Cancer Answers: Protecting Against Skin Cancer, May 2, 2010

Dr. David Leffell, Protecting Against Skin
Cancer
 May 2, 2010Welcome to Yale Cancer Center Answers with Dr. Ed Chu and
Dr. Francine Foss, I am Bruce Barber.  Dr. Chu is Deputy
Director and Chief of Medical Oncology at Yale Cancer Center and
Dr. Foss is a Professor of Medical Oncology and Dermatology
specializing in the treatment of lymphomas.  If you would like
to join the conversation, you can contact the doctors
directly.  The address is canceranswers@yale.edu
andthe phone number is 1888-234-4YCC.  This evening
I will be sitting in for Ed and Francine and I am pleased to
welcome Dr. David Leffell to the program.  Dr. Leffell is the
David Paige Smith Professor of Dermatology and Surgery and Deputy
Dean for Clinical Affairs at Yale School of Medicine.Barber
In all your years of doing this, what is it that you have found is
the best way to deliver the message as to how serious skin cancer
is?Leffell
 I think we have learned that scaring people doesn't work. 
When you are trying to communicate a public health message, if it's
framed in a negative, we all shut down.  It's important to try
to discuss skin cancer and the causes of skin cancer, which are
largely preventable, in a way that listeners can latch on to and do
something about.  I think we have been successful in
communicating that most skin cancers are caused by ultraviolet
radiation from the sun, and as a result I think most people know
that sun protection is important.  The elements of a sun
protection program are probably not as obvious or easily
understood.  In addition, any step in preventative medicine
that you are going to take involves effort, and if you are going to
take that effort there has to be a sense that the payoff is
there.  For patient's that have had a lot of skin cancers, or
for patient's that have had skin cancers at a young age, they get
it.  They don't want to see me, they don't want to see my
nurses, they want to stay away from dermatologists and the best way
to do that is to actively engage in a sun protection program. 
Another area that I think has been difficult to communicate is the
types of skin cancers, because not all skin cancers are the
same.  There are really two basic categories, the first is
melanoma and melanoma is a cancer of the pigment producing cells in
the bottom layer of the top layer, or epidermis, of the skin. 
Melanoma is relatively well known to people because, unfortunately,
in some cases it can be quite serious and the cancer, if not
effectively treated, can metastasize, spread, and lead to
death.  However, it should be remembered that the majority of
melanomas when diagnosed early are largely treatable and those are
the cases you don't really hear about.  Importantly, early
diagnosis is your best defense against melanoma and we can talk
about various points and key elements of diagnosis later on. 
The other category of skin cancers, which by far is the more common
type of skin cancer, is non-melanoma skin cancer.  Included in
this category are two types of skin cancers that listeners may be
familiar with, basal cell cancer and squamous cell cancer. 
Basal cell cancer occurs in about a 3:1 ratio compared to squamous
cell cancer. Both of them are caused by ultraviolet radiation from
the sun that causes mutations in the cells of the skin that lead to
uncontrolled growth.  Basal cell cancer occurs on sun exposed
areas, primarily the face, backs of the hand, and the V of the
chest in women, and the good news is that basal cell cancer does
not spread in the blood stream by and large and is easily treated
in a variety of methods.  Squamous cell cancer is4:18 into mp3 file 
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 similarly a skin cancer that occurs on sun exposed areas and is
easily treated with a variety of methods.  However, a small
percentage of squamous cell cancer can metastasize, in other words
spread to other parts of the body and cause death in that fashion,
but it's a very small percentage.  It's interesting because
when patients come in for a consultation and have a basal cell
cancer, they say, 'That's a good one right doc? That's a good one
to have?'  Well of course none of them are great to have, but
if you have to have a skin cancer, basal cell cancer and even
squamous cell cancer, which for the most part are easily treated,
are conditions that we can effectively manage. When you get a
diagnosis of skin cancer, it becomes a jumping off point for your
physician, your nurse, and others to start to educate you about sun
protection.Barber
Full disclosure, I am a patient of yours, and I think in part it
was from producing this show and having heard you speak about the
dangers of skin cancer and the preventative measures that are
possible that I became aware.  Before we go into how you
diagnose and treat skin cancer, let's back up just a second and go
to the two things that I have heard you talk about at one point or
another, and one of those things was powerful enough for me to go
in and start getting my annual checkup every year, the full
body.  I have heard you talk a lot about protection, wearing
the right kind of clothes and covering up, and that's probably very
hard for you to get your patients to do as much as you would like
to see, but that's obviously very important, and the second part
are those annual screenings.  Speak for a little bit about
each one of those and their importance.Leffell
 Science is a great thing, in fact when it comes to disease we know
much-much more now then we ever did before, but we still don't know
as much as we need to know, and that's speaking generally. 
