Skin Cancer

1. Skin Cancer What to look for and how to prevent it Emily Louise Keimig MS MD Clinical Instructor Department of Dermatology

2. Objectives Identify risk factors for skin cancer Discuss the three most common types of skin cancer Discuss prevention Vitamin D

3. 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

4. Structure of the Skin

5. Basal Cell Carcinoma

6. Basal Cell Carcinoma 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 BCC

7. Basal Cell Carcinoma Dome-shaped growth Patch Shiny pink or red May have slight scale Common on trunk Grows slowly May be mistaken for a patch of eczema Signs and Symptoms Visible blood vessels Pink or skin colored May have flecks of brown or black May flatten in the center Bleeds easily Crusting and oozing

8. Basal Cell Carcinoma Scar Non-Healing Sore Bleeds easily Won’t heal or heals and then returns Oozing and crusting Sunken center Visible blood vessels Signs and Symptoms Waxy feeling Hard Pale-white to yellow color Looks like a scar Difficult to see the edges

9. Basal Cell Carcinoma 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) Risk Factors

10. Basal Cell Carcinoma 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 Detection and Treatment

11. Actinic Keratosis

12. Actinic Keratosis 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 AK

13. Actinic Keratosis Rough patch on the skin Persistently dry lips AKA actinic cheilitis Signs and Symptoms May be painful when rubbed May itch or burn

14. Actinic Keratosis May grow quickly and look like a horn May have a tan or brown color Signs and Symptoms

15. Actinic Keratosis 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 Risk Factors

16. Actinic Keratosis Evaluation by dermatologist for any suspicious lesions Cryotherapy or liquid nitrogen therapy Field treatment Medicated creams Imiquimod 5-Fluorouracil Diclofenac Photodynamic therapy (PDT) Detection and Treatment

17. Squamous Cell Carcinoma

18. Squamous Cell Carcinoma 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 SCC

19. Squamous Cell Carcinoma Rough bump or lump on the skin Dome shaped crusted bump Signs and Symptoms

20. Squamous Cell Carcinoma Sore that doesn’t heal Bowen’s Disease Squamous Cell Carcinoma in situ Flat Reddish Scaly patch Grows slowly Signs and Symptoms Or heals and then returns

21. Squamous Cell Carcinoma Involving the nail Involving the lip Signs and Symptoms

22. Squamous Cell Carcinoma 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 Ulcer or sore that has been present for years Suppressed immune system Papillomavirus (HPV) infection X-rays for acne Risk Factors

23. Squamous Cell Carcinoma 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 Diagnosis and Treatment

24. Melanoma

25. Melanoma 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 Statistics

26. Melanoma Signs and Symptoms • Anyone can develop melanoma • Look for the ABCDEs of melanoma • Asymmetry • Border • Color • Diameter • Evolving

27. Melanoma Melanoma Normal Mole Asymmetry http://www.health.com/health/gallery/0,,20723732_6,00.html One half is unlike the other half Two sides should be mirror images of one another May be different in shape or color

28. Melanoma Asymmetry

29. Melanoma Melanoma Normal Mole Regular Smooth Discrete Border Irregular Scalloped Poorly defined http://skincancer.dermis.net/content/index_eng.html

30. Melanoma Border http://skincancer.dermis.net/content/index_eng.html

31. Melanoma Melanoma Normal Mole One color Color Varied Multiple colors Tan, brown or black White, red, or blue http://skincancer.dermis.net/content/index_eng.html

32. Melanoma Color http://skincancer.dermis.net/content/index_eng.html

33. Melanoma Melanoma Normal Mole Can be over 6mm Should have all other features of a normal mole Diameter Usually larger than 6mm in diameter Can be smaller! May have other features mentioned earlier in addition to size http://skincancer.dermis.net/content/index_eng.html

34. Melanoma Melanoma Normal Mole Stable over time Evolving Looks different from other moles “ugly duckling” Changing in size Changing in shape Changing in color

35. Melanoma Under the Nail http://www.skindermatologists.com/p/nail.html

36. Melanoma Mouth http://www.oralcancerfoundation.org/facts/rare/om/

37. Melanoma Hands and Feet http://imaging.ubmmedica.com/cancernetwork/journals/oncology/images/unwinding/200408-1192-6.gif

38. Melanoma 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 Risk Factors

39. Melanoma 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 Diagnosis and Treatment

40. Melanoma 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 Prognosis

41. How to Prevent Skin Cancer Sun avoidance Sunscreen use Sun protective clothing

42. 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

43. Sunscreen 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 General Facts

44. Sunscreen 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 What to look for and how to apply

45. 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

46. Indoor Tanning

47. 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

48. Indoor Tanning 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 Risks

49. A Word About Vitamin D

50. 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