What is the Skin?
The skin is a tissue, meaning that it is a collection of cells organized as a unit.
The skin serves to physically protect the body and keep germs from getting into it.
Adults have about 1 and 1/2 square yards of skin, which is specialized for various
body areas-- i.e. thicker on the back and thinner on the face. People living in very
cold climates (i.e. Eskimos) have more outer layers of skin over their whole bodies,
while individuals in temperate climates (i.e. Polynesians) have generally thinner
skin. Some skin areas are rich in hair follicles and sweat glands, such as the armpits ("axilla").
Others are bald and don't perspire such as the fingertips. The nail beds are an
extension of the skin forming a hardened ("cornified") skin called nails. Most skin can be transplanted from one area of the body to another, called a "skin graft".
This may be needed after injury or operation has removed the cells which generate
new skin in an area. New skin cells arise at the deepest level of the skin, and
gradually push their way upwards toward the surface as they mature. The main types of cells
found within the skin are basal cells, which form the bottom layer, squamous cells, which push toward the surface to form the skin we see, and melanocytes, which produce melanin pigment that colors the skin. In Black individuals the melanocytes
produce pigment for each squamous cell, while in White individuals they produce pigment
in clumped areas known as freckles, moles, or "cafe au late" spots, as well as a moderate increase with sun exposure ("suntan"). The layer below the skin is called
the "subdermal" layer, it is rich in blood vessels, nerves, and fat. The subdermal layer also contains
"lymph channels", which connect to pea-sized "lymph nodes". The are glands which
filter the blood serum, and can be conduits for spread of infections or cancer. When
the lymph nodes are invaded by germs or cancer, they tend to enlarge ("lymphadenopathy").
The subdermal supplies the lower levels of the skin with oxygen and nutrients. However,
as the skin cells push up toward the surface, they die and become hardened, or "cornified", by a protein substance called "keratin" . This keratin is produced by"keratinocyte" cells within the skin, and it is what makes our nails hard, and rhinoceros' horns
hard also. Skin calluses are areas of increased keratinization; as are keloid scars.
The keratinized epithelium is harder and more durable than normal skin, and is formed
in response to trauma. If no further trauma occurs, the skin very gradually returns
toward it's normal state (scar fading). Besides for it's cosmetic purpose, the skin
protects us from dehydration by keeping our water from evaporating out too quickly,
protects us from outside infection,s, and absorbs some sunlight to manufacture activated
vitamin D necessary for bone growth and proper calcium metabolism. Most skin ailments
are minor, and heal quickly alone or with mild medicine. Examples are mild burns,
cuts and abrasions-- the skin is among the quickest healing tissues in the body. Over-rapid
production of new skin cells leads to psoriasis, and eczema often arises from some
irritation or allergen. Acne comes from rapid sebum (oil) production that blocks
pores. Sometimes, however, the skin develops cancer, which does not heal without therapy.
What is Skin Cancer?
As above, the skin is made of various cells, including basal cells, squamous
cells, and melanocytes. Normally these cells divide very quickly in womb life, early
childhood and through puberty to grow the adult body. In adulthood, the middle and
upper layers of skin will grow to repair an injury or to replace cells which have died of
old age. If the basal (underlying) layer is damaged, as in a third degree burn, then
the skin must be grafted to heal properly. Like all body cells, the division of skin
cells is under very tight control, by the genetic material ("genes") within each cell.
