Combating Skin Cancer

It’s deadly, it’s common, and it’s happening to younger people. But new treatments and preventions can save lives.

Summer is almost here, but many people in Florida slide from one season to another with little notice. After all, this is the sunshine state. But our rays of sunshine come with a warning: skin cancer! May is Skin Cancer Awareness Month. Statistics prove we need to heed and take action on experts’ tips and suggestions. Florida has one of the highest number of cases of melanoma, the deadliest form of skin cancer.

According to the American Cancer Society, skin cancer is the most diagnosed cancer in the U.S., with more than 5 million new cases each year.

Basal cell and squamous cancers are the most common. Almost all those cases can be cured – especially if they are found and treated early.

Melanoma accounts for only about 1% of skin cancers but causes a large majority of deaths. And Florida has the second-highest number of melanoma skin cancer cases in the country, the Society said.

“It’s a shocking statistic,” said Dr. Alysa Herman, a dermatologist practicing in Miami and a spokeswoman for The Skin Cancer Foundation. “Although I won’t say that I’m surprised, I think anywhere where people can be outdoors for long periods of time, for the majority of the year, you’re going to get an increase in skin cancer incidents of all types.”

HERMAN

In Florida, the American Cancer Society estimates the number of melanoma cases in 2024 will be 9,880, with an estimated 790 deaths.

Meanwhile, nationwide, there will be an estimated 100,640 new melanoma cases with an estimated 8,290 deaths.

“We’re one of the few states where we don’t have a ‘winter,’” Herman said. “And even in our winter, our winter is attractive to people who have real winters. And even though the sun’s intensity is not as strong as it is in the summer months, it’s still strong. And I think just geographically we’re closer to the equator, so the intensity of our sun is stronger than northern states would be.”

“The reality is more that the melanoma statistic represents our aging population, where Florida has a very high predominance of aging patients,” said Dr. Bently Doonan, an assistant professor who researches melanoma and immunotherapy development and design at the University of Florida Division of Hematology & Oncology.

“Melanoma specifically relates to UVB radiation exposure, which is what causes sunburns. So, it takes only five sunburns in your lifetime to double your risk of melanoma.” — Dr. Bently Doonan, an assistant professor University of Florida Division of Hematology & Oncology

“As we age, really the time that we’ve acquired chronic sun exposure is the largest contributor to the development of skin cancer,” he said. “So, the more patients your state has of people that live long enough, the more cases of sun cancer your state will have,” he said.

“Melanoma specifically relates to UVB radiation exposure, which is what causes sunburns. So, it takes only five sunburns in your lifetime to double your risk of melanoma. Our basal and squamous cells are more traditionally the chronic sun exposure we associate with UVA. So, the burn rate or the frequency at which you get burned causes the mutation in the cells that become melanoma. But because your body can surveil, destroy, and remove these, that’s why most of us don’t end up with melanoma. But given enough time and opportunity, the right environment, and the right limitations of your specific immune response to the melanoma, these can develop and then progress,” Dr. Doonan said.

DOONAN

So how should we deal with sun exposure, particularly in the summer, when the sun’s rays are most intense?

Wearing sunblock is one form of protection, but it doesn’t provide total protection, Dr. Doonan said. He recommends the “layered” approach.

First, avoid sun exposure at the time when the sun’s ultraviolet rays are most intense, from 10 a.m. to 2 p.m. (the Skin Cancer Foundation goes even further, recommending 10 a.m. to 4 p.m.) Then,

• Wear protective clothing.

• Wear sunblock.

• Seek shade.

Dr. Herman said some of her patients will protest that they don’t go to the beach or don’t even play golf anymore. She responds,

NOTE: Basal and squamous cell carcinoma of non-genital skin sites are not reportable regardless of the extent of disease at the time of diagnosis or the date of first contact with the reporting facility. SOURCE: Florida Cancer Data System, Florida Statewide Cancer Registry

“But you leave your house every day, and you run errands. You leave your front door to get into your car. You leave your car to go into that building, and you’re driving on the highway or a main street, and you’re getting exposure through the windows of the car.”

