Skin Cancer Awareness

Dr. Michael Girardi, Skin Cancer Awareness
May 16, 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
Francine welcomes Dr. Michael Girardi.  Dr. Girardi is an
associate professor of dermatology and associate clinical director
of the immunology and immunotherapy research programs at Yale
Cancer Center.  Here is Francine Foss.Foss
Michael, we are here today to talk about non-melanotic skin
cancers.  Overall there are two different types of skin
cancer, melanoma and non-melanotic.  What are these
non-melanotic skin cancers?Girardi
Non-melanoma skin cancer is kind of a catch-all term for all the
other skin cancers, among the most common of which are basal cell
carcinoma and squamous cell carcinoma. These are the most common
cancers in the world, and therefore, they become a particular
problem and concern for patients particularly at risk, and the time
is quite good to think about these and talk about these as we head
into the spring months.Foss
Exactly, and I know that you are going to tell our audience that we
all need to start breaking out our sunscreen now.Girardi
We do, we certainly need to think about it.  The data is
indisputable in terms of sun exposure and tanning salon exposure as
being among the most and biggest risk factors for non-melanoma skin
cancer.Foss
So Michael, reiterating what you just said, that these cancers are
the most common cancers, what is the lifetime risk of say the
average person in the United States to get one of these types of
cancers?Girardi
When we talk about skin cancer in general, and we talk about risk
and how common they are it's in the group of melanoma. We talk
about over a lifetime of about 1 in 70, and this actually seems to
be increasing.Foss
That sounds like a really high number.Girardi
Yes, it's quite high and when we talk about non-melanoma skin
cancer we are talking about two or three times greater for
non-melanoma skin cancers than melanoma itself.2:34 into mp3 file 
http://yalecancercenter.org/podcast/may1610-cancer-answers-girardi.mp3Foss
Can you talk a little bit about risk factors?  Sun seems to be
the biggest risk factor.Girardi
Sun exposure, and there is certainly a fair amount of consideration
for someone's genetics, and so it's again a combination of what
type of genes they have that could predispose them so we often ask
patients about their first-degree relatives, that is parents,
siblings, or children and whether there is a family history of skin
cancer in these patients.  We will ask about basal cell
carcinoma, squamous cell carcinoma, as well as melanoma itself in
the family. Patients who have a family history of skin cancer are
at a far greater risk than people who do not, so clearly there are
genes that predispose patients to skin cancer, and genes that
protect people from skin cancer.  When we talk about risk
factors we have to look at a patient's skin type and that is how
fair they are.  In particular, among the fairest are those
with red hair who freckle at lot, these people are at the greatest
risk of getting non- melanoma skin cancer as well as melanoma
itself.  We also talk about their lifestyle.  What kind
of lifestyle do they have that would give them that kind of sun
exposure?  In particular, in Connecticut, we will think about
tennis players and golfers on one hand, we will think about
farmers, and people who spend most of their time at work outside as
also being at great risk for this.  It runs the gamut of all
different types of people and their sun exposure.  We have to
strongly consider the beach lovers, the sun worshipers and also
sailors in particular are another group in Connecticut that are at
great risk for a lot of sun exposure over years that will
predispose them to skin cancer.Foss
Can you talk about sun exposure in general?  Is there a risk
for younger people who have had sun exposure say for 10-15 years or
so, or is the risk more for people who have had exposure over a
longer period of time?Girardi
The answer is both, and here is how I would break it out.  I
think photo protection has to be on the minds of parents even with
their newborn babies, and the data shows that even single
blistering sunburn substantially increases the risk of a person's
chance of getting melanoma over their lifetime.  So a burn
that causes blisters in childhood actually increases that person's
risk of melanoma for their entire life.  Melanoma seems to be
more of a concern for single or multiple episodes of blistering
sunburn, so this intense hit, even when you are young, whereas
non-melanoma skin cancer seems to be more of a concern with regards
to chronic sun exposure, so people who have been repeatedly exposed
to the sun or tanning salons for that matter.Foss
When we talk about sun exposure, how long and how much sun?6:02 into mp3 file 
http://yalecancercenter.org/podcast/may1610-cancer-answers-girardi.mp3Girardi
That varies tremendously and it varies tremendously because
people's susceptibility varies tremendously from the fairness of
their skin and as we talked about, the genetics of their
protection. So for the most part, you want to completely avoid
getting to a point where you are going to get sunburns, in
particular getting a blistering sunburn, so people need to
determine, based on their skin type and on their family history,
how much sun exposure that really is.  There is actually one
particular downside to too little sun exposure, and you will hear
an argument for sun exposure for vitamin D levels, and in fact
vitamin D is particularly important for the immune system and
functions of the immune system, so patients who are at risk for
skin cancer who are protecting themselves also need to make sure
that they are having adequate intake of vitamin D, or have their
level checked by a primary care physician.  So to answer your
question, it's almost like saying how much smoking is too much, but
we can't avoid sun exposure completely because there is a downside
to that.Foss
Basically if you are the type of person who can go out there and
not in an hour develop any kind of sunburn at all, are you okay to
go outside without sunscreen?Girardi
No, I would not say that. I would say that you still need to wear
sunscreen and minimize your exposure.Foss
Okay.Girardi
The kind of guidelines you want to follow is when you can, you want
to avoid most of the mid-day sun because these are the direct rays
most likely to cause damage to the skin cells and we have expanded
that over the years as we have seen the data come in to being from
10 a.m. to 4 p.m.  So not just around noon and not just 1
p.m., so it's quite a window.  Now of course nobody can avoid
sun exposure or being outside all the time during those
hours.  But when we need to be outside then we need to protect
our skin and we can do that with sunblock, which is my preferred
term as opposed to suntan lotion or suntan oil, and really you want
SPF of at least 15.  I tell my patients at risk to actually go
to at least 30 with the SPF.  I prefer the physical blockers
which contain zinc oxide or titanium dioxide as the protector, but
people can protect themselves by also wearing clothing and they
actually make tight weave clothing under different brands that are
particularly good at blocking the rays of the sun, and so in these
ways we can still enjoy life, we can still get out there and still
be protected from most of the damaging rays of the sun.9:12 into mp3 file 
http://yalecancercenter.org/podcast/may1610-cancer-answers-girardi.mp3 Foss
When we are going out and conducting our normal daily activities,
not specifically sunbathing, but say on your weekend when you do
all your errands and you are in and out of the house all the time,
do we need to worry about that level of sun exposure, do we need to
wear sunscreen all the time?Girardi
This is somewhat debatable.  I think that over many years that
little bit of sun exposure everyday will take its toll, in
particular for patients who are at risk, and so they make some very
nice daily moisturizers now that are appropriate for application to
the face, the hands, and the arms that will contain SPF of 15 and I
think that can serve as your daily maintenance in protecting
yourself from the sun.Foss
In terms of thinking about these kinds of cancer, we hear a lot
about melanoma, but we don't really hear a lot about these
non-melanotic skin cancers.  Can you talk a little bit about
what the different types are?Girardi
Well the primary reason we don't hear as much about them and the
reason melanoma gets most of the hype is that melanoma is the
deadliest of the skin cancers, and it's one of the biggest causes
of death in young people, so it does get it's deserved share of
concern in that regard, but non-melanoma skin cancers are, as I
said earlier, are more common and fortunately not as deadly as
melanoma.  The most common type is basal cell carcinoma, and
basal cell carcinoma arises predominantly in sun exposed
areas.  It can be quite benign looking at first, more like a
pink little bump; sometimes it has a translucent or pearly quality
to it.  Other times it's very fragile, so the slightest little
rub, the slightest little scratch will lead to an area of bleeding
or a scab that seems to not heal, and whenever a patient sees this
kind of change they need to bring it to the attention of their
primary care physician, and hopefully to a dermatologist who can do
a shave biopsy, a very, very simple procedure to have it examined
for basal cell carcinoma.  Basal cell carcinoma is not the
type of skin cancer that can really travel in the body, and so if
you are going to get cancer that's one to get, but on the other
hand it can be quite invasive, it can go deep into the skin and
that could be a particular concern when it occurs in anatomical
areas where surgery can become a problem such as on the face, near
an eye, a nose, or lip, and so it still has concerns for treatment
and we want to catch them early so that we can minimize the
surgery.  The other major type of non-melanoma skin cancer is
squamous cell carcinoma and squamous cell carcinoma often looks
very different than basal cell carcinoma.  It often arises as
a hard little bump as opposed to the basal cell carcinoma, which is
usually soft, and this hard little bump can become painful and
that's a sign that it's actually become invasive. Because squamous
cell carcinoma, unlike basal cell carcinoma,12:37 into mp3 file 
http://yalecancercenter.org/podcast/may1610-cancer-answers-girardi.mp3does have a small chance of travelling in the body or
metastasizing in particular if it's in certain areas such as on a
lip, ear, or other areas on the face, we also want to catch that
early and get rid of that early through surgery.Foss
Mike, are there a lot of folks out there who have these small
tumors like these basal cell cancer and don't even know about
them?Girardi
Yes, because they can often look fairly benign early, patients will
often ignore them and this can become a problem.  Now, a lot
of times the basal cell carcinoma can sit there for years and grow
very slowly as most of them do, but other times they can grow
fairly rapidly and become invasive, so bring it to the attention of
your doctor and have it dealt with and then the patient can move on
from there.Foss
A strong message for everybody out there who is a sun
worshipper.  We are going to take a short break now for
medical minute, please stay tuned to learn more information about
non-melanotic skin cancer with Dr. Michael Girardi.Foss
Welcome back to Yale Cancer Center Answers.  This is Dr.
Francine Foss, and I am joined by my guest Dr. Michael Girardi
Associate Professor of Dermatology and Associate Clinical Director
of the Immunology and Immunotherapy Research Program at Yale Cancer
Center.  We are here today discussing non-melanotic skin
cancers. Mike, we talked before the15:09 into mp3 file 
http://yalecancercenter.org/podcast/may1610-cancer-answers-girardi.mp3break about the fact that there are a lot of folks out there who
probably have these non-melanotic skin cancers and don't even
realize it yet.  If somebody has a suspicious lesion,
something that they are worried about, what would they do next?Girardi
They would bring it to the attention of their primary care
physician and my bias is that they should insist that it be seen by
a dermatologist, a specialist in the care of patient's skin so that
it can be appropriately examined and a determination made as to
whether it would be appropriate to do a biopsy on a lesion. People
hear the word biopsy and I think there is hesitation there, but
really a skin biopsy is a very simple procedure.  The skin is
easily accessible and often it's just a small piece, 2 mm or 3 mm
piece of the area in question needs to be sampled and it does not
need to be sampled deep, so skin biopsy is the definitive way to
determine whether a particular lesion on the skin is a skin cancer
or not and this is done by a dermatologist and it's quite a simple
procedure.Foss
I can say that I have actually been to your office and you have
done that procedure on me and just to let the audience know, I had
no idea that Dr. Girardi did a procedure.  We were talking and
then he said we are done, and so clearly it is a painless
procedure.  In addition, you mentioned the issue of shaving,
when do you do a biopsy, and when do you do a shave?Girardi
A shave is actually a type of biopsy.  It is probably the
simplest type of biopsy.  It is done with a razor that
basically takes a sliver of the skin off.  We also do another
type of biopsy called the punch, and that's the more common one
that will give us a little more information about the deeper area.
We have to determine whether most of what we are looking at is in a
superficial part of the skin or whether there could be a component
that is deeper.  For melanoma, we will often do a punch to
make sure that no part of its gone deep.  In squamous cell
carcinoma we will sometimes do a punch to examine the deeper
portion.Foss
We also hear about the use of liquid nitrogen to burn these tumors
off, when do you do that?Girardi
Well, liquid nitrogen is a dermatologists and sun damaged patient's
best friend in several ways.  It's most commonly used to
freeze off the precancerous lesion that can precede squamous cell
carcinoma and these are called actinic keratosis, and these arrive
again in sun damaged areas as gritty little bumps and you can
sometimes feel better then you can see. Not all of these will go on
to become squamous cell carcinoma.  Somewhere in the18:11 into mp3 file 
http://yalecancercenter.org/podcast/may1610-cancer-answers-girardi.mp3range of one in 50 to one in 100 will actually go on to, but
this is the easiest
 way to nip it in the bud and that is to freeze it with liquid
nitrogen and we use a spray canister that keeps it under a high
pressure and produces a very tight fine spray with precision to be
able to destroy one by one these actinic precancerous
keratosis.Foss
This is also something that most people wouldn't even know that
they had unless they came to see a dermatologist.Girardi
Yes, I think that there is some education that needs to go on from
the primary care physician or dermatologist as what to look for
with actinic keratosis because again if we can freeze these off
early or treat them with a cream, which is another way we can treat
these sun damaged areas with a fair number of actinic keratosis,
then we can do a lot to prevent future surgeries, future
development of basal cell and squamous cell carcinoma and
protection, therefore, against the slight chance that one of the
squamous cell carcinomas could travel in the body.Foss
Going back to the whole issue of who should be screened, can you
talk a little bit about what populations of patients need to have
preventive screening?Girardi
Anyone with lesions in question need to be screened whether they
have seen a new lesion that there is some concern about in terms of
some of the signs and symptoms I talked about earlier, but if a
primary care physician sees a lesion in question they will refer it
to a dermatologist so that the patient can be examined with the
full body skin exam to look for that. Patients who are at genetic
risk with a family history, again if they have a family history of
melanoma in a primary relative, that patient really needs a full
body skin examination by a dermatologist on a yearly basis.Foss
Starting at what age?Girardi
At any age, children even with a history of melanoma need to be
screened, in particular, if they have a large number of nevi or
moles.Foss
So once the diagnosis is made, and you have mentioned that it's
made by a biopsy of the skin lesion, what happens after that?Girardi
Then a treatment plan needs to be put in place, an appropriate
treatment plan.  If it's on what we call the truncular or
extremities skin, that is the
 back, the abdomen, the chest, or the arms or legs then these can
usually be21:01 into mp3 file 
http://yalecancercenter.org/podcast/may1610-cancer-answers-girardi.mp3treated by simple excision within the office of a dermatologist
or by
 destruction, the most common form being electrodesiccation and
curettage which means an electrical destruction as well as a
scraping by curettage.  If there is any concern about adjacent
areas such as we see with skin cancers on the face, then often the
patient is sent for a special procedure called Mohs, micrographic
surgery, and that's done by a specialist who will take the patient
and they will do a very tight excision without a lot of normal skin
being taken off and they will examine that tissue right there in
the office while the patient waits to see if the lesion is
completely removed.  Any positive margins at that time will be
dealt with at that same time, so that patient will be brought back
into the room and a little bit more skin at that one edge that
might still have some skin cancer left will be subsequently removed
in another stage. This procedure will minimize the amount of normal
tissue that needs to be taken out and also ensure that the lesion
is completely excised, so it has a dual purpose in that regard and
it has become a major benefit to patients with skin cancer
particularly on the face.Foss
And again, only certain patients require that kind of
procedure.Girardi
Correct, and that determination is made by the dermatologist as
well as the Mohs surgeon who will see the patient first in what we
call a Mohs consultation.Foss
Mike, can you talk about how frequently these tumors recur after