When it comes to skin cancer, we not only understand what the
environmental agent is that causes skin cancer, namely ultraviolet
radiation from the sun, but we also understand some of the genetic
steps that take place leading to the multiplication of these
abnormal cells, and why is this important, I am actually in fact
answering your question, though it seem like I am not.  When
we understand what causes a disease and when there are steps we can
take to interfere with the cause of the disease, we are in a much
stronger position to practice healthy habits.  We are all
eager to eat well and not be overweight and ensure that we exercise
and do a whole range of things that science has shown can be
beneficial at a population level, so when it comes to skin cancer
you want a program of sun protection, you don't want to go crawl
under a rock or hide in the basement, you want to enjoy life, you
want to be active and that usually is best executed outdoors. 
So what's the strategy to prevent skin cancer while at the same
time enjoying life?  I think it is possible to pursue the
following steps; number one, you want to avoid the sun during peak
hours between ten and four, that doesn't mean live in a basement
between 10 and 4, it means avoid the sun during those peak hours,
stay in the shade and certainly don't actively schedule your kids'
ball games at high noon, only shootouts should take place at high
noon.  In addition, you want to wear sun protective clothing;
you want to wear a brimmed hat, not a baseball cap, as attractive
as they may be, you want to wear a brimmed hat. This is a problem,
golfers obviously, and tennis players,8:38 into mp3 file 
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 people that are in active sports and are concerned about how they
look, at least for men, it's a challenge, but patients that have
had skin cancer would rather wear a hat then see me and are able to
put into action that aspect of sun protection.  Remember, the
majority of skin cancers are on the head and neck, so a brimmed hat
that protects the ears as well is very important.  There is
now sun protective clothing you can wear that looks like normal
clothing, it doesn't look like a prison uniform as they used to,
and they have a tight weave that is chemically treated and they
actually are UPF rated, meaning ultraviolet protective factor
rated, so that you can get a sense of how much protection you are
getting; and of course you want to use sunscreen.  Sunscreen
has evolved dramatically over the years.  I am a consultant to
Coppertone and work with their scientists on the development of
sunscreen products and ways to make them more attractive to
individuals because we know that using sunscreen is a
nuisance.  There are now continuous spray products that go on
more easily and leave your hands un-sticky, but the bottom line is
that there is a huge amount of benefit provided by sunscreen
because regardless of the chemical reaction that takes place, it
does prevent the damaging ultraviolet rays from injuring the
skin.Barber
One of the best innovations in our time, I believe, is the spray-on
sunscreen, and I say this as the father of four.Leffell
 It is great when you have little children, you just line them up
and spray them as they run out the door, but all kidding aside, I
think that there will be newer technologies coming down the
pike.  People wonder if there will ever be a pill that you can
take that will provide the type of protection and it's certainly
theoretically possible.  We can talk later about various
innovations in terms of sun protection, but the reality is that
avoiding the sun during peak hours, wearing sun protective clothing
including a brimmed hat, and the regular use of sunscreen and
reapplying it every couple of hours while you are active outdoors,
are all key components of an important sun protection program.Barber
When I was a kid we didn't know as much, and I had blistering
sunburns as a child and it reached a point where I said, you know,
I should be concerned about that and that's when I decided to go in
for the full body exam.  Talk a little about the benefits of
doing that regularly.Leffell
 As I mentioned, melanoma, when diagnosed early, is most
treatable.  Similarly basal cell cancer and squamous cell
cancer when diagnosed promptly are easily treated by a variety of
means.  The byword here is early, and the way you can maximize
the chance of having an early diagnosis of skin cancer is to first
know your own skin, and secondly, have regular full body skin exams
by a dermatologist or someone else trained in skin lesions. 
