Skin cancer awareness is essential as the sunny summer months approach. Being aware of skin cancer types and how they are identified and treated is necessary to help protect people's health.

According to the American Academy of Dermatology, around 9,500 people are diagnosed with skin cancer daily in the United States. It is predicted that one in five Americans will develop skin cancer in their lifetime.

While some people may think that a tan is radiant or that a one-off sunburn isn't a big deal, UV rays can cause severe damage to the skin's DNA. The real risk is that too much sun exposure can lead to severe skin cancers.

If cancers are not detected early enough, there is a risk that they could spread and, in some cases, lead to death.

What is skin cancer?

Skin cancer is a general term used to describe the growth of unusual and abnormal cells in the outermost layers of the skin. These abnormal cells may develop due to damage to the skin's DNA. This damage leads to mutations that form into malignant (cancerous) tumors such as those found in the main kinds of skin cancer.

What are the skin cancer types?

The four main skin cancer types include:

1. Basal cell carcinoma: uncontrolled basal cell growth of the epidermis.
2. Melanoma: comes from melanocytes, the cells that give skin color.
3. Squamous cell carcinoma: uncontrolled growth of abnormal squamous cells of the epidermis.
4. Merkel cell carcinoma: a rare, yet aggressive, form of skin cancer that causes nodules or tumors that appear flesh-colored, purple, blue, or red on the skin.

People need to be aware of skin cancer variations and what they might look like to seek early treatment. Fortunately, with early identification, many skin cancers can be treated successfully.

What causes skin cancers to form?

Skin cancers are caused by damage to the epidermis's DNA. The two primary causes in America are damage from ultraviolet (UV) light from the sun and the use of UV tanning beds. However, each kind of skin cancer is different and may have varied causes and risk factors.

Basal cell carcinoma (BCC)

Basal cell carcinoma is the most common type of skin cancer, affecting around 3.6 million people in the United States each year. It is the uncontrolled and abnormal growth of the basal cells located in the epidermis.

Fortunately, this cancer is usually easy to spot on the face, ears, neck, shoulders, back, and scalp (areas that regularly see the sun). While locally damaging, BCC is usually able to be removed. Rarely the tumors may metastasize and spread, in which case there is a potential for the cancer to be fatal.

Melanoma

Melanocytes create skin color, which are affected in melanoma cases. Typically melanomas look like moles, although they can also be colorless, which is the case with flesh-colored amelanotic melanoma. Melanomas can appear anywhere on the body.

Data from 2022 suggests that around 197,700 cases of melanoma are expected in the United States each year. Around half of those cases will not be invasive, but the other half are likely to be invasive. Invasive melanoma goes deeper past the epidermis and into the dermis.

Melanoma is the most dangerous out of squamous cell, basal cell, and melanoma cancers. However, they are generally curable when caught in the early stages before spreading.

Squamous cell carcinoma (SCC)

Squamous cell carcinoma affects the squamous cells, making them grow abnormally and uncontrollably. Usually, this cancer is linked to excessive UV exposure from the sun or tanning beds. As the second most common form of skin cancer, around 1.8 million people in America receive a diagnosis annually.

While SCCs can grow and spread quickly, early identification can help. Areas most likely to have SCCs include the ears, scalp, face, hands, and neck.

Merkel cell carcinoma

Merkel cell carcinoma is aggressive but rare. It does tend to spread to other parts of the body quickly without treatment.

This kind of cancer generally appears as a fast-growing, painless nodule, or tumor, on the skin. The nodule may be skin-colored or may appear in shades of red, blue, or purple. They can occur anywhere, but they are most likely on the face, head, and neck. Merkel cell carcinoma is unique because it doesn’t always appear in sun-exposed areas of the skin. It's also much more likely in the elderly and those with immune deficiencies.

Merkel cell carcinoma may be caused by exposure to UV radiation, but it's not the only cause. Approximately 8 out of 10 people with this condition have the Merkel cell polyomavirus, a common childhood virus. As a result, it's most common in the elderly and those with weakened immune systems in which the virus can propagate and suppress the genes that control the growth of tumors.

Identifying and staging skin cancer

Skin cancer can be treated in multiple ways depending on the type. To begin with, patients go through a full body examination. The exam gives the provider a better idea of what testing needs to be done to confirm the type of cancer.

A biopsy is performed to remove any suspicious spots or skin for testing. This biopsy will determine if the skin is cancerous and the type of cancer that is present.

A biopsy can't determine the extent of the skin cancer, but it can give patients and their providers more information on how pervasive the cancer may be. For example, someone with basal cell carcinoma is unlikely to have further complications from the cancer following removal because this type rarely spreads. However, someone with Merkel cell carcinoma may need further testing to determine if the cancer has spread elsewhere.

After identifying the type of cancer, it is assigned a stage category. Staging may depend on where the cancer has formed and how deeply it has penetrated or spread around the body.

