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ARE YOU PLAYING SOLAR ROULETTE?
Actinic Keratosis l Squamous
Cell Carcinoma l Basal Cell Carcinoma l Malignant
Melanoma l Prevention
SKIN CANCER
Skin cancer is a malignant growth on the skin which can have many causes. Skin
cancer generally develops in the epidermis (the outermost layer of skin), so
a tumor is usually clearly visible. This makes most skin cancers detectable
in the early stages. There are three common types of skin cancer, each of which
is named after the type of skin cell from which it arises. Cancers caused by
UV exposure may be prevented by avoiding exposure to sunlight or other UV sources,
wearing sun-protective clothes, and using a broad-spectrum sun screen.
A WORD OF WARNING
Skin cancer represents the most commonly diagnosed malignancy, surpassing lung,
breast, colorectal and prostate cancer.
Skin cancer is the most common Cancer in South Africa at present. Dramatic
increases in skin cancer have also been reported in other countries around
the world. Of particular alarm is the fact that certain skin cancers can kill,
if not treated early. Melanoma, particularly, is a lethal type of skin cancer.
Sun damage to the skin accumulates over time. It is lifetime sun exposure,
not recent sun-tanning that adds to your risk. Up to 80% of sun damage is thought
to occur before the age of 18. Ultraviolet rays bounce off sand, snow, and
other reflective surfaces; about 80% can pass through clouds. The thinning
of the ozone layer may be allowing more ultraviolet rays reach the earth. People
who have fair skin, blonde or red hair, blue, green, or gray eyes are at the
greatest risk. Because their skin has less protective pigment, they are the
most susceptible to sunburn. Even those who are darker-skinned can develop
keratosis if they heavily expose themselves to the sun without protection.
Three contributing factors in the increase of the
incidence of skin cancers are:
· The depletion of the ozone layer which is responsible for the screening
of the ultraviolet A and B rays
· Over-exposure of individuals to the sun
· Inappropriate protection of the skin when exposed to the sun
Individuals who neglect protecting their skin against the harmful rays of the
sun are indeed engaged in a game of solar roulette. The odds of developing
skin cancer are against them.
The
outermost part of the skin is called the epidermis. It is where most
skin cancers start. Here you find three kinds of cells: flat, scaly
cells on the surface called squamous cells; round cells called basal
cells; and cells called melanocytes, which give your skin its color.
These three cell types each can develop a distinctive type of cancer.
The type of cancer is named after the cell- Squamous cell carcinoma,
Basal Cell Carcinoma or Melanoma.
TYPES OF SKIN CANCER
The most common types of skin cancer are basal cell carcinoma (BCC) and squamous
cell carcinoma (SCC) which may be locally disfiguring but are unlikely to metastasize
(spread to other parts of the body). The most dangerous type of skin cancer
is malignant melanoma. This form of skin cancer can be fatal if not treated
early but comprises only a small proportion of all skin cancers.
· Actinic Keratosis
" Keratosis" means "hardening of the skin" and "actinic" means "as
a result of the sun." This type of cancer manifests itself many years after
the skin has been damaged by the sun. 
An actinic keratosis is a scaly or crusty bump that forms on the skin surface.
They are also called solar keratosis, sun spots, or pre-cancerous spots. Dermatologists
call them "AK's" for short. They range in size from as small as a
pinhead to over 2cm. They may be light or dark, tan, pink, red, a combination
of these, or the same color as ones skin.
The scale or crust is horn-like, dry, and rough, and is often recognized easier
by touch rather than sight. Occasionally they itch or produce a pricking or
tender sensation, especially after being in the sun. They may disappear only
to reappear later. Half of the keratosis will go away on their own if one avoid
all sun for a few years.
One often sees several actinic keratoses show up at the same time. Keratoses
are most likely to appear on sun exposed areas: face, ears, bald scalp, neck,
backs of hands and forearms, and lips. They may be flat or raised on appearance.
Why is it dangerous? 
Actinic keratosis can be the first step in the development of skin cancer,
and, therefore, is a precursor of cancer or a pre-cancer. It is estimated that
10 to 15 percent of active lesions, which are redder and more tender than the
rest will take the next step and progress to squamous cell carcinomas. These
cancers are usually not life threatening, provided they are detected and treated
in the early stages. However, if this is not done, they can bleed, ulcerate,
become infected, or grow large and invade the surrounding tissues and, 3% of
the time, will metastasize or spread to the internal organs.
The most aggressive form of keratosis, actinic cheilitis, appears on the lips
and can evolve into squamous cell carcinoma. When this happens, roughly one-fifth
of these carcinomas metastasize. The presence of actinic keratoses indicates
that sun damage has occurred and that any kind of skin cancer -- not just squamous
cell carcinoma can develop. People with actinic keratosis are more likely to
develop melanoma also. Sun exposure is the cause of almost all actinic keratoses.
