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Skin Cancer Prevention and Early Detection

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									Skin Cancer
Prevention and Early Detection

This activity is accredited for up to 1 hour of AMA PRA Cat. 1 credit. To obtain CME credit for this module, complete and print out the online evaluation and return with $10 to: TMA/POEP 401 West 15th Street Austin, TX 78701-1680

Skin Cancer:
Prevention and Early Detection
Objectives: After completion of this module, the primary care physician should be able to: 1. Describe melanoma and nonmelanoma skin cancer mortality and incidence. 2. Describe the changes over the past several decades in the epidemiology of skin cancer. 3. Describe the magnitude of the skin cancer problem in the United States. 4. Identify persons who are at increased risk of skin cancer.

Skin Cancer:
Prevention and Early Detection
Objectives (continued): 5. Counsel patients concerning skin cancer prevention. 6. Identify cutaneous lesions that may be cancer or precursor lesions. 7. Help perform skin cancer screening. 8. Recommend and refer for appropriate management of suspicious lesions. 9. Relate prognosis of patients found to have malignant melanoma.

Skin Cancer Incidence and Mortality
1,300,000 47,700

7,700 New Cases
1,900 Deaths New Cases

Deaths Deaths

(basal and squamous cell)


Source: Cancer Statistics 2000, American Cancer Society

Mortality from Skin Cancer

• Malignant Melanoma • Squamous Cell Carcinoma • Basal Cell Carcinoma

~ 20% 2% < 1%

Primary Prevention of Skin Cancer
Avoid Exposure to Ultraviolet Radiation • Use sunscreen > SPF 15 • Wear hats and other protective clothing • Schedule outdoor activities before 10am and after 4pm • Avoid all indoor tanning activity including tanning salons

Primary Prevention of Skin Cancer
Proper Use of Sunscreens
• Apply generously and evenly • Reapply every 2 hours - if perspiring - if swimming • Consider waterproof formulas

Secondary Prevention of Skin Cancer
Screening and Early Detection • Inspect moles for changes • Remove suspicious moles • Remove actinic keratoses and other precancerous lesions

Screening for Skin Cancer
Suitability to Screening • Disease is highly prevalent • Causes significant morbidity and mortality • Natural history known • Early treatment reduces morbidity and mortality • Acceptable, safe, inexpensive screening test available

Recommendations for Skin Cancer Screening
• Skin examinations by a physician, as part of every cancer-related checkup • Monthly self-examinations are recommended for persons with: - personal history of skin cancer - family history of skin cancer - precursor lesions - sun damaged skin

Screening Examination for Skin Cancer
• • • • Source of bright light Examination table Magnifying lens Hand-held blow dryer

Incidence per 100,000 persons







25-34 35-44

55-64 65-74


Nonmelanoma Skin Cancer by Age

Risk Factors for Nonmelanoma Skin Cancer
1. 2. 3. 4. 5. 6. 7. 8. Exposure to ultraviolet radiation Fair skin Exposure to chemical carcinogens Exposure to viral carcinogens Exposure to ionizing radiation Chronic irritation or inflammation Immunosuppression / photosensitive drugs Family history/ genetics / propensity to sunburn

Nonmelanoma Skin Cancer & Complexion
Skin Type

Sunburn/Tanning History
Always burns, never tans Always burns, minimal tan Burns often, tans gradually (light brown) Burns minimally, tans well (moderate brown) Burns rarely, tans profusely Never burns, deeply pigmented (black)

Source: Fitzpatrick, et al. Dermatology in General Medicine. 1987.

Clinical Course of Basal Cell Carcinoma
• Usually slow growing • Rarely metastasizes • May cause functional or cosmetic impairment

Clinical Appearance of Basal Cell Carcinoma
• Pink, pearly, translucent papules with prominent telangiectasia • May ulcerate in center • Uncommon subtypes - Scar-like appearance - Red macules

(pictures of Basal Cell Carcinoma)

Precancerous Lesions
• Precursors to squamous cell carcinoma – Actinic keratoses – Bowen’s disease – Red scaly macules on sunexposed area

(picture of Actinic keratosis)

Treatment of Actinic Keratosis
• • • • • • • Liquid Nitrogen Trichloroacetic acid Topical cream Actinex Chemical peels Dermabrasion Laser

(pictures of Liquid Nitrogen [on skin])