The important point is that the skin exam should be thorough, it
should involve looking through the scalp, for those fortunate
enough to have hair, and otherwise a straightforward exam
suffices.  It should involve looking in every nook and cranny
all the way down to the soles and between the toes.  And why
is this important?  Well while12:40 into mp3 file 
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 it is true that the majority of non-melanoma skin cancer occurs on
sun exposed areas, melanoma can occur anywhere, it can occur in the
groin, it can occur on the palm, it can occur behind the ear. 
Very often when I describe the strategy for an annual skin exam,
usually to the spouse of a patient that is in the room, the spouse
will say, "Well, I know I don't have anything, I don't need to go
to a dermatologist,' and while it's great to be that confident, in
reality, it's probably a more helpful strategy to have an annual
full body skin exam. More importantly than that, since so many of
the lesions that are diagnosed are actually identified first by the
patient, I think you have to follow the rule of know your skin, so
on a regular basis, whether it's every month or every couple of
months, or quarterly, look over your skin and have your spouse or
partner look over the areas that you cant see, because you are
going to number one, identify things when they first change and the
only way to know that you are identifying them as they change is to
know what the baseline was. We talk about the warning signs of melanoma the A, B, C, Ds, but
in reality my consideration is that the most important factor is
the patients own sense.  People have a sixth sense about their
own skin and invariably patients will come in and say, 'I just
don't like this thing, there is something weird about it, and we
teach our residents, our dermatologists in training, that when a
patient is concerned about a lesion, even if it looks to us like
nothing especially concerning, it needs to be biopsied.  You
need to have respect for the patient's own sense of their own
body.  Remember, a dermatologist only sees the patient for a
few minutes at whatever intervals, whereas you, the patient, live
with your skin everyday.  At some point, you may get overly
cautious, but then that's the job of the dermatologist to educate
about what you should be concerned about and what is normal. I
should mention, I have a book that I wrote in 2000 called Total
Skin, which was really intended to be a home reference guide
for skin that would hopefully be reliable, reputable, and
comprehensive and I recently was able to post it on the web and it
is there free of charge for any one that wants to go to
totalskinmd.com. You can also reach it through the Yale site, but
the point I am making is that there are full color plates there
that can give an idea of what certain things look like, and while
they are not intended to be comprehensive because everyone has
different skin and things can look different, the same thing can
look different in different people, but it at least gives you some
sense of what to look for.Barber
That is terrific, and that's exactly what brought me to you the
first time, I heard you talking about that exact same thing and I
thought, well I feel something, and then I went in and it was
nothing.  So I think that's an important thing too.Leffell
 Right.Barber
Let's talk some more about your book when we come back, and about
if a diagnosis of cancer is made what steps are available to a
patient at that point.  We are speaking with Dr. David
Leffell, the author of the aforementioned
Total Skin. We are going to take a short
break, we will be right back.16:32 into mp3 file 
http://www.yalecancercenter.org/podcast/may0210-cancer-answers-leffell.mp3Barber
Welcome back to Yale Cancer Center Answers.  I am Bruce
Barber, and I am very pleased to be joined today by Dr. David
Leffell, David Paige Smith Professor of Dermatology and Surgery and
Deputy Dean for Clinical Affairs at Yale School of Medicine. We are
talking about skin cancer.  Before the break we talked about
the fact that you released your book online for free, Total
Skin.Leffell
 That's right.  The book came out in 2000 and I decided that
if I felt it was important enough to write in the first place, it
was important enough to make more broadly available and it's now
posted on the web and there is completely free access.  I
don't know if it can be downloaded into a Kindle, I haven't looked
that far, but it's at totalskinmd.com and it's also accessible
through the dermatology website at yale.edu.Barber
And it will help you get a handle on maybe what you are seeing on
your body.Leffell
 It will, the book covers many things other than skin cancer, but
it's written in a way that's intended to be engaging and with a lot
of extraneous information provided to lubricate the drier material
that might otherwise turn people off.Barber
Let me ask this, you are obviously doing some pretty amazing stuff
at Yale.  There are always interesting things going on. 