When certain damage occurs within these genes, control over ordered cell division
may be lost, and the nature of these cells dramatically changed. Any type of skin
cell can give rise to skin cancer, if it's reproduction goes out of control, and it divides
in a disorganized way. Skin cancer, like any type of cancer, starts in just one single cell . The abnormal cells may pile up in a clump, called a "tumor" . A tumor simply means a swelling, which can be caused be infection or many other
non-cancerous conditions. A tumor which merely grows in it's local area, and cannot spread distantly
to other body areas, is called"benign" and isn't cancer. Most lumps and bumps (tumors) found within the skin are benign
. In contrast, a tumor which can spread
to distant body areas (whether it actually does or not) is called"malignant", and this is cancer . The process of spread is called "metastasis" . A cancer which starts within the skin is called a "primary skin cancer" . Just because a cancer is found on the skin does not prove it originated there;
it may have started somewhere else (e.g. lung, breast, kidney) and metastasized to
the skin. It is this capacity for spread, both local and distant, which makes any
cancer so dangerous. When basal or squamous cells become cancerous, they are calledcarcinomas, while when the melanocytes become cancerous, this is called melanoma, which has such a different character that it is another topic.
How Common is Skin Cancer?
Skin cancer is the most common cancer in the United States, with over 500,000 new
cases each year causing 3,800 deaths . The number of cases has increased each year. The most common type of skin cancer is Basal cell carcinoma (BCC) which is 75% of skin cancers. Squamous cell carcinoma (SCC) makes up 15% of skin cancer, while the remaining 10% are melanomas, and variant types
of BCC and SCC. Other very rare cancers arise from sweat glands or touch and temperature
receptors in the skin. Some come from immune cells in the skin ("lymphomas") . Skin is a common area for other organ cancers to metastasize to, because of it's
large surface area and good blood supply. These have much different natures and
therapy than "primary skin cancer", and are discussed in their pertinent transcripts.
What Causes or Increases Risk for Skin Cancer?
As for any cancer, the precise reason why one person develops skin cancer and
another does not remains unknown . However, several "risk factors" increase the risk:
Risk Factors for Skin Cancer:
1) Chronic sunlight exposure, particularly in fair skinned, light haired or redhead
people, is strongly linked to all types of skin cancer. This is from the
ultraviolet
(UV) rays in sunlight, which damages skin cells and their ability to repair
themselves. The increase in skin cancer over the past few decades is thought
partly due to depletion of the ozone layer, which filters out UV rays, and also
people wearing less clothing and being out on the beach more. People living about the equator get more skin cancer, and farmers and sailors who get lots
of sun to their ears, nose and hands get skin cancers in those areas.
2) Previous burns and scars have a higher risk to develop skin cancer, called
Marjolin's ulcer. Also, areas of the skin that have lost their pigment
(called vitaligo) get it more frequently.
3) Exposure to radiation increases all types of cancer risk, including skin cancer.
4) Frequent skin contact with certainchemicals, like arsenic, and coal tars, will
cause changes in the skin which can become cancerous.
5) Certainviruses, like the human papillomavirus linked to genital cancers, lead
to skin changes which may develop cancer.
6) Various genetic diseases (either inherited from parents or arising spontaneously) lead to poor repair of skin damage, which may then become cancerous. Examples are Ataxia-Telangectasia and Xeroderma Pigmentosum. These people must scrupulously avoid exposure to sunlight.
7) Conditions which lower the immune system activity can lead to skin cancer,
as well as other cancers like lymphoma. Things that lower the immune
system include diseases like AIDS, inborn deficiency of immune cells, or
drugs given to prevent transplanted organs (like kidneys) from being rejected.
You can see that all of these risk factors either disable the skins cell's ability
to repair pair damage, or prevent the immune system from catching the beginnings
of cancer and killing it as it does when it works properly. The more skin cells a
stimulated to divide, by injury, irritation or whatever, the more change an abnormal cell
has to arise with the genetic damage that heralds cancer. The holds true for virtually
all cancers.
What are the common Symptoms of Skin Cancer?
Fortunately, most skin cancers are easily seen and brought to a doctors attention
early, since they are on the skin surface and obvious. However, all doctors
have seen patients who come in with grossly disfiguring tumors that have been ignored.
Most skin cancers occur in areas of sun exposure, which includes the face, ears, arms,
legs and trunk. A doctor must know how to tell a suspicious skin sore from the very
common non-cancerous conditions, such as warts and skin tags, and be able to teach
the patient this. However, the only way to absolutely diagnose any skin cancer is by
examining a sample of it ("biopsy") under a microscope.