Clinical Course of Squamous Cell Carcinoma
• Faster growing • May metastasize (3 - 30%) • May cause functional or cosmetic impairment

Clinical Appearance of Squamous Cell Carcinoma
• • • • Red nodule With or without ulceration On sun-exposed skin On traumatized skin

(pictures of squamous cell cancer)

Biopsy of Nonmelanoma Skin Cancer
• Shave biopsy • Punch biopsy

Punch Biopsy
• Local anesthesia • Sizes: 2 - 3 - 4 - 5 - 6 mm • Control of bleeding - Chemical - Electrical - Suturing

(picture of biopsy of lesion on nose)

Treatment of Nonmelanoma Skin Cancer
• • • • • • Curettage and electrodessication Moh’s micrographic surgery Cryosurgery Excision Radiation therapy Photodynamic therapy

Risk of Developing Second Nonmelanoma Skin Cancer
• 50% within 5 years • Greatest risk within the 1st year (20%)
Source: Marghoob, et al. 1993

Part II - Melanoma
Lifetime Risk of Malignant Melanoma Rate / 100,000

Projected 2000 1996 1992 1985 1980 1960 1935 1:1500 1:600 1:250

1:75 1:87 1:105 1:150

Adapted from: Rigel, et al. J. Am. Derm. 34: 839-47, 1996.

Risk Factors for Malignant Melanoma
• • • • • • • Prior history of skin cancer Fair skin Family history Sun exposure Immunosuppression Age Precursor lesions

Previous Skin Cancers as a Risk Factor for Melanoma
History of Skin Cancer Previous melanoma Previous nonmelanoma skin cancer or precancer Relative Risk 9 4

Source: Balch, et al, 1992; Rhodes, 1987.

Additional Risk Factors for Melanoma
• • • • Light pigmentation Family history of malignant melanoma >3 sunburns during childhood >3 years outdoor occupation during childhood • Immunosuppression
Source: Balch, et al, 1992.

Age as a Risk Factor
Number of Cases >70 60-69 50-59 40-49

4,950 (28%)
3,338 (19%) 2,642 (15%)

2,981 (17%) 2,640 (15%)
1,096 (6%)


National Cancer Database. Demographic characteristics of patients diagnosed with Malignant Melanoma of the skin, 1994

Precursor Lesions as a Risk Factor for Melanoma
Precursor Lesions
Changing mole Dysplastic mole/ familial melanoma Dysplastic mole/ no familial melanoma Congenital mole Lentigo maligna

Relative Risk
>400 148
27 21 10

Source: Balch, et al., 1992; Rhodes, 1987.

A – Asymmetry B – Border C – Color D – Diameter

(pictures of 2 Dysplastic Nevi)

Benign Pigmented Lesions
• • • • • • Simple Lentigo Junctional nevus Compound Nevus Intradermal nevus Solar lentigo Seborrheic keratosis

Benign Pigmented Lesions
• • • • • • Simple lentigo Junctional nevus Compound nevus Intradermal nevus Solar lentigo Seborrheic keratosis

(picture of a Benign Nevus)

(pictures of the following) Superficial Spreading Melanoma Lentigo Maligna Melanoma Nodular Melanoma

Acral Lentiginous Melanoma

Biopsy for Malignant Melanoma
• Incisional • Narrow Excisional • Avoid shave biopsies if clinician is suspicious of melanoma

Establishing Prognosis in Melanoma
• • • • Thickness of tumor Location of tumor Ulceration Clark Level IV/V

Definitions of TNM


Primary Tumor Regional Lymph Node Involvement
Distant Metastasis


The AJCC Revised Melanoma Staging 2002
Stage TNM Classification IA IB IIA T1a N0 M0 T1b N0 M0 T2a N0 M0 T2b N0 M0 T3a N0 M0 T3b N0 M0 T4a N0 M0 T4b N0 M0 T1-4a N1a M0 T1-4a N2a M0 Histologic/Clinical Features <1 mm without ulceration and level II/III <1 mm with ulceration or level IV/V 1.01-2 mm without ulceration 1.01-2 mm with ulceration 2.01-4 mm without ulceration 2.01-4 mm with ulceration >4 mm without ulceration >4 mm with ulceration Single regional nodal micrometastasis, nonulcerated primary 2-3 microscopic positive regional nodes, nonulcerated primary


