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Skin Cancer Awareness & Prevention -- July 11, 2011 -- Dr. Ronald Nelson


Skin Cancer Awareness & Prevention
July 11, 2011
Dr. Ronald Nelson

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is melanoma?

Melanoma is a kind of skin cancer. It is not as common as other types of skin cancer, but it is the most serious.

Melanoma can affect your skin only, or it may spread to your organs and bones. As with other cancers, treatment for melanoma works best when the cancer is found early.

This topic is about melanoma that occurs in the skin. It does not cover melanoma that occurs in the eye or in any other part of the body besides the skin.

What causes melanoma?

You can get melanoma by spending too much time in the sun. Too much sun exposure causes normal skin cells to become abnormal. These abnormal cells quickly grow out of control and attack the tissues around them.

Melanoma tends to run in families. Other things in your family background can increase your chances of getting the disease. For example, you may have abnormal, or atypical, moles. Atypical moles may fade into the skin and have a flat part that is level with the skin. They may be smooth or slightly scaly, or they may look rough and "pebbly." Having many atypical moles increases your risk of melanoma. Also, it may be a sign that melanoma runs in your family.

What are the symptoms?

The main sign of melanoma is a change in a mole or other skin growth, such as a birthmark. Any change in the shape, size, or color of a mole may be a sign of melanoma.

Melanoma may grow in a mole or birthmark that you already have. But melanomas may grow in unmarked skin. They can be found anywhere on your body. Most of the time, they are on the upper back in men and women and on the legs of women.

Melanoma may look like a flat, brown or black mole that has uneven edges. Melanomas usually have an irregular or asymmetrical shape. This means that one half of the mole doesn't match the other half. Melanoma moles or marks may be any size, but they are usually 6 mm (0.25 in.) or larger.

Unlike a normal mole or mark, a melanoma can:

  • Change color, size, or the shape of its border.
  • Be lumpy or rounded.
  • Become crusty, ooze, or bleed.

How is melanoma diagnosed?

Your doctor will check your skin to look for melanoma. If your doctor thinks you have melanoma, he or she will remove a sample of tissue from the area around the melanoma (biopsy). Another doctor, called a pathologist, will look at the tissue to check for cancer cells.

If your biopsy shows melanoma, you may need to have more tests to find out if it has spread to your lymph nodes.

How is it treated?

The most common treatment is surgery to remove the melanoma. That is all the treatment that you may need for early-stage melanomas that have not spread to other parts of your body.

After surgery, your doctor will set up a schedule of frequent checkups that will happen less often as time goes on. Your doctor will talk with you about how you can lower your chances of having another melanoma.

If your melanoma is very deep or has spread to your lymph nodes, your doctor may talk with you about taking a medicine called interferon. Or your doctor may recommend that you enroll in a clinical trial.

Can you prevent melanoma?

The best way to prevent all kinds of skin cancer, including melanoma, is to protect yourself whenever you are out in the sun. It's important to avoid exposure to the sun's ultraviolet (UV) rays.

  • Try to stay out of the sun during the middle of the day (from 10 a.m. to 4 p.m.).
  • Wear protective clothes when you are outside, such as a hat that shades your face, a long-sleeved shirt, and long pants.
  • Get in the habit of using sunscreen every day. Your sunscreen should have an SPF of least 15. Look for a sunscreen that protects against both types of UV radiation in the sun's rays-UVA and UVB.
  • Use a higher SPF when you are at higher elevations.
  • Avoid sunbathing and tanning salons.

Check your skin every month for odd marks, moles, or sores that will not heal. Pay extra attention to areas that get a lot of sun, such as your hands, arms, and back. Ask your doctor to check your skin during regular physical exams or at least once a year. Even though the biggest cause of melanoma is spending too much time in the sun, it can be found on parts of your body that never see the sun.


Preventing Skin Cancer

There are many risk factors for developing melanoma. The risk factor you can best control to reduce your risk of melanoma is exposure to ultraviolet (UV) radiation from the sun.

To help prevent skin cancer:

  • Protect your skin.
  • Stay out of the sun during the midday hours (10 a.m. to 4 p.m.).
  • Wear protective clothing. This includes a hat with a brim to shade your ears and neck, a shirt with sleeves to cover your shoulders, and pants. The best fabric for skin protection has a tight weave to keep sunlight out.
  • Use a sunscreen every day with an SPF of at least 15. Look for a sunscreen that protects against both types of ultraviolet radiation in the sun's rays-UVA and UVB.
  • Use a higher SPF when you are at higher elevations.
  • Set a good example for your children by protecting your skin from too much sun.
  • Avoid sunbathing and tanning salons. Studies suggest that your risk of melanoma increases by 75% if you start using artificial tanning before you are 30 years old.3
  • Examine your skin regularly, and have your doctor check your skin during all other health exams, or at least once a year.
    • People who burn rather than tan, especially those who have red hair or blue eyes, also have a high risk and should take extra precautions to prevent melanoma.