A "symptom" is something the patients experiences and reports upon (e.g. pain), while a "sign" is something that can be observed or measured (e.g. swelling). Concerning possible
signs and symptoms of skin cancer include:
1) A sore that doesn't heal anywhere on the skin surface. Basal Cell Carcinoma
tends to be flat, plaque-like, have raised edges and be brownish, black
or pearly grey in color. Squamous Cell Carcinoma often appears as a red bump.
The cancer will grow slowly over time, perhaps doubling in size in 3 - 6 months.
The area may bleed or become infected as the cancer penetrates deeper into
the surrounding tissues. Skin cancer may lie dormant, but it does not heal
by itself.
2) A change in a wart or mole, especially if it starts spreading, develops irregular edges, grows larger, or changes color. Purple is particularly worrisome
for
cancer. Skin cancer tends to grow slowly (over months).
3) Areas of chronic scaling, especially if they develop over an existing sore or
white area of the the skin.
4) New firm lumps under the skin surface, or bumps with a bluish tinge showing
through the skin may show a cancer from another organ (such as the
breast)
which has spread, or "metastasized" to the skin.
5) Rarely, the first indication of skin cancer is by feeling enlarged glands, called
"lymph nodes" to which the skin cancer has spread. It is rare for BCC to go
to lymph nodes (<0.1%), but SCC can spread to them about 2% of the time.
Also, if the skin cancer arises from a previous scar or burn, the chance
of it
spreading to local lymph glands is as high as 30%.
6) It is very rare, but possible, for skin cancer to spread to distant organs, such
liver, lung, bone and brain. Symptom in organs mean advanced disease.
*** Although not an absolute rule, early skin cancer is painless, grows over a period
of weeks to months (not "overnight") and feels firm.SCC is often a flat plateau of
slightly raised tissue, like a disc under the skin surface.BCC has a flat or pitted
("ulcerated") center with raised edge borders, and often has pearly scales
especially around it's edges. Metastasis to the skin from another organ cancer
usually
are in the trunk, face, upper arms and thighs ("proximal" body areas). Primary
skin
cancer has a propensity to develop in sun-exposed areas, such as the face,
ears,
nose, arms and hands. Anything with a purple color is particularly worrisome.
How is Skin Cancer Diagnosed and Evaluated?
Whenever a patient develops an area suspicious for skin cancer, they should report
it to their physician. Moreover, ideally a general physician should examine every
square inch of a patient during an annual physical exam, to detect "lesions" (abnormal areas) that the patient hadn't noticed. It is not uncommon for people to
miss areas of their scalp, back, gluteal fold (between the buttocks), perineum (between
the genitals and anus), and backs of thighs since our eyes are not well positioned
to see these places. A person should not feel embarrassed at pointing out something
"troublesome" in even the most private area to their doctor-- if so, they should find a new doctor whom they are completely comfortable with. Most lumps in
the skin are due to infection, scarring, fatty changes ("fat necrosis"), or other
benign tumors. "Lipoma" is the medical name for a benign fatty skin tumor, which may at first grow quickly and then remain unchanged for years. That's what
Abraham Lincoln had on his face, as many adults do.
While new lumps or appearance changes in the skin may suggest cancer, the only
certain was to diagnose any cancer is by taking a sample of it, called a"biopsy". The
biopsy material is examined by a "pathologist", a physician specializing in diagnosing disease using tissue samples. A biopsy may
be done by removing the entire suspected cancer, with a safety margin of normal tissue
around it. This is called an"excisional biopsy". Alternately, just a small sample of the tumor may be taken, either by cutting a piece
off of it or using a punch device to take a core of it. This is called an"incisional biopsy" and is used for either large tumors, those of sensitive cosmetic areas like the face,
or those for whom the suspicion of cancer is very low.
