Skin Cancer Reaching Epidemic Levels

Awareness, Screening May Help Reduce Cases

doctor's visitWhile dark, unsightly moles may trigger skin-cancer scares in patients, most are likely to dismiss the signs that signal the majority of cutaneous malignancies. With numbers on the rise, physicians can take steps to help identify cancers and encourage early treatment.

Melanoma, basal cell and squamous cell carcinomas represent 99 percent of all skin cancer cases, with the majority being non-melanoma skin cancer (NMSC). With 1 in 3 fair-skinned Americans at risk of developing skin cancer in their lifetime, the cost to treat NMSC ranks 5th among all cancers, which is remarkable given that they are almost always treated in an outpatient setting.

“The incidence of skin cancer in the U.S. has reached nothing short of epidemic proportions with no sign of relent,” said dermatologist Sherrif F. Ibrahim, M.D., Ph.D. “The number of non-melanoma skin cancers treated annually is approaching 3 million, far exceeding that of all other human malignancies combined.”

According to Ibrahim, it’s a myth that people living in northern latitudes are not affected by this epidemic. “The Greater Rochester area has not been spared from the inundation of skin cancer. Our population of farmers, golfers, and snowbirds contributes to an abundance of skin cancer in our community,” he said. “Our Department of Dermatology sees thousands of cancers annually, with the Division of Mohs Surgery treating a large percentage of cases from across upstate New York.”

Surgical treatments effective

Many treatment options exist for NMSC, with surgical management preferred for the treatment of localized melanoma and national guidelines indicating the width of surgical margins needed for tumor removal. For small or superficial cancers located on the trunk or extremities, treatments such as curettage and electrodesiccation, photodynamic therapy, cryotherapy and topical immune modulators yield an acceptable cure rate.

However, NMSC most often occurs on the head and neck, encroaching upon vital structures such as the eyes, nose or lips, and requires more delicate surgical extirpation. For these tumors, intra-operative margin control using Mohs micrographic surgery has the highest cure rate.

Named after its founder and originator, Frederic E. Mohs, MD, the dermatologist performing this surgery acts as surgical oncologist, pathologist, and reconstructive surgeon for each case, Ibrahim explained. Patients typically spend the majority of the day in the office as the obvious tumor is initially removed under local anesthesia with a very narrow margin (1 to 2 mm) and a full peripheral margin analysis is performed while the patient waits. The sections removed are mapped in meticulous fashion to allow the Mohs surgeon to pinpoint the location of any residual tumor, allowing for maximal preservation of normal tissue and cure rates approaching 100 percent. Once clear margins are obtained, reconstruction of the defect is performed on the same day.

Awareness can lead to early treatment

Often, by the time patients arrive for treatment, they have larger, more invasive tumors that require more extensive surgery. Unaware that the growth they have had for 2 to 3 years is not a mole, the skin cancer grows in a locally destructive fashion. Furthermore, those who develop one NMSC are at significantly higher risk for additional cancers.

“Practitioners in essentially every specialty can take simple steps to inform their patients about skin cancer,” said Ibrahim. “Lessons can be drawn from countries such as Australia and New Zealand, where rates of skin cancer surpass those in the United States but have decreased from their peaks as a result of intensified public awareness campaigns. These nations integrate sun protection at the elementary school level with covered outdoor areas at schools and ubiquitous public service announcements. It is evident from these efforts that education regarding the risks of sun exposure instituted at a young age is essential, with the early introduction to the use of sunscreens and protective clothing.”

Ibrahim stresses teaching patients to perform self-skin examinations, alerting them to the signs and symptoms of what might be a skin cancer, and encouraging them to have suspicious lesions evaluated in expedited fashion.

“We must applaud the recent efforts at legislation to prevent the access to indoor tanning booths by minors, much as we have done for other health concerns such as tobacco and alcohol, and support the use of sunless tanning agents. As physicians, we must deflate the hype that the sun is a safe and necessary source of vitamin D when oral supplements are readily available and common fortified foods exist.

“Lastly, the importance of performing a quick skin check as part of our routine physical examinations cannot be underestimated, particularly for patients in more rural locations. From scalp to toes, this can take less than one minute and potentially prevent the significant morbidity that results from neglected skin cancers,” he said.

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