The AJCC Revised Melanoma Staging 2002 (continued)
Stage TNM Classification
IIIB T1-4a N1b M0 T1-4a N2b M0 T1-4a/b N2c M0

Histologic/Clinical Features
Single regional nodal macrometastasis, nonulcerated primary 2-3 macroscopic regional nodes, no ulceration of primary In-transit met(s)* and/or satellite lesion(s) without metastatic lymph nodes Ulcerated primary with 1-3 regional nodal micrometastasis 1 macroscopic metastatic regional node, ulcerated primary 2-3 macroscopic metastatic regional nodes, ulcerated primary

T1-4b N1a/N2a M0
IIIC T1-4b N2a M0 T1-4b N2b M0

The AJCC Revised Melanoma Staging 2002 (continued)
Stage TNM Classification IIIC Any T N3 M0 Histologic/Clinical Features 4 or more metastatic nodes, matted nodes, or in-transit met(s), and/or satellite lesion(s) and metastatic nodes Distant skin, subcutaneous, or nodal mets with normal LDH levels Lung mets with normal LDH All other visceral mets with normal LDH or any distant mets with elevated LDH


Any T any N M1 Any T any N M2 Any T any N M3

Swetter, Susan M., MD. “Malignant Melanoma.” eMedicine Journal 2.5 (2001). 12 Jun. 2001 <>.

Malignant Melanoma:
Relative Survival According to AJCC Stage
Stage IA IB IIA IIB IIC IIIA TNM Classification T1a N0 M0 T1b N0 M0 T2a N0 M0 T2b N0 M0 T3a N0 M0 T3b N0 M0 T4a N0 M0 T4b N0 M0 T1-4a N1a M0 T1-4a N2a M0 5 Year Survival Rate (%) >95 80-95 70-80 50-70 30-50 60-70 50-60

Malignant Melanoma:
Relative Survival According to AJCC Stage
Stage IIIB TNM Classification T1-4a N1b M0 T1-4a N2b M0 T1-4a/b N2c M0 T1-4b N1a/N2a M0 T1-4b N2a M0 T1-4b N2b M0 Any T N3 M0 Any T any N M1 Any T any N M2 Any T any N M3 5 Year Survival Rate (%) 40-50 20-40 30-50 30-45 20-30 10-30 10-30 5-10 <5 <5



Swetter, Susan M., MD. “Malignant Melanoma.” eMedicine Journal 2.5 (2001). 12 Jun. 2001 <>.

Treatment for Malignant Melanoma
Surgical margins are based on depth Lesion Margin In situ 0.5 cm < 1mm 1.0 cm > 1mm 2.0 cm
Source: Balch, et al, 1992

Sentinel Node Biopsy
• Standard of care • Recommended for Breslow depth melanoma > 1mm or any Breslow depth melanoma which exhibits ulceration or is a Clark Level IV/V • Identifies nodal involvement without radical lymph node dissection

Biopsy Pearls
• Never perform a shave biopsy • Never perform a biopsy and discard the specimen • Always orient extremity biopsies in the long axis of the extremity • Do not feel obligated to complete an excisional biopsy for large lesions • Do not complete a wide local excision or any type of rotational flap/skin grafting

Clinical Course of Melanoma

• If treated early: 100% cure rate • If untreated: 100% mortality

Incidence of All Skin Cancer Increasing

• Increase in recreational sun exposure • Depletion of ozone layer

• Basal cell – most common • Melanoma and squamous cell - present the greatest risk to life • Counsel patients to use sunscreens daily and to report any changes in moles • Risk factors - changing moles, exposure to UV-B, fair skin that burns easily • High risk persons - annual complete skin exams

Reading List
2. 3.

4. 5.


American Cancer Society. Good News about Skin Cancer - Slide Set. Publication No. P-72, March 1989. American Joint Committee on Cancer. Manual for Staging of Cancer, 5th Edition. J.B. Lippincott Company, Philadelphia, 1997. Balch CM, Houghton A, Peters L. Cutaneous Melanoma, Chapter 44, In: DeVita VT, Jr., Hellman S, Rosenberg SA (eds), Cancer: Principles & Practice of Oncology, 3rd Edition. J.B. Lippincott Company, Philadelphia, 1988. Balch CM, et al. Cutaneous Melanoma, 2nd Edition. J.B. Lippincott Company, 1992. Boring CC, Squires TS, Tong T. Cancer statistics, 1992. Cancer J Clin 43: 7-26, 1993. Breslow A. Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma. Ann Surg 172: 902-908, 1970.