Individuals who are immuno-suppressed as a result of cancer chemotherapy, AIDS,
or organ transplantation, are also at higher risk. It seems that while the
body is healthy, the lesions are kept in check. When one becomes ill they grow
and become malignant more often, although this is not yet proven. Because more
than half of an average person's lifetime sun exposure occurs before the age
of 20, keratoses appear even in people in their early twenties who have spent
too much time in the sun.
How is it treated?
There are a number of effective treatments for eradicating actinic keratoses.
Not all keratoses need to be removed. The decision on whether and how to treat
is based on the nature of the lesion, age, and health.
Cryosurgery, one of the most common treatments done, freezes off lesions through
application of liquid nitrogen. This is done with a special spray device or
cotton-tipped applicator. It does not require anesthesia and produces no bleeding.
The longer the spot is frozen the better the chance it will never come back.
Longer freezes can result in hypo-pigmented areas.
Curettage is another treatment. The physician scrapes the lesion and may take
a biopsy specimen to be tested for malignancy. Bleeding is controlled by cautery
--application of an acid or heat produced by an electric needle.
Shave Removal utilizes a scalpel to shave the keratosis and obtain a specimen
for testing. The base of the lesion is destroyed, and the bleeding is stopped
by cauterization.
Chemical peels make use of acids (Jessners solution and/or trichloroacetic
acid) applied all over the area. The top layers of the skin peel off and are
usually replaced within seven days by growth of new skin. Redness and soreness
usually disappear after a few days.
Topical cream is effective in treating keratoses, particularly when lesions
are numerous. 5-fluorouracil (Efudex, Carac) cream works by directly attacking
the pre-cancerous cells. This is applied once to twice daily for 2 to 4 weeks.
Treatment leaves the affected area temporarily reddened and raw and will cause
some discomfort resulting from skin breakdown. The more raw and inflamed the
skin becomes, the better the end result. Solaraze gel is a non-steroidal medication
that also works fairly well on AK's. Treatment is twice daily for ninety days.
Large, multiple or inflamed actinic keratosis need to be treated to prevent
their conversion to squamous cell carcinoma. This avoids the potentially more
invasive and extensive treatment of a subsequent malignancy. Regular follow-up
visits are usually needed when there are many keratoses.
Back to top
· Squamous Cell Carcinoma
A squamous cell carcinoma (or SCC) is a skin cancer that may appear as a bump
or as a red, scaly patch. It often is found on badly sun-damaged, fair skin,
and because of this often develops on the rim of the ear, the face, and the
lips. It is not as dangerous as melanoma, but still leads to an estimated 2,300
deaths every year. When properly treated the cure rate is 95 percent.
SCC may spread to the lymph nodes in the area (lymph nodes are small bean-shaped
structures that are found throughout the body; they produce and store infection-fighting
cells).
SCC's develop in several different circumstances and vary greatly as to how
dangerous they are. Like other forms of cancer, such as cervical and colon,
they may be closer to pre-cancerous, highly malignant or somewhere in between.
Most develop out of actinic keratoses (rough sun spots), some from old wounds,
and some due to a weakened immune system.
The most common types of SCC are Bowens disease ("SCC in situ") and
keratoacanthoma. These types are only rarely a threat, but could develop into
a more dangerous type if not treated promptly. At times, aggressive SCC will
be found that looked like a different type of skin cancer, so only a biopsy
can determine what the risk is with certainty.
Bowens disease looks like a dry rough patch. Prior to seeing a dermatologist,
it is often thought to be a fungus or rash. Keratoacanthoma is a rapidly forming
lump with a central dry core. It is frequently thought to be a "boil" or
cyst before evaluation. The risk of metastasis is probably under 1%.
SCC's that are invasive are more dangerous. They most commonly appear as a
lump, and are often open sores that bleed easily. The risk of metastasis is
around 3%. Some of these may be considered high risk because of size, location
or features seen on the biopsy. They may be found on the ear, lip or in an
old wound. They are larger, deeper, and may invade nerves or have cell that
are "poorly differentiated". The risk of metastasis from a high risk
SCC runs from 10 to 30%.
How is it treated?
The treatment for an SCC depends on its type, location and risk. For most SCC
the best treatment is excision (the SCC is cut out and the hole stitched up).
Along with a surrounding strip of normal appearing skin, this is sent to a
pathology laboratory. The lab checks to confirm complete removal complete removal
of the SCC. Small, surface SCC can also be destroyed by freezing (cryosurgery)
or electrodessication and curettage (ED&C). Cryosurgery uses liquid nitrogen
for small superficial lesions, while C & E removes the SCC by scraping
of the tumor and cauterizing the base. It usually requires fewer visits to
complete and the wound usually heals rapidly without needing stitches.