We used to think that most of the damage was done before the age of 18, Dr. Herman said. When she began her practice 20 years ago, patients would say, “There’s no point in me wearing sunblock because I read that 80% of my exposure was before the age of 18,” she said. “Well, thankfully, about a decade or so ago, that data was revised, and I think the number is somewhere around 18% is before the age of 18. I thought that that was probably the most helpful study to be able to share with patients because it made them feel empowered that their actions today can impact the future health of their skin.”

Skin cancers can take various shapes, colors, and other characteristics. “Patients get frustrated because they’re like, ‘Tell me what to look for.’ And we have brochures with various pictures,” Dr. Hermans said. “And the truth of the matter is there’s no one specific characteristic.”

Squamous cell carcinoma on the nose. THE SKIN CANCER FOUNDATION / COURTESY PHOTO

There are subcategories in the different types, she said. “Basal cell carcinoma can be superficial. It can have a nodular subtype, which is a bump. It can have an Infiltrative subtype, which you don’t really see much on the skin; maybe it’s an indentation.” That’s why seeing your dermatologist is of real value, she said.

Then they give guidelines, like if it’s bleeding and not seeming to heal, if it’s painful, if it’s growing and has never grown before, or if it demonstrates some abnormal biological behavior, then you needs to see a dermatologist; she said.

When treating the two most common forms of cancer, basal cell, and squamous cell, Mohs surgery is considered the most effective technique, the Skin Cancer Foundation said.

Dr. Herman is a Mohs surgeon. “It’s a very tried and true procedure, which has been around since the 1930s and which still to this day offers the highest cure rates for any treatment used for skin cancer,” she said. The surgery is an outpatient procedure done with local anesthesia.

TUREK

It involves removing the cancer tissue in real-time, layer by layer, until none is left. The tissue layer is brought to a lab in the same facility, and a Mohs technician cuts, inks, and stains it. The surgeon looks at it under a microscope and examines the margins to see if any part of the tumor (growth) is seen on the slide. Each slide corresponds to an area on the patient so the surgeon can map it out and return to remove the tissue.

Melanoma is more invasive and must be treated with surgery.

However, Dr. Herman said the most innovative advance in treating skin cancer in general is immunology, with the advent of immunotherapies. These are drugs and systemic medications given by oncologists. “That has been really a game changer for patients with advanced skin cancer where surgery is no longer curative.”

QUELLER

“I can tell you that when I was in training when patients had advanced melanoma, it was universally fatal. And I have in my practice, I think 5 or 6 patients now that are all five, seven, nine, 11, 12 years out of a stage four diagnosis, all alive and well thanks to the advent of immunotherapy rather than chemotherapy, which destroys the immune system and destroys all the cells,” she said.

Dr. Doonan, who researches melanoma and immunotherapy development, said that when cells in the body are going to turn into a tumor, they have to mutate and evolve. “But our bodies are adept at noticing those changes in removing and killing those cells before they turn into tumors, or else none of us would make it to 50, 60, 70, or 80 years of life,” he said. The immune system finds something that shouldn’t be there, attacks it, kills it, and gets rid of it the same way it detects bacteria and viruses and gets rid of them, he said.

“So, what we then realized by this dynamic relationship is that if you can improve your immune system’s response to cancer, you can potentially kill cancer using your own body’s natural system of defense.” So now melanoma doctors have developed different strategies “that are all utilizing naturally occurring things of your immune system, amplifying, enhancing them or improving them in some way to tip the scales back in favor of your body’s own abilities to kill and destroy these tumors.”

He said one of the most used forms is “immune checkpoint inhibitors.” “These are antibodies that we use that are given through an IV and interact with a certain cell in your body and the tumor. So instead of the tumor giving these fighting cells in your body a signal that says go to bed, it gives them a signal that says do something. Stay on high alert, be active, and try to kill things you see that shouldn’t be there. And they work quite well.”