The biopsy material is studied
by the pathologist using special stains, which highlight the process of rapid cell
division common to cancer. (S)he will identify the cell of origin of the overgrown
tissue, and may subject the biopsy material to immune or gene tests to help determine
whether it is "benign" (shows no evidence of cancer) or "malignant" (cancerous). If the tumor is malignant, the pathologist will then specify the name
of the particular cancer, based upon the cell of origin. If an excisional biopsy
was performed, with the goal of removing the entire tumor, (s)he will look at the
margins (edges of the removed specimen) to be sure that they are "clear" or free of any cancer
cells. This procedure makes the diagnosis of cancer, and if a "full thickness" biopsy
was obtained, it gives an idea of how deeply the cancer penetrates.
Once cancer is detected, the next step is to evaluate how extensive it is. Fortunately
skin cancer has less tendency to spread
than any other cancer, accounting for it's excellent cure rate. Spread, that is metastasis, of the most common type, BCC, is exceeding rare and so doing extensive tests to look it elsewhere in the body
is unwarranted. However, the cancer can grow downward to penetrate into the subdermis, so it is
important, for treatment, to know how far it has spread locally, both along and beneath
the skin surface. Spread to even local lymph nodes is seen in less than 1% of patients, but a nearby swollen lymph node ("lymphadenopathy") must still be checked if any
suspician exists. Note that local infection can swell lymph nodes.
Spread to lymph nodes is somewhat more common for theSCC type, especially if it starts in the face or scalp, where it has a predilection to go to lymph nodes around the parotid gland (which
makes saliva). Thus it is appropriate to get a CT scan of the head and neck to look
for these enlarged lymph nodes; if they are found they need to be surgically removed.
The CT scan is basically a computerized combination of multiple X-rays to reconstruct
a multiple 2-dimensional slices of a body area, which can be combined in the viewer's
mind to provide a 3-dimensional image of that area. CT scan is useful for picking
up tumors or enlarged lymph nodes larger than 1 cm.
(about 1/2 inch) across. Ideally, the CT scan should be given with "contrast", injected into an arm vein, which highlights blood vessels and allows the scan to
have better resolution of the area's tissues. Insist upon"omnipaque" or equivalent contrast, it is more expensive but more comfortable and less likely
to cause an allergic reaction or kidney problems than older type contrasts. Magnetic
Resonance Imaging(MRI) is also excellent for imaging "soft tissue" (muscle, fat, cartilage, nerves, blood
vessels) but is 3 times as expensive as CT scan (~$1000) it's rarely done for early
skin cancer.
Preventive ("prophylactic") removal of regional lymph nodes is not done
for BCC or SCC although it may be appropriate for other skin cancer (i.e. melanoma or Merkle cell
cancer). If the tumor is large (>3 cm) a CT scan of the chest may be gotten to rule
out spread to the lung or liver. Other tests, such as bone scans orbrain CT, are only gotten if there are specific symptoms in those areas, or if there is suspician
that the cancer has arisen elsewhere but it's origin remains obscure.
How is the Extent of Skin Cancer Gauged?
Like any cancer, the extent of skin cancer is given by the"stage". While several different staging systems exist, the one most commonly used in the U.S.A.
was developed by the American Joint Committee on Cancer, or "AJCC" . The stages are:
Stage I means the cancer is less than 2 cm (about 1 inch) across
Stage II means the cancer is larger than 2 cm across
Stage III means the cancer either invades areas deeper than the skin.
(like local cartilage or bone) and/or has
spread to lymph nodes.
Stage IV means that the cancer has spread to distant areas in the body
(such as lung, liver, bone, or brain).
Is Skin Cancer Preventable?
Skin cancer is thought to be the most preventable cancer. This is because the main risk factor for skin cancer is excessive exposure to sunlight.