Before we get into a more broad discussion of how you diagnose and
treat skin cancer, is there any one thing right now that's got you
really excited about what's going on in the field?Leffell
 In 1996, Allen Bale, along with a group of us, discovered the skin
cancer gene and since that time a lot of groups around the world
have continued to tease apart the mechanics of the genetics of skin
cancer and we are gearing up to do a research study into a molecule
that we think may play a19:47 into mp3 file 
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 role in inhibiting skin cancer.  It's a phase 1 study, which
involves a small number of people and is intended to look at the
safety of the particular compound, but this is just an example of
how far we have come.  When I was in medical school in the
very early 1980s, skin cancer was really not as common as it is
now.  When I was in residency 25 years ago, the treatments
available were relatively straightforward and simple.  Over
the past 25 years, a surgical approach called the Mohs technique
has really become the gold standard for many skin cancers. 
That's an office procedure where the skin cancer is removed by a
dermatologist layer by layer and then reconstruction or plastic
surgery is done if necessary, but it is still surgery.  The
Holy Grail here, since we understand the core genetic mechanisms,
is to develop a treatment that you can use topically or orally that
interferes with the mistake the body has made, or the mistake that
ultraviolet radiation has induced, so that the skin can start
behaving better.  Having said that, over the past 10 to 15
years, there has been an innovative treatment developed that has
been generally available for treating skin cancer.  It's
actually a topical medication that was originally
approved for treating warts, genital warts in
fact, and it is a chemical or a compound that stimulates the immune
system of the skin to release compounds that are anticancer in
nature.  The compound, the medication, is called imiquimod,
and its brand name is Aldara.  Fortunately, a generic version
has just been released and it's applied to the skin on a regular
basis depending on the regimen recommended by your doctor.  It
stimulates an immune reaction.  The skin does get red,
inflamed, and irritated but that's a good sign that means that the
compound, the medication, is working and in so doing it actually
will destroy cancer cells.  Now, it's not intended for every
type of skin cancer but in properly selected cases we have been
quite successful at avoiding surgery, which as I said earlier, is
of course our ultimate goal.Barber
Let's walk through the procedure by which someone would discover
they have skin cancer, and then how you would decide to treat that
patient.  I would imagine most people end up in your office
having been referred by a primary care physician?Leffell
 Actually, we at the dermatologic surgery program see patient's
only by physician referral, and the majority of physicians that
refer to us are dermatologists who have made a diagnosis of skin
cancer in their patient's.  The majority of the skin cancers
are treated by the dermatologist using a variety of straightforward
surgical means that are performed in the office with just local
anesthetic.  However, for certain specific cases, the Mohs
technique, named after Frederic Mohs who developed
it at the University of Wisconsin, is considered to be advantageous
for the patient.  There are other approaches to skin cancer,
again depending on the type of the skin, its location, the health
of the patient, a whole range of factors go into the decision
making process.  Radiation therapy is used in some cases for
treating skin cancer.  The important thing is to be guided by
a dermatologist, by your primary care physician who increasingly
are also diagnosing skin cancer, and to not assume when it comes to
treatment that one size fits all.  The patients that we see
of23:53 into mp3 file 
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 course have been referred for consultation because of the
complexity or the challenge of the case, or for the Mohs
procedure.Barber
The thing I hear a lot about in listening to this show when Ed and
Francine are here is the multidisciplinary approach that's being
used at Yale, talk about that a little bit.Leffell
 For example, when we are treating a complex skin cancer of the
scalp, we will remove it with the Mohs technique and then our
plastic surgery colleagues may be involved in reconstructing the
area, and then our radiation therapy colleagues may be involved in
providing postoperative radiation therapy if the cancer is
considered aggressive or extensive.  In addition, the teamwork
concept really starts at the level of the doctor interacting with
the nurses, the residents, the fellows, and all of the people that
come together to provide the highest quality, and most
sophisticated care.Barber
What is your advice to someone who has just gotten this diagnosis?