Early signs

The most important warning sign for melanoma is any change in size, shape, or color of a mole or other skin growth, such as a birthmark. Watch for changes that occur over a period of weeks to a month. Use the ABCDE rule to evaluate skin changes, and call your health professional if you have any of the following changes.

  • A is for asymmetry. One half of the mole or skin growth doesn't match the other half.
  • B is for border irregularity. The edges are ragged, notched, or blurred.
  • C is for color. The pigmentation is not uniform. Shades of tan, brown, and black are present. Dashes of red, white, and blue add to the mottled appearance. Changes in color distribution, especially the spread of color from the edge of a mole into the surrounding skin, also are an early sign of melanoma.
  • D is for diameter. The mole or skin growth is larger than 6 mm (0.25 in.) or about the size of a pencil eraser. Any growth of a mole should be of concern.
  • E is for evolution. There is a change in the size, shape, symptoms (such as itching or tenderness), surface (especially bleeding), or color of a mole.

Signs of melanoma in an existing mole include changes in:

  • Elevation, such as thickening or raising of a previously flat mole.
  • Surface, such as scaling, erosion, oozing, bleeding, or crusting.
  • Surrounding skin, such as redness, swelling, or small new patches of color around a larger lesion (satellite pigmentations).
  • Sensation, such as itching, tingling, or burning.
  • Consistency, such as softening or small pieces that break off easily (friability).

Melanoma can develop in an existing mole or other mark on the skin, but it often develops in unmarked skin. Although melanoma can grow anywhere on the body, it often occurs on the upper back of men and women and on the legs in women. Less often, it can grow on the soles, palms, nail beds, or mucous membranes that line body cavities such as the mouth, the rectum, and the vagina. On older people, the face is the most common place for melanoma to grow. And in older men, the most common sites are the neck, scalp, and ears.1

Many other skin conditions (such as seborrheic keratosis, warts, and basal cell cancer) have features similar to those of melanoma.

Later symptoms

Later signs of melanoma include:

  • A break in the skin or bleeding from a mole or other colored skin lesion.
  • Pain in a mole or lesion.

Symptoms of metastatic melanoma may be vague and include:

  • Swollen lymph nodes, especially in the armpit or groin.
  • A colorless lump or thickening under the skin.
  • Unexplained weight loss.
  • Gray skin (melanosis).
  • Ongoing (chronic) cough.
  • Headaches.
  • Seizures.


Diagnosis: Exams and Tests

Evaluation of a skin lesion

A physical exam of the skin is used to evaluate the skin for melanoma. If melanoma is suspected, a skin biopsy will be done. For this, your doctor will remove a sample of skin tissue and send it to a pathologist to be looked at under a microscope. If the biopsy shows melanoma, the pathologist will measure the thickness of the melanoma to find out how advanced the cancer is.

Other techniques may include total-body photography to monitor for changes in any mole and to watch for new moles appearing in normal skin. A series of photos of the suspicious lesions may be taken. Then the photos can be used as a baseline to compare with follow-up photos.

Evaluation of lymph nodes

Your doctor will do a physical exam that includes checking the lymph nodes to see whether they are larger than normal. This may be followed by a sentinel lymph node biopsy to see whether the melanoma has spread to the lymph system.

Evaluation for possible metastases (spread of cancer)

A complete medical history and a physical exam are needed to find out whether the cancer has spread (metastasized) to other parts of the body. Imaging tests, including positron emission tomography (PET scan), computed tomography (CT scan), or magnetic resonance imaging (MRI), may be used to identify metastases in other parts of the body, such as the lungs, brain, liver, or other organs.

Early Detection

Skin self-exam is a good way to detect early skin changes that may point to melanoma. A skin self-exam is used to find suspicious growths that may be cancer or growths that may develop into skin cancer (precancers). Adults should examine their skin once every month. Look for any abnormal skin growth or any change in the color, shape, size, or appearance of a skin growth. Check for any area of injured skin (lesion) that does not heal. Have your spouse or someone such as a close friend help you monitor your skin, especially places that are hard to see such as your scalp and back.