While light skinned, fair haired people, or those with genetic diseases may be more
susceptible to UV light induced DNA damage leading to cancer, sunlight remains the
major source of that UV light. Using a sunblock with a SPF rating of at least 20
(which reduces UV rays to less than 1% of ambient) while "sunbathing" will help prevent a new skin cancers from forming in all patients. Those with albino
complexions, Ataxia-Telangeictasia or Xeroderma Pigmentosum must take extreme precautions,
using clothing or sunblock even in Northern latitudes on winter days. Also, any new lesions should be promptly evaluated and promptly treated, and not just be "observed"
without a competent medical opinion. There is evidence that increasing vitamins"A" and"E" in the diet helps reduce the risk of many "epithelial" (lining or covering cells)
malignancies, including skin cancer. However, extreme doses of the fat soluble
vitamins (A,D,E,K) should be avoided since they can build up in fat and become toxic.
As we will see, one of the treatments ("Retinoin") for skin cancer is a Vitamin A derivative.
How Curable is Skin Cancer?
This depends upon the type and stage. In general, BCC is easier to cure than SCC, and of course smaller cancers are easier to cure than extensive ones. In general:
Stage Cure at 5 years
I 98%
II 90%
III 70%
IV 30%
**Overall cancer cure for all stage combined is 85%, since most patients have the more favorable BCC, and early stage disease, when they
seek medical help. This makes skin cancer (overall) among the most curable cancers!
What is the Conventional Treatment For Skin Cancer?
Historically, the two treatments for skin cancer were surgery to remove it, radiation therapy, or both for more advanced cancer
. The choice of which therapy was, and still is, based on the size of the cancer,
the location of the cancer, the condition of the patient, and the wishes of both
the patient and physician. Any skin cancer discovered must be treated, and should
never be "watched". It is also critical to ensure that that the cancer is "primary skin cancer",
and has not spread to the diagnosed site from some other body area. The treatment
for uncomplicated early skin cancer is straightforward, but some choice still exists:
Surgery was and is excellent treatment for small cancers in areas that are not cosmetically
too sensitive, such as the arms, legs, trunk and scalp. It has the advantage of being
quick, safe, and effective for smaller cancers that can easily be completely removed.
After surgery over 90% of BCC and 75% of SCC remained controlled for tumors less that 5 cm. (~2 inches across).
Surgery can be done painlessly
under local anesthesia for small tumors, with full healing expected within 3 - 4
weeks. For patients prone to develop keloid scars, a small dose of radiation (~8
Gray) can be given to the incision which prevents most keloid formation. Conventional
surgery techniques include"curettage", which is basically scraping off the tumor, but this has the disadvantage of being
difficult to examine for "clear margins"
(i.e. there may be some cancer left behind. Alternatively, as is done for early
cervical cancer, "cold-knife" surgery cuts out the entire tumor and makes it easy for the pathologist to examine
the specimen. Cancer cells are damaged by surgery which uses heat, such as"fulguration","cauterization", and"electrocoagulation" -- these burn the tumor off, but do not allow good information about how complete
the removal was.
**The overall cure rates for surgery for tumors smaller than 5 cm. is over 90%, making it quick, effective, and reasonable treatment for non-cosmetically sensitive areas
. About 1/2 of patients for whom surgery fails can be saved with radiation therapy,
although a higher dose will and larger area will need treating, compared to if radiation
had been chosen as the initial treatment.
Radiation Treatment has been used for almost 100 years for skin cancer, and is (in general) just as effective
as surgery. It works better for BCC than SCC . It's main advantage is in treating cancers in cosmetically sensitive areas, like
the eyelid, lip, nose, and hands, since the patient's appearance after treatment
will usually be much better than after surgery. Modern radiation therapy is very
safe and effective. Prior to getting radiation therapy, the patient is seen in consultation
by a "Radiation Oncologist", a cancer physician who specializes in administering radiation. There are 2 standard
methods of giving radiation-- "External Beam" and"Brachytherapy" . External Beam is the more common type and shines a beam of photons or electrons
onto a predesignated area of the patient's sin . Thus, it can cover a large area
of possible cancer spread. Brachytherapy also called "Interstitial" treatment, means putting radioactive needles through an area of deeper cancer invasion
(e.g. lip) to treat deeper tissues. Both techniques may be used in a given patient.