I mean you see this everyday, you are probably pretty comfortable
with the range of treatment options, but it's got to be very
difficult for somebody to hear the words 'skin cancer'.Leffell
 It is, and I think that we as treating physicians don't take
anything for granted and don't make any assumptions about what
people know or don't know.  What we assume is that it's a
diagnosis that is very worrisome and in some cases extremely
worrisome to people so we spend time discussing it.  It's not
uncommon to have the patient come in with a lesion on their arm and
they will tell us that they are convinced it's skin cancer and the
reason they know is because they went on the web and they have
diagnosed it.  I would recommend that you not use the web for
diagnosis, use it to learn about things as we talked about earlier,
but make sure of the source of your information.  Having said
that, aside from doing your own judicious reading, rely on and have
confidence in your dermatologist or your primary care doctor. 
The type of skin cancer whether it's a basal cell cancer or
squamous cell cancer, is important.  If it is melanoma, it's a
bit of a different story because there are other factors that go
into the evaluation and treatment and at Yale, we have an
interdisciplinary melanoma program, a tumor board, where cases are
presented and recommendations are made about treatment. 
Remember that I said the majority of melanomas are diagnosed very
early and are easily and readily treatable by simple surgical
procedures, but there are criteria that one monitors in melanoma
that can have implications for a different approach. For example,
an evaluation of the lymph nodes, whether it is felt that the
melanoma is advanced and it's necessary to consider enrollment in a
clinical trial, all of these are factors that come into play and I
think it's important to find a physician who is willing to sit down
with you and talk to you about the diagnosis because there is, as I
have conveyed in this conversation, such a wide range of
seriousness or potential seriousness from basal cell cancer, all
the way to melanoma.27:53 into mp3 file 
http://www.yalecancercenter.org/podcast/may0210-cancer-answers-leffell.mp3Barber
In the minute or so that we have left, let's go back over the two
key things we started off with, the annual skin exam, and just
protection.  My last question is at what age should somebody
start doing those annual skin exams? Is it the kind of thing where
if you haven't had one it's never to late to start, or is there a
specific age that you think of?Leffell
 That's a great opportunity to talk about the risk factors for skin
cancer.  People that have fair skin that burn easily, for
example that have blonde, red, or strawberry hair and blue, gray,
or green eyes, people that have had blistering sunburn at some
point in the past, and people that have a family history of
melanoma, all of these are individuals that are at increased risk
for skin cancer in general.  It's not a bad idea for people
that fit that profile to have a full skin exam when they become
adults.  If there is a strong family history of melanoma, then
the pediatrician will be guiding you about the proper evaluation of
children.  But in general, full body skin examinations should
start when you are an adult and I think should be based on your
family history and the extent to which those exams are helping
educate you about what to look for.Barber
That is great, and these have been such great points that you have
made.  I am so appreciative of you taking the time and I hope
somebody else is trigged in the way I was to go see their
dermatologist and do a great job taking care of their skin. 
Dr. David Leffell is the David Paige Smith Professor of Dermatology
and Surgery and Deputy Dean for Clinical Affairs at Yale School of
Medicine.If you have questions or would like to share your comments,
visit yalecancercenter.org where you can also subscribe to our
podcast and find written transcripts of past programs.  I am
Bruce Barber and you are listening to the WNPR Health Forum on the
Connecticut Public Broadcasting Network.