There are other steps you can take to prevent skin cancer or detect it at an early stage.

  • Be aware of the risk of skin cancer and the steps you can take to prevent it, including staying out of the midday sun, wearing protective clothing, and using sunscreen on exposed skin.
  • Have your doctor examine any suspicious skin changes. He or she may check your skin once a year. Or your doctor may suggest a skin exam more often, especially if you have:
  • Familial atypical mole and melanoma (FAM-M) syndrome, which is an inherited tendency to develop melanoma. Examine your skin every month and be examined by a doctor every 4 to 6 months, preferably by the same doctor each time.
  • Increased exposure to ultraviolet (UV) radiation because of your job, hobbies, or outdoor activities.
  • Abnormal moles called atypical moles (dysplastic nevi). These moles are not cancerous. But their presence is a warning of an inherited tendency to develop melanoma.

Treatment Overview

Surgical removal (excision) of the affected skin is the most effective treatment for melanoma. Excision involves removing the entire melanoma along with a border (margin) of normal-appearing skin. More treatment may be needed based on the stage of the melanoma.

Initial treatment

Melanoma may be cured if caught and treated in its early stages when it affects only the skin. If melanoma is confined to the skin (primary melanoma), you will have surgery to remove the affected skin. If the melanoma is thin and has not invaded surrounding tissues, excision may cure the melanoma. In more advanced stages, melanoma may spread, or metastasize, to other organs and bones, requiring additional treatment such as radiation, chemotherapy, or immunotherapy.

Treatments used for melanoma include:

  • Surgery. Your doctor may use one of these surgeries:
  • Local excision. This surgery takes out the melanoma and a little of the tissue around it.
  • Wide local excision. This surgery removes more of the tissue around the melanoma. Lymph nodes may also be removed during this surgery.
  • Lymph node dissection (lymphadenectomy). This is surgery to remove lymph nodes to see if they have cancer cells. Or this may be done to remove lymph nodes that are cancerous.
  • Sentinel lymph node biopsy. This surgery removes the first lymph node that the cancer may have spread to from the tumor. If this lymph node does not have any cancer cells, then you may not need to have more lymph nodes removed.
  • Chemotherapy.
  • Radiation therapy.
  • Immunotherapy.

Side effects of treatment

The side effects of treatment for melanoma will depend on the type of treatment you have and your age and overall health. The side effects of surgery, chemotherapy, or radiation may be mild enough that you can do things at home to manage them. See the Home Treatment section of this topic for more information.

Some of the treatment side effects can be avoided. For example, your doctor may prescribe medicines to control nausea and vomiting caused by chemotherapy. Be sure to talk to your doctor about all the side effects that you have.

Ongoing treatment

Regular follow-up appointments are important after you have been diagnosed with melanoma. Your doctor will set up a regular schedule of checkups that will happen less often as time goes on.

Learn to do a skin self-exam and to check for swelling in your lymph nodes, and report any changes to your doctor. It's a good idea to get in the habit of doing this skin and lymph-node check at the same time every month.

Treatment if the condition gets worse

Metastatic melanoma

Swollen or tender lymph nodes may be a sign that the melanoma has spread (metastatic melanoma). Any enlarged regional lymph nodes should be removed and checked for melanoma.

When melanoma has spread to only one tumor in another location, metastatic melanoma sometimes can be successfully treated with surgery. But metastatic melanoma usually responds poorly to most forms of treatment.

When successful treatment is not possible, the goal of treatment for metastatic melanoma is to control symptoms, reduce complications, and increase comfort (palliative care).

Your doctor may recommend that you join a clinical trial if one is available in your area. Clinical trials study other treatments, such as combinations of chemotherapy, vaccines, and immunotherapies. They are also studying targeted therapy with agents such as PLX4032 and ipilimumab.

Recurrent melanoma

Melanoma can come back after treatment. This called recurrent melanoma. This kind of melanoma, like metastatic melanoma, usually cannot be cured with treatment. But your medical team will keep you comfortable and help you live as long as possible. Treatments that may help include:

  • Surgery to remove any tumors.
  • Hyperthermic isolated limb perfusion. If the melanoma is on your arm or leg, chemotherapy medicine may be added to a warm solution and injected into the bloodstream of that limb. The flow of blood to and from that limb is stopped for a short time so the medicine can go right to the tumor.
  • Radiation or immunotherapy to relieve symptoms (palliative therapy).
  • Medicines injected directly into tumors.
  • Lasers to destroy tumors.
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