Radiation kills cancer cells by damaging their DNA, they die when they try to
divide. Thus, damaged cancer cells die even after the treatment is complete. Radiation
will also kill normal cells, which limits the amount that can be given. However,
it usually takes more radiation to kill normal cells than cancer cells, and normal cells
can often repair the radiation damage, while cancer cells can not. Furthermore, radiation
will usually stimulate normal skin cells to start dividing more quickly to repair
the perceived injury. Nevertheless, it is important to be as exacting as possible
in the administration and dose of radiation, so as to minimize the injury to adjacent
normal cells. Fortunately, the radiation dose to deeper tissues underlying the skin
can be controlled with modern techniques, which makes the skin the safest area to radiate.
To receive therapy, a patient is first seen in "consult" by the radiation oncologist, who reviews the patient's history, medical record,
and current complaints. S(he) performs a directed examination of the cancer area,
trying to estimate it's undetected ("subclinical") extension. The area of treatment is marked out, using a watercolor marker, and several
pinpoint sized permanent tattoo marks may be placed to forever denote the treatment
area.
There are 2 basic machines used for treating the skin-- photons with an "Orthovoltage Machine" or electrons with "Linear Accelerator" ("LINAC") . Orthovoltage equipment was invented first, it is similar in energy to the earliest
X-ray therapy machines, which tended to over treat the skin while under treating
underlying organs. That is because they gave Low Energy (less than 400 Kilovolts)
photons, and the lower the energy the less penetrating the photon beam. Updated Orthovoltage
Machines are designed for treating superficial sites, and we are intentionally minimizing
the dose to deep tissues. Simple thin lead-type blocking shields can be cut out with a scissors, and placed over areas that don't require treatment. Thus the treatment
"field" can be designed with some artistry by the radiation oncologist, and a BCC on the cheek can be treated while shielding the eye and bridge of the nose. In contrast,
for LINAC photons, which are high energy (~4 - 25 Megavolts) the lead shields have
to be at least 3 inches thick!
Electron Beam therapy with the LINAC also is much higher energy (~ 6 Megavolts)
but electrons are much less penetrating than photons. Nonetheless, the blocks for
shielded areas must be thicker, and usually placed up in the "head" of the treatment
machine. A larger field can be treated with a LINAC, and the treatment may be given
from several different angles. In fact, for a condition called "mycosis Fungoides" (a
form of T-cell Leukemia involving skin) the entire skin surface may be treated this
way, turning the patient rotisserie style. Many modern departments treat with LINAC
electrons because they don't have an Orthovoltage Machine. LINAC electrons may be more deeply
penetrating than the very low energy Orthovoltage photons, but the dose to deep organs
is generally too little to cause apparent harm.
For Interstitial Brachytherapy, the patient has a template with holes in it
designed to fit over the area to be treated (e.g. lip, cheek, nares) and multiple
small needles of Iridium-192 are placed through it under local anesthesia. The "implant"
may remain in place for a time averaging 2 days, during which the patient is hospitalized
in a specially shielded patient room. The dose from an implant is usually on the
order of 30 Gray, given at 0.6 Gray per hour. After therapy is complete, the needles
and template are removed, and the patient goes home. Again, this is only used when
the cancer has penetrated deeply into the underlying tissue. It has the advantage
of giving a very high dose to the tumor area, but very small dose to surrounding
normal tissues. It is only done by specialized Radiation Therapy departments, usually found at
University Hospital Academic Centers.
