15 Dec Dermatologist Discusses Personalized Approach to Skin Cancer Treatment
MedicalResearch.com Interview with:
Dr. Kristine A. Romine MD
CEO and Founder of Camelback Dermatology & Skin Surgery
MedicalResearch.com: Would you give a brief overview of the different types of skin cancer?
Response: There are multiple types of skin cancer, including: melanoma, basal cell carcinoma, squamous cell carcinoma, and actinic keratosis. Known as the deadliest form of skin cancer, melanoma develops when irreparable DNA damage results in malignant transformation of melanocytes. This type of skin cancer is most commonly caused by intense UV exposure from the sun or tanning beds, which activate mutations that lead skin cells to rapidly multiply and form malignant tumors. Melanoma can range in color from dark brown to black and are rarely red or even skin colored. They are usually irregular and asymmetrical. In 2018, there were an estimated 91,270 new cases of melanoma (American Cancer Society, 2018).
Basal cell carcinoma (BCC) is the most common type of skin cancer and cancer diagnosed. BCCs arise in the skins’ outermost layers. BCCs resemble open sores, red or pink plaques, pearly nodules with telangiectasia, or scars. It is estimated that 4.3 million BCCs are diagnosed in the U.S. every year (Skin Cancer Foundation, 2018).
Squamous cell carcinoma (SCC), the second most common type of skin cancer, arises from the squamous cells in the skin that have been exposed to UV over long periods of time. SCCs appear as scaly red or pink macules, papules, or plaