- A history of sunburns
- Age. Older people have more cumulative sun exposure. Also cells are more likely to develop mutations over time.
- Family history of skin cancer
- Hometown. A patient from Florida is at a higher risk than one who grew up in rainy Seattle.
- History of immunosuppressant medication
James "Skip" Martin had a kidney transplant as a teenager, and, since transplant recipients of solid organs, such as a kidney, lung or heart, have a much higher-than-average risk of skin cancer, Martin undergoes frequent screenings for cancer.
Transplant recipients who have received a solid organ have to take medication that prevents their immune systems from rejecting the organ. The problem is that compromising the immune system diminishes the body’s surveillance of abnormal cells, thereby diminishing its ability to keep some cancers in check.
Skip's transplanted kidney failed a few years ago. He now receives regular dialysis and is on the waiting list for a new kidney. Skip had his transplant at Yale Medicine, and as part of his post-treatment follow-ups, he receives full-body skin checks from Oscar Rene Colegio, MD, PhD, assistant professor of dermatology and pathology at Yale School of Medicine.
Martin, who is an electronics technician, had several additional factors that greatly increased his risk of skin cancer: He's a male with fair skin and blue eyes who's in his mid-50s and has a history of several squamous cell carcinomas which began developing in 2013.
A vigilant approach to monitoring cancer
Yale Medicine’s department of dermatology is well known for identifying, diagnosing and treating even the most challenging cases of skin cancer and for monitoring the patients for recurrence of cancer or other skin issues. High-risk patients are referred to Yale Medicine by other dermatologists for ongoing management, Dr. Colegio says.
All of the patients Dr. Colegio sees at Yale Medicine are considered to be high-risk–often because they had cancer in the past. "That's the strongest predictor of future skin cancer risk," he says.
That isn’t because those initial cancers are spreading. In fact, basal cell and squamous cell carcinomas rarely spread and almost never metastasize. Instead, it's that these types of cancers form in skin that is exposed to ultraviolet light, and multiple cancers can form over time in an area of regular exposure, such as the face, head, chest or extremities.
While skin cancer, especially melanoma, does occur in parts of the body that are always covered, it's crucial to constantly monitor the areas that are often exposed to the sun. “Within the department, there’s an expectation that we all practice with the highest level of attention to detail,” Dr. Colegio says. “I’ve had patients tell me that they’ve never had a doctor look at all of their skin the way we do. That’s part of the culture here. Screening is exceptionally thorough, with rigorous attention to detail.”
When assessing risk, Dr. Colegio asks a patient about past sunburns, family history of skin cancer, hometowns (a patient from Florida is at a higher risk than someone who grew up in rainy Seattle), and her age.
Older people have had more cumulative sun exposure, but also their cells are more likely to develop mutations over time. (Experts are researching other ways that internal processes can lead to an increased risk later in life, Dr. Colegio says, including how age affects the immune system.)
During the screenings, Dr. Colegio would often find suspicious lesions on Martin's forehead and arms and would never hesitate to biopsy.
Martin's wife, Kimberlee, often accompanied him on his screenings. She had never been to a dermatologist on her own or had a full-body skin check. But her knowledge of her husband's high risk made Kim more aware of her own. The fair-skinned 53-year-old loves going to the beach in Connecticut, where she grew up and still lives. "I'd definitely gotten a lot of sun," she says. After accompanying Skip to see Dr. Colegio, she'd started keeping an eye out for suspicious moles and spots on her own skin.
The caregiver asks a question
A few years ago, Kim noticed something on her face, under her right eye and right below her sunglasses. The spot would crust up, scab over and go away, then reappear in the same area. Kim remembered getting a sunburn there in the past. After months of growing annoyance, she decided to call Dr. Colegio and make an appointment for herself. "I just wanted him to look at it," she says.
Dr. Colegio agreed that the lesion warranted concern. "I detected a basal cell carcinoma in that visit, with diagnosis confirmed by biopsy," he says. Dr. Colegio referred Kim to Yale Dermatologic Surgery, where the basal cell carcinoma was removed by Mohs micrographic surgery. Kim has a tiny scar where the spot used to be, but she says you really have to look closely to see it.
Kim's skin cancer made her higher risk, so she now also sees Dr. Colegio for regular visits: He recommended full-body skin checks every year.
Last spring, it was Skip's turn to accompany Kim to the dermatologist when she went to get something checked out. Dr. Colegio did a biopsy on her suspicious spot, and as the couple was leaving the office, Skip mentioned that he had a new spot on his other arm. "Even though it was about 5 p.m. and everyone was heading home, Dr. Colegio said to us, 'You're not leaving without me taking a look at that,'" Kim says. He immediately shifted his focus to Skip.
Through a biopsy, Dr. Colegio confirmed that Skip had another squamous cell carcinoma. And because it was caught early, the doctors were able to treat it right away.
"We're so lucky that we both happened to be there that day, and that Dr. Colegio was able to catch it," Kim says. "He's such an attentive, thorough doctor, and caring, too. We love him. He always takes time for us. We wish we could see him for all of our medical issues."
Kim's lesion of concern turned out to be benign, so that day's visit fortunately resulted in only one diagnosis of skin cancer.
Knowledge is Power
Now the Martins are at Dr. Colegio's office twice a year, although he's usually only examining one of them at a time. Skip continues to be screened every six months; Kim every 12. "What I like about their story is that diagnoses have been made inadvertently through complete care of the family," Dr. Colegio says.
While he reiterates that one skin cancer is usually a red flag for future cancers, Dr. Colegio says that patients with a confirmed diagnosis shouldn't feel helpless. "There are things that even high-risk patients can do to protect themselves against developing additional skin cancers," he says.
Dr. Colegio refers to a German study of two groups of organ transplant recipients who'd already been diagnosed and treated for skin cancer. The group of patients who put on sunscreen every day for two years was found to have a significant reduction in skin cancer rates than the other group that were less diligent about their sunscreen use.
"Vigilance clearly pays off," he says.