Reading List
7. 8. Breslow A. Prognosis in cutaneous melanoma: Tumor thickness as a guide to treatment. Pathol Annu Part 1:1 20, 1980. Chuang TY, et al. Basal cell carcinoma. A population based incidence study in Rochester, Minnesota. J Am Acad Dermatol 22(3): 413-7, 1990. Chuang TY, et al. Squamous cell carcinoma. A population bases incidence study in Rochester, Minnesota. Arch Dermatol 126(2): 185-8, 1990. Clark WII Jr. The histogenesis and biological behavior of primary malignant melanoma of the skin. Cancer Res 29: 705-717, 1969. Fitzpatrick TB, et al. Dermatology in General Medicine, 3rd Edition. McGraw Hill, Vol. 1, 1987. Freidman RJ, Rigel DS, Kopf AW. Early detection of malignant melanoma: The role of the physician examination and selfexamination of the skin. Publication No. 90-40M-No. 334-PE, American Cancer Society, 1990. Gillmore GD. Sunscreens: A review of the skin protection value and educational opportunities. J Sch Health 59(5): 210-213, 1989.


10. 11. 12.


Reading List
14. 15. Girasek DC. Motivating the public to take advantage of skin cancer screening. J Am Acad Dermatol 15 (2pt 1):309-315, 1986. Koh HK, Lew RA, Prout MN. Screening for melanoma/skin cancer: Theoretic and practical considerations. J Am Acad Dermatol 20 (2 pt 1): 159-172, 1989. Mackie R. Skin Cancer. Year Book Medical Publishers, Inc., Chicago, Ill., 1989. Marghoob A, et al. Risk of another basal cell carcinoma developing after treatment of a basal cell carcinoma. J Am Acad Dermatol 28:22-8, 1993. Miller SJ. Biology of basal cell carcinoma (part I). J Am Acad Dermatol Jan;24(1):1-13, 1991 Miller SJ. Biology of basal cell carcinoma (part II). J Am Acad Dermatol Feb;24(2 pt 1): 161-75, 1991. Popescu, NA et al. Cutaneous malignant melanoma in Rochester, Minnesota: trends in incidence and survivorship, 1950 through 1985. Mayo Clinic Proc 65(10): 1293-302, 1990. Preston DS, Stern RS. Nonmelanoma cancers of the skin. N Engl J Med Apr 22;328(16): 1199, 1993. Rigel DS, et al. Importance of complete cutaneous examination for the detection of malignant melanoma. J Am Acad Dermatol 15 (5 pt 1): 857860, 1986.

16. 17. 18. 19. 20.

21. 22.

Reading List
23. Rhode AR. Risk factors for cutaneous melanoma: a practical method of recognizing predisposed individuals. JAMA, 258: 3146-54, 1987. 24. Shouse T, Day CT, Jr. Cutaneous Malignant Melanoma - Slide Presentation. American Cancer Society, Texas Division, Publication No. M68.10, 1989. 25. National Institute of Environmental Sciences. Report on Carcinogen. 9th Edition, 2000. 26. Texas Cancer Data Center. 2000. 27. American Cancer Society. 2000. <>. 28. Balch, CM, et al. A New American Joint Committee on Cancer Staging System for Cutaneous Melanoma. Cancer. 88(6):14841491, 2000. 29. Swetter, Susan M. Malignant Melanoma. eMedicine Journal. 2(5), 2001. <>. 30. Sunbelt Melanoma Trial. 2000.

Other POEP CME Modules
• • • • • • • • • Breast Cancer (in CD-ROM format) Cancer in Special Populations Cervix Cancer Head and Neck Cancer Lung Cancer Nutrition and Cancer Risk Reduction Prostate Cancer Colorectal Cancer Surveillance of Cancer Patients

To order these modules in spiral bound or 35mm slide format, contact POEP at or call 800-880-1300, ext. 1672.

To obtain CME credit for this module, complete and print out the online evaluation and return with $10 to: TMA/POEP 401 West 15th Street Austin, TX 78701-1680
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