they are excised?Girardi
That depends on a lot of factors.  That depends on how it was
treated, what the anatomical location was, and what the primary
skin cancer type was.  For melanoma, we often take a fairly
wide excision, meaning a 1-cm rim of normal tissue, for basal cell
and squamous cell carcinoma we will often do that also except when
we are near an anatomical location where we have to try to minimize
the removal of the normal tissue, and then we go to Mohs
surgery.  In general, for lesions treated in the office by
simple excision or electrodesiccation and curettage, we see a 95%
cure rate.  Now that means over the years we might see
recurrence, but that can easily be treated itself.Foss
Do these patients ever require CT scans or PET scans, or other
imaging studies?Girardi
That's rare, certainly in basal cell carcinoma there is not any
real concern for
 metastasis there.  For squamous cell carcinoma in particular
areas, could be a concern, as I said earlier on the lips, on the
ears, and we see a small24:22 into mp3 file 
http://yalecancercenter.org/podcast/may1610-cancer-answers-girardi.mp3percentage of patients who can develop spread to lymph nodes
with
 squamous cell carcinoma.  Whenever there is an enlarged lymph
node in these types of patients, then it is appropriate to do some
of this screening with a CAT scan or PET CT scan to ensure that it
has not travelled in the body.Foss
Mike, is there any role for radiation therapy in patients with
these invasive squamous tumors?Girardi
Actually yes, radiation therapy has been a big help for patients
where you cannot completely excise some of these lesions because
they have gone too deep or where patients really cannot tolerate
surgery for one reason or another. Radiation treatments can be done
in a therapeutic radiology center such as Yale Cancer Center and
really be a help to these kinds of patients.Foss
We talk a lot about multidisciplinary approaches to cancer and you
mentioned the Mohs surgery and use of radiation therapy.  Is
there a multidisciplinary center here at Yale Cancer Center to
address these invasive skin cancers?Girardi
Yes, we talked about the role of the therapeutic radiologist, the
Mohs surgeon, and the dermatologist, so we also have to talk about
the role of the oncologist.  When these cancers get out of the
box, when they metastasize to a lymph node or to elsewhere in the
body, the oncologist is really the person who is going to be
driving the boat as to what therapy is going to minimize the amount
of damage to the patient, and this can be in the form of
chemotherapy, but also some of the newer agents that are more
selective targets of these types of cancers.Foss
Can you elaborate on what some of those new treatments might be,
the EGF receptor for instance, we hear about that with squamous
tumors.  Is that appropriate for skin cancer?Girardi
Yes, so as I was mentioning these are some of the newer targeting
agents that will actually target some of the receptors that are
positive on the cancers and the EGF receptor, for example, is
positive on some of the squamous cell carcinomas that can
metastasize, and so this can be a very helpful treatment that's
really come to the forefront over the last couple of years for
these patients who develop metastatic squamous cell carcinoma.Foss
I know that you have done a lot of research in your lab looking at
the effect27:12 into mp3 file 
http://yalecancercenter.org/podcast/may1610-cancer-answers-girardi.mp3
 of the immune system on the development of cancer.  Can you
talk a little bit about what are you doing?Girardi
My laboratory at Yale focuses on some of the earliest events in
skin cancer, and that starts from what happens to damaged
cells.  How are they handled by immune cells within the skin
and immune cells that can come to the skin from the blood? We look
at the various types of immune cells using genetically modified
animal models to see how they handle their response to damaged skin
cells, how they eliminate them and in some cases how they actually
facilitate their growth. It is a double edged sword, the role of
the immune system in skin cancer, and that's a major focus of where
we try to look at the potential targets for prevention and for
treatment.Foss
In the future hopefully you will be developing some immunotherapy
approaches for these patients with skin cancer.Girardi
I will keep trying.Foss
Excellent.  Michael, it has been a pleasure to have you here
tonight to talk to us about non-melanotic skin cancer.  This
has been a terrific show and I think all of us are going to leave
this show knowing that we need to use our sunscreen.  Until
next week, this is Dr. Francine Foss from Yale Cancer Center
wishing you a safe and healthy week.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.