Radiation Therapy itself ispainless, the patient does not become sick, radioactive, orlose hair outside the treated area . External Beam therapy is normally given for 3 or 5 days per week for 2 - 5 weeks,
and takes only a few minutes per day. There are many schemes for dividing up the
radiation dose over time, each treatment is called a "fraction" . The "Fractionation" schedule is based upon the size and extent of the cancer, and
also patient convenience. The usual dose of radiation is about 45 Gray (units of
radiation) and in general, the cosmetic results are better if more fractions are given over a longer
period of time.
The side effects of radiation therapy are divided into 2 categories,"Acute" and "Late" Effects. Acute effects occur during the treatment period, while Late effects may
occur months to years later. Acute effects abate after treatment is complete, while
Late Effects tend to be more permanent. Typical acute effects include skin redness
and soreness starting after a week or two of treatment, this may progress to frank
skin peeling ("desquamation") . Dry desquamation tends to itch ("pruritis"), and is the type first seen. Moist desquamation
means the area is wet and weeps fluid often flecked with blood (called "serosanguinous
fluid"). Generally, the therapy for Dry desquamation is to wet the area with topical creams, and for Wet desquamation to allow the area to dry out! Steroid creams
(e.g. flucinolone, topicort) will help reduce skin reaction. If the treatment area
is painful, mild analgesic (i.e. acetominophen, ibuprofen) or even narcotic (tylenol
#3, darvocet) will help alleviate pain. While "holes" are not burned in
patients with modern therapy, if the area had been replaced by tumor, what will be
left after the tumor is gone but a hole? These usually scar in gradually. As mentioned,
Acute Effects will resolve after completion of treatment.
Late Effects may show as the skin being lighter, tighter, and may show little bluish capillary
markings called "telangiectasias" . The tissue under the skin may feel more thick or "woody", called "fibrotic induration" . It is important to protect such skin from direct sunlight after radiation therapy,
and use at least an SPF 20 sunblock for prolonged exposure. Also, any wounds from
cuts or scratches to the area should be taken care of meticulously. While most patients
can get treated, those who have specific rare diseases such as xeroderma-pigmentosum
or ataxia telangiectasia should not as their skin doesn't heal well with radiation.
Also, Those with basal-cell nevus syndrome are at higher risk for getting cancerous
melanoma if they get radiation, so they should get surgery instead.
**The overall cure rate with radiation for small skin tumors is 95%. If radiation fails, about one-half of patients can still be saved ("salvaged") with radical surgery.
Surgery and Radiation Together:
Radiation alone is less effective if the cancer invades deeply into cartilage or
bone, such as behind the ear. Then both surgery and radiation have been used together
to increase cure. The usual approach is "pre-operative" radiation to shrink the tumor,
followed by limited surgery to remove any residual cancer. The area may
have poorer healing when both are used together.
What is the Latest Effective Treatment for Skin Cancer?
The best therapy for simple, small cancers remains conventional surgery of radiation
therapy, since they are almost 100% effective and quite safe. However, there are
some newer developments for larger or more widespread cancers:
Chemotherapy with Topical 5-Fluorouracil (5-FU) is effective only on superficialBCC or SCC arising in sun damaged areas. It is an easy cream to apply, but requires very
close follow-up to make sure the cancer is actually getting better, and it may recur
years later. Retinoid pills (accutane, a vitamin A derivative) may help prevent cancers
in susceptible individuals, but the side-effects are still to worrisome to recommend
it's use. It is being tried in trials for patients with xeroderma pigmentosum or
basal cell nevus syndrome in whom radiation can't be used.
Surgery Improvements were developed by Moh, and now over 200 institutions do "Moh's micrographic surgery" . This basically involves taking very small pieces of the cancer at a time, and continually
examining the margin to see if all the cancer cells have been removed-- it is a tedious
process, but results in higher cure rates for cancers that have penetrated deeply or are about the nose cartilage or scalp. In general it can be more effective
that radiation with 80% cure for cancers that have invaded deep cartilage, compared
to about 60% with radiation alone. It is excellent for recurrent cancer after either radiation or surgery treatments. The modern laser is
a good cutting tool for the specialized surgeon, and it seals blood vessels as it
cuts.
