Dr. Ronald Setzkorn
May 18, 2016
Skin cancer remains the most common malignancy diagnosed in the United States. The incidence of this appears to be greatly under-reported but it is clear that skin cancer is more common than all other cancer types combined. Basal cell cancer is most common of these cancers with squamous cell cancer being the second most common. For example, Dr. H.W. Rogers in 2006 use national representative databases and estimated the non-melanoma cancer incidence in the US that year to exceed 3.5 million cases. One should note that the reporting of non-melanoma skin cancers to Tumor Registries throughout United States is not required and this would lead to under-reporting. Fortunately, this diagnosis rarely leads to death.
As with all cancers, “an ounce of prevention is worth a pound of cure.” The development of these cancers has a direct relationship with the amount of prior sunlight exposure and years of exposure in a person’s past. This is particularly true for sunlight exposure as a child or teenager. There is a greater amount of sun exposure in countries closer to the equator where sunlight is more intense. It is also more intense at noon and at other times during the day and more intense during summer than other times of the year. Light skinned people appear to be more often affected than dark skinned. Also the frequency of prior severe burns causing peeling of skin appears to be related to the future incidence of skin cancers, for instance farmers and other people who have jobs outdoors often experience higher rates of skin cancer later in life. These factors can be reduced by limiting sunlight exposure, particularly as a child or young adult and by the use of sunscreen with a Sun Protection Factor of 15 or greater.
A close friend of mine and former partner worked in the cancer program of a large hospital in Saudi Arabia. I find it interesting that he reported virtually no cases of skin cancer in this very hot dry and sunny climate almost certainly relating the fact that it is a cultural norm for Saudi Arabian citizens to cover virtually all skin with clothing. Conversely, the incidence of skin cancer in Australia remains very high where there is no such cultural norm to cover up skin exposure.
There are also advantages to early detection and management as opposed to neglecting this group of malignancies. An area of irregular skin that is bleeding, or crusting or one which does not heal needs to be evaluated. This evaluation would include biopsy if cancer is suspected. Given the high cure rates for basal cell and squamous cell cancer, it is not clear how many lives would be saved but even under the circumstances, the morbidity of curing these cancers would be lower with early diagnosis.
Also in the setting of melanoma, the cure rate is significantly higher with early diagnosis then with a delayed diagnosis of higher stage disease. When I spent time at Massachusetts General Hospital years ago, I was informed of a program where dermatology residents were given the task of examining every surgical patient (cholecystectomy, appendectomy, etc.) for incidental skin cancers during their hospital stay and then registering their outcomes regarding melanoma. I was informed that in following these patients, they had no cases of subsequently fatal melanoma in this patient population for over 30 years. I do not know if this program is still ongoing.
For those many patients who ultimately are diagnosed with skin cancer, the goals of care would be to achieve cure with the best functional and cosmetic outcome. A diagnosis of skin cancer would involve a biopsy and generally the input of the family physician, dermatologist or surgeon. The subsequent management of skin cancer would involve dermatologists, surgeons and radiation oncologists and occasionally now medical oncologists for situations beyond the scope of standard management.
The optimal care would involve patient preference and the balancing of inconvenience, risks and benefits of each approach, the expected outcome in terms of cancer free survival and long-term appearance and function. One option is that of radiation therapy and the basic principles from which this field of medicine evolved came from the study and management of skin cancers. There has been a significant evolution in the care of skin cancer patients over these decades. For many patients, this care could now include six to ten 5 minute sessions of brachytherapy; a treatment in which a small device temporarily holding a radioactive seed is placed a short distance away from the cancer to provide these treatments and is done without the need for anesthesia or the removal of tissues.
We at Dayton Physicians Network UVMC location became the 13th facility in the US to offer the new modality of Valencia HDR care in 2005. For patients who are medically or technically inoperable, radiation linear accelerator based therapy still provides for optimal outcomes for these more difficult of circumstances but it often requires 25 or more separate brief sessions of therapy to complete this care. This inconvenience, however; is generally non-morbid and successful.
I have been blessed in being a part of many successful outcomes for patients who otherwise would have required amputation of ears or significant deformity of noses etc. In total, I have witnessed success in over 95% of cases over 30 years. Surgery however still provides the main stay of care for most patients and excision and/or Moh’s surgery remain an important part of the curative management of many of these patients.
In summary, skin cancers are surprisingly common and are rarely fatal for the majority of basal cell and squamous cell subtypes. Prevention, early detection and weighing all options for cure remain central to the care of these patients. As is well stated in the 2016 National Comprehensive Cancer Network guidelines; “The goals of primary treatment of skin cancer are the cure of the tumor and the maximum preservation of function and cosmesis. All treatment decisions should be customized the particular factors present in the individual case and for the patient’s preference.”
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