High-risk
tumors are best treated by wide excision (removal of a large
margin of normal skin) or Mohs' Surgery. Mohs surgery is
a specialized microscopically controlled surgical technique
that removes the entire tumor, and only the tumor. It has
the highest cure rate, and is the least disfiguring. If used
on larger cancers or on a difficult site a dermatologic surgeon
or plastic surgeon may also be needed to repair the defect
left after excision. Mohs surgery should almost always be
used if the SCC comes back at the same site.
Radiation therapy (X-ray treatment) may be added after surgery of a high-risk
SCC. It can add measurably to the cure rate. It is probably used less often
than it should be. Occasionally, radiation is used as the sole treatment in
inoperable tumors, or in those that have already spread. Oncologists are not
normally involved in the treatment of ordinary SCC. If the SCC spreads one
will be needed to give chemotherapy. This is only used for advanced disease.
Once a person has developed one SCC, he is always at risk of developing another
one. The actinic keratoses on the skin are the breeding ground for future SCC
and these should be treated. One may also be at risk for other forms of skin
cancer. Regular dermatology examinations, at least twice yearly, will be needed
for at least 2 years.
The best way to avoid developing more skin cancers is to protect the skin from
further sun damage. Use sunscreen of at least SPF30 and wear a broad brimmed
hat. Eat a healthy, low fat diet. Take supplements. Early treatment of SCC
makes treatment easier, so learn the signs of skin cancer, and check the skin
once each month. Promptly seek care for any suspicious growths.
Back to top
· Basal Cell Carcinoma (Rodent Ulcer)
Basal cell carcinoma (BCC) is the most common form of cancer. Basal cells line
the deepest layer of the epidermis. Basal cell carcinomas are malignant growths/tumors
that arise in this layer and are also called basal cell epithelioma and basal
cell cancer.
It is most often found on the face, neck, hands, or other parts of the body
that have been exposed to the sun. The good news is detection is relatively
simple and if found early, treatment is simple and usually successful.
This type of cancer can have
many different appearances:
A red patch or irritated area;
A smooth, shiny and waxy looking bump;
A white or yellow scar-like area;
A smooth reddish growth;
Or an open sore that won't heal, bleeds or oozes.
Not all growths on your skin are cancer. A dermatologist often has to take
a biopsy to confidently diagnose skin cancer.
The usual cause of Basal cell cancer is chronic sun overexposure and sunburns.
The ultraviolet light in sunlight is a form of radiation, and this damages
your skin leading to skin cancer. Much of the sun exposure is from ones youth
and leads to cancers that result show up years later. Basal cell carcinoma
is usually a problem for people with fair skin and a poor ability to tan. Other
determining factors include your family's history of skin cancer problems and
an impaired immune system.
How is it treated?
The factors that influence the choice of treatment are the size, shape, location
and type of basal cell cancer, and the particular expertise of the dermatologist.
Other factors to consider are the availability of special facilities, the age
and health of the patient and whether cancer is a recurrence of a previously
treated site.
Small basal cell cancers can be treated by many methods. Most commonly used
is curettage and electrodessication (scraping away the tumor tissue and then
destroying a thin surrounding layer with heat). Other commonly used treatments
are surgical excision and cryosurgery (liquid nitrogen freezing using a temperature
probe sometimes to ensure temperature of -50°C). Superficial basal cell
carcinomas can be treated with topical chemotherapy.
Large or recurrent basal cell cancers are treated best with Mohs' surgery (a
specialized type of microscopically controlled surgery). Radiation treatments
and excision with skin grafting or surgical reconstruction can also be used.
For Basal cells cancers that are in between, many methods can be used if properly
selected. Overall, Moh's micrographic surgery offers the best cure rates with
lowest recurrence rates.
People with a basal cell carcinoma have almost a 30% chance of developing another
skin cancer in the next 5 years. Regular exams by a dermatologist, and a monthly
scan of ones own skin for new and changing growths should be done. Of course,
all skin cancer patients should limit or avoid sun exposure, wear hats and
other protective clothing, and use sunscreens with a sun protection factor
of at least 30.
Back to top
· Malignant Melanoma
Melanoma is tumor of the skin that is cancerous (malignant). It grows from
the melanocytes, the cells that color and tan the skin. Melanoma is also called
cutaneous melanoma or malignant melanoma. The UV A and UV B rays have the potential
to disturb normal cell development, converting these cells into the lethal
Melanoma.
It
is a more serious problem than the more common skin cancers, basal cell
cancer or squamous cell cancer. Unlike these cancers, melanoma often
will spread (metastasize) to other parts of the body.
It is the 5th most common disease in men and 6th most common disease in women.
Approximately 83% of diagnoses are made from the local site. Melanoma can spread
by local extension (through lymphatics) and/or by hematogenous routes (through
the bloodstream) to distant sites. The risk of relapse may decrease over time,
but late relapses are not uncommon.
Melanoma can appear on the body as a new mole, or one that has changed in size,
shape, feeling or color, or developed oozing or bleeding. Adult men most often
get melanoma on the trunk, especially between the shoulder blades, or on the
head or neck. Women most often get melanoma on the arms and legs. It can rarely
form in children.
Most melanomas are dark, but some are not, and may be flesh colored or pink
to red.
If
there is a serious question of skin cancer, the
mole or pigmented area will be cut out (local
excision). This is usually done in a doctor's
office. It is important that this remove the
entire mole if possible.
The lab will analyze the removed skin. If melanoma is found they will report
how deep and aggressive it appears. Then a physical exam and lab tests will
be done to look for signs that cancer cells have spread to other parts of the
body. This is called staging. A doctor needs to know the stage of the disease
to plan treatment.
In the earliest melanomas, the abnormal cells are found only in the outer layer
of skin cells and do not invade the body. It is more advanced if the growth
goes deeper than 4 millimeters into the skin. Most melanomas fall between these
two extremes. More serious still are melanomas that have spread to the body
tissue below the skin, show additional tumor around original tumor (satellite
tumors), or have spread to lymph nodes or other organs.
How
is it treated?
Surgery is the primary treatment of all stages of melanoma. A second procedure
is normally done to ensure complete removal of the melanoma. Complete removal
of all the melanoma before it has spread is the only sure cure for melanoma.
Usually, the biopsy site and a rim of apparently normal skin are removed. This
is called a re-excision. The amount removed depends on how deep the melanoma
has grown. Skin may have to be taken from another area of the body and put
(or "grafted") where the cancer has been taken out.
Chemotherapy uses drugs to kill cancer cells. However, chemotherapy has not
been shown to be very effective in treating melanoma. Clinical studies are
being done to find chemotherapy drugs that are more effective. Radiation uses
x-rays to kill cancer cells and shrink tumors. Radiation shrinks and slows,
but does not usually cure, melanoma.
Treatment of advanced (stage III) melanoma may involve surgical removal of
the tumors and any affected lymph nodes, followed by systemic or local chemotherapy
with single or multiple agents. The five-year survival rate for treated Stage
III patients is about 60 percent, and both the disease and the treatment often
compromise quality of life.
Back to top
PREVENTION OF SUN-INDUCED
SKIN CANCERS
·Time Factors
The most dangerous time for sunbathing is between 11H00 and 15H00, especially
at midday, when the sun's rays are the most vertical. Short bouts - approximately
five to ten minutes per day - of sunbathing are recommended in order to develop
an even tan. Tanning in this way will protect the skin against Actinic Keratosis
and Basal Cell Carcinoma but is not a guarantee against Melanoma
· Physical Factors
It is important to protect skin areas using large-brimmed hats, flimsy long
sleeved blouses or shirts, umbrellas or by remaining in shady areas
· Sunscreen Lotions
Sunscreen should be applied before you walk out the door in the morning. If
you're on your way to the beach, apply your SPF again when you get there. Special
precautions should be taken as regards the duration that the sunscreen cream
affords your skin protection and re-application after swimming. Also, towel
drying exposed areas is recommended before re-applying lotion. The higher the
SPF the longer you have protection from the suns damaging UV rays
· Outdoor Sport
People engaged in outdoor sport must adhere to every safety precaution possible
when exposed to long periods in the sun. Ongoing research needs to be done
in this area to determine the risk of sportsmen and sportswomen over-exposed
to the ultraviolet rays of the sun
· Sun beds
Dermatologists warn against the use of ultraviolet sun beds and lamps. Long-term
use of such equipment may cause Solar Keratosis, Squamous Cell Carcinoma and
Basal Cell Carcinoma. Research has also shown that Malignant Melanoma has a
three times increase amongst regular users of sunlamps. The use of Sun beds,
by people younger than 16, has been banned in the USA and UK.
· Removal of Moles at
a risk of developing into
a Melanoma
Moles in the following areas that may be subjected to sunlight, chafing or
irritation, should be removed as a precautionary measure: face; between the
shoulders (especially in males); chest region; girdle area; buttocks; pubic
region; calf (especially in females) and the soles of the feet and palms of
the hands
Physical Examination
Any suspicious skin lesions should be reported to your doctor or Dermatologist
as soon as possible
Skin Self-Examination on
a Monthly Basis
All individuals should practice regular skin self-examination on a monthly
basis. Mothers should accept responsibility for their families. Males whose
task may require working outdoors for long periods of time should take extra
precautions to protect themselves and engage in regular self-examination. It
is important to install the habit of self-examination and skin protection in
children at an early age. Your skin is the outer protection of your body. You
in turn need to protect your skin.
Don't take a chance with Solar Roulette ! ! !
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