in the battle against the cancer, chemotherapy, and radiation therapy. The U.S. Food and Drug Administration (FDA) recently approved a new drug, peginterferon alfa- 2b, for the treatment of Stage III melanoma, and in March of this year the FDA approved the drug Yervoy, the first drug proven to extend the overall survival of advanced melanoma patients. Other drugs are in clinical trials at this time.
Responding to the Word ‘Cancer’
Delivering the news that a patient has melanoma is difficult; however, an informed patient is known to have a more positive outlook and to become more engaged in treatment.
“I tell the patient what the situation is and what their options are,” comments Dr. Hall Reynolds of the Chattanooga Skin & Cancer Clinic. “With few exceptions, they will need surgery. It is the only sure thing, and the earlier the better.”
Reynolds has seen melanoma in patients of all ages, from babies in utero to the elderly. One memorable case involved a teenage girl with an inconspicuous area on her ear. It turned out to be invasive melanoma and was removed.
In every case, the patient should be prepared to ask questions and to take notes as answers are given. Many of the questions are central to the future course of treatment, including the stage of the melanoma, the chances of recovery, treatment options, any required follow-up treatment and its side effects, the likelihood of recurrence, and the impact on the patient’s family and personal quality of life.
Take charge of your health: follow the medical advice to reduce your risk of skin cancer; check for suspicious moles or skin marks and get regular exams from a dermatologist… lead prevention by seeking early detection.