The stages of skin cancer are:

• Stage 0 (carcinoma in situ)
• Stage I
• Stage II
• Stage III
• Stage IV

The stages are progressive. Stage 0 is the least problematic, while stage IV means that the cancer has spread beyond the original location and may now be in the lymph or other areas of the body. Here's more detailed information on each stage.

Stage 0 (carcinoma in situ)

Stage 0 is when the melanoma or cancer may not have spread beyond the epidermis yet. Since the cancer is confined to a small area, removing this cancerous area of the skin is more manageable.

Stage I

Stage I is when the disease is localized. It may have spread further but is still thin.

Stage II

Stage II refers to a localized disease thickened compared to Stage I.

Stage III

Stage III takes place once the cancer has spread to the lymph nodes. At this point, it is easier for it to travel throughout the body.

Stage IV

Stage IV is the final stage and when the melanoma may spread to other organs in the body. Stage IV is the most invasive stage and must be addressed as quickly as possible, as it has the worst prognosis.

Prevention advice from Dr. Patrick Blake

Dr. Patrick Blake has been working with patients to address skin cancer and has some excellent tips that people can follow to know when they need to get checked out:

1. New moles in adulthood are uncommon, so it's a good idea to have a dermatologist check it if one forms.
2. If any skin area hurts or bleeds persistently, this is worth looking at during an exam.
3. Rapidly developing spots or growths could be cancerous and should be seen by a professional.

While it's less common, people can get skin cancer at any age. Dr. Blake has seen basal cell carcinomas in people as young as 19. When spotted early, it is possible to have skin cancer removed. Even later stages may respond to treatment, so it's valuable to identify the cancer type and get it staged quickly. Mohs surgery is one option that Dr. Blake provides for patients dealing with skin cancer.

What is Mohs surgery?

Mohs surgery is a different approach to removing skin cancer. Instead of performing a standard cut in routine surgery, you try to scoop out the specimen and then change the angle you're viewing by flipping it.

"The main upside is that it lets you see the edges," said Dr. Blake. "With Mohs, you take 99% of the edge compared to around 5% with the traditional method. Mohs gives you a much higher cure rate, close to 99%, compared to around 90% for any regular excision."

Mohs is most commonly used to treat squamous and basal cell carcinomas, but can also be effective on early melanomas. In areas where the skin is limited, Mohs surgery is also beneficial because it helps you save more skin. For example, the face is a common area for Mohs surgery unless a patient expressly states they don't want it.

The limitation of the surgery is that it does take longer than a traditional excision. Usually, patients will need to stay in the office for a few hours, so it's not a quick in-and-out technique.

Dr. Blake began performing Mohs surgery after being exposed to this technique during his residency. The Mohs surgery helps him make sure that there is no cancer remaining. This ensures the cancer can no longer continue to spread when performing skin grafts or removing cancerous areas of the skin. Mohs is unique because results on all cancer being removed are provided within an hour,  whereas a routine excision can take days in a standard lab.

The typical workflow of a Mohs surgery includes Dr. Blake:

• Taking photos
• Cleaning the area
• Numbing the area
• Taking a specimen

Then, the technician freezes the sample, placing some stains on it. They'll also cut it, giving the doctor back samples to review under the microscope.

Why does this process work so well for patients? Instead of waiting to find out if they have to return for further surgeries, they are able to be healed all in one session. The doctor is able to determine if all cancer has been removed on the spot, rather than a few days after a sample has been sent out for review. The patient stays at the office and can continue to have additional sections of the skin cut away until it is truly free of cancer.

Then, once all cancer is removed, the area is stitched and closed.  

What are the best tools to fight skin cancer?

The best tool to fight skin cancer is prevention. Dr. Blake gives the following suggestions to stay protected:

1. Avoid UV rays by staying out of the sun and wearing the right sunscreen. Tanning beds should be avoided, too, since these direct a large amount of UV radiation on the skin.
2. Avoid smoking, as smoking significantly increases the risk of skin cancer. In one study, smoking was linked to making melanomas more fatal. Why? Smoking may decrease the immune system's ability to fight cancer.
3. Get to know the UV index. If the index is over three, it's essential to wear sunscreen and protective clothing, and generally avoid the sun.
4. Wear sunscreen daily on the neck, face, and ears as well as other sensitive areas.
5. Avoid planning activities around the sunniest parts of the day, between 11 a.m. to 3 p.m., when sunburn is more likely.

Remember, it doesn't take a sunburn to cause skin cancer. Any UV exposure can damage the skin's DNA and eventually lead to skin cancer in some people.

Learn more with Portrait

Share these tips with your patients, and encourage them to get started with skin cancer prevention early. If you’re interested in learning more about Dr. Blake and Portrait’s Collective, sign up here.

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