Cryotherapy means freezing the tumor with liquid Nitrogen, it forms a scab which falls off. It's
only useful for very small cancers in debilitated patients.
Radiation Improvements include hyperthermia, where the cancer is heated before radiation treatments to about 120o F and is safe and effective for improving the results for cancers recurrent after
surgery, or for metastasis of cancers (such as breast) to the skin. It is done at
many University Hospital Radiation centers. There may be more local reaction (i.e.
redness and tenderness) to the area with hyperthermia, and it is not shown to improve survival.
However, it is usually well tolerated and greatly enhances the effectiveness of the
radiation. Computerized treatment planning can tell precisely how much radiation
is going to the tumor and how much to surrounding normal tissues. It is now known that
decreasing the size of each fraction will decrease late effects, so slow treatment
is preferable for most patients. For Interstitial Brachytherapy, new technology called
"High Dose Rate" (HDR) Brachytherapy allows the treatment to be given in just a couple minutes instead of a couple days.
The template may be left in place so the patient can go about their business, having
no radioactive sources in them, and then return to the Department for another treatment. The late effects of Brachytherapy are also less is it is "fractionated" instead
of given all at one session.
Photodynamic Therapy is useful for superficial cancers such as skin and bladder. It involves putting
a special "hematoporphyrin" dye which is untaken by cancer cells on the tumor,
and then exposing it to a beam of light which selectively kills the cancer cells
that have untaken the dye. It is useful in patients with basal cell nevus syndrome where
radiation shouldn't be used.
Interferons when injected lead to disappearance of someBCC, but it requires many injections and careful follow-up to make sure the cancer doesn't
come back. The side effects of interferons include fever and muscle aches, but they
are generally safe. This type of therapy may be offered as part of a "clinical trial" to test it's effectiveness, alone or in combination with other treatments. Be sure
you understand the ramifications of participating in any clinical trial, since
you may be giving up the option for a proven effective therapy in order to test an
experimental one.
The overall conclusion is that skin cancer, while the most common cancer in the world, is also the most curable
. It is important to get treatment early when the cure rates are highest, and newer
techniques now offer hope for patients who get skin cancer with rare genetic diseases
or who have advanced disease. Cosmetic appearance can also be preserved for most
patients, with plastic surgery reconstruction or skin grafts if necessary. Today's non-melanoma
skin cancer patients have good reason to hope for total cure with therapy, without
being disfigured.
This is the full transcript, offered freely in the spirit of internet sharing, of CancerAnswers' report on Skin Cancer Treatment. Much more, including latest additional treatments for Skin Cancer can be found on our order page. Thank you for using CancerAnswers as your information resource.
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ADDITIONAL TOPICS
Acute Leukemia
Anal Cancer
Bladder Cancer
Bone Cancer
Brain Cancer
Breast Cancer: Early
Breast Cancer: Advanced
Cartilage Cancer
Cervical Cancer
Chronic Leukemia
Colo-rectal Cancer
Esophagus Cancer
Fat Cancer
Gall-Bladder Cancer
Hodgkin's disease
Kidney Cancer
Larynx Cancer
Liver Cancer
Lung Cancer
Lung "small cell" Cancer
Lymphoma
Melanoma
Mesothelioma
Mouth Cancer
Multiple Myeloma
Muscle Cancer
Muscle and Fat Tumors
Nasal Cavity Cancer
Nasopharynx Cancer
Ovarian Cancer
Pancreas Cancer
Penile Cancer
Plasmacytomia
Prostate Cancer
Skin Cancer
Stomach Cancer
Testicle Cancer
Thyroid Cancer
Tongue Base and Tonsil
Cancer of Unknown Origin
Uterine Cancer
Vaginal Cancer
Vulvar Cancer
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