“Now, our expectation is that even with metastatic melanoma, 50 to 60% of people aren’t going to die from their melanoma. And so you go from zero (survival) to more than half of them.”

Anywhere you have skin, you can technically develop a skin cancer, Dr. Herman said. On your scalp, behind your ears, between your toes, anywhere. “People also think that you have to be light-skinned and fair to develop skin cancer. All skin types develop skin cancer.”

Dr. Herman said it’s alarming that she’s seeing such young patients. “I can tell you that I have a significant number of patients that are in their 20s now.” She said many times, diagnoses are delayed because nobody seems to think that the little spot on their cheek could be skin cancer.

Casey Turek, a dermatology nurse practitioner at PGA Dermatology Skin & Aesthetics Center in Palm Beach Gardens, said she recently had a 23-year-old patient “that had a suspicious spot that she didn’t do anything about for four years and was just diagnosed with melanoma,” she said. She also just had a 23-year-old with skin cancer on the bottom of her foot.

Turek believes that younger people don’t take skin cancer seriously. She said they think it’s just something on the surface of their skin, something topical. But something topical can be invasive, too.

Dr. Jenna Queller of DermWorks, a boutique dermatology office in Boca Raton, said people should come in for a yearly body check and check themselves for possible skin cancer every month.

She tells her patients to use the ABCDE method when checking their skin:

A for asymmetry

B for borders

C for color

D for diameter (anything larger than 6 mm, which is about the size of a pencil eraser)

E for evolving – how is it changing?

“A lot of people think a tan is healthy,” Dr. Quellen said. However, “If someone says you look pale, that’s a good thing.” She said that if you have a tan, that’s a sign of sun damage. “There is no such thing as a good tan or healthy tan.” ¦

In the KNOW

Ten tips for sun safety in Florida

1. Time of day: The hours just before and after midday are most hazardous for UV exposure, generally from 10 a.m. to 4 p.m. (Other experts narrow it to 10 a.m. to 2 p.m.) Avoid outdoor activities during this time, if possible. Use the shadow rule: if your shadow is shorter than you, the sun’s rays are at their strongest, and you should find shade.

2. Minimize direct and reflective exposure: Seek shade as much as possible. Be extra careful around water and sand. These surfaces reflect the sun’s damaging rays, which can increase the chance of sunburn.

3. Length of exposure: Damage from harmful rays can occur in as little as 15 minutes.

4. Clothing: Wear a long-sleeved shirt and long pants. Dark clothing with tightly woven fabric blocks more sun than white or loosely woven fabrics.

5. Hats: Dark-colored, wide-brimmed hats made of tightly woven fabric are excellent for covering the face, nose, ears and neck. Avoid straw hats which may allow UV rays to penetrate through the holes.

6. Sunglasses: Large, wraparound sunglasses provide good protection since they prevent UV rays from entering from the side. Ensure the label says they protect against UVA and UVB rays.

7. Use Sunscreen: Sunscreen reflects, scatters or absorbs UV rays. Choose a broad-spectrum sunscreen that protects against both UVA and UVB radiation. Make sure it is water resistant and has an SPF of 30 or higher.

• Apply sunscreen to all exposed skin 30 minutes before going outdoors (the suggested amount is about 1 ounce, the same as 2 tablespoons). Reapply at least every two hours. Make sure you also apply sunscreen to the face, ears, hands and lips.

• When swimming, reapply much more frequently, even if the sunscreen is labeled waterproof.

8. Children: Keep babies younger than 6 months old completely covered and in the shade.

9. Medications: Be even more cautious if you take medications that may make you more sensitive to the sun. This can include antibiotics, anti-inflammatories, antifungals, blood pressure medications, chemotherapies and antihistamines.

10. Use sunscreen every day – even if it’s cloudy! Overexposure to UV rays can also occur on cool, hazy, and cloudy days. It’s not the temperature that burns your skin. It’s the sun’s invisible ultraviolet radiation.

Source: AIM at Melanoma, a global foundation dedicated to finding more effective treatments and, ultimately, the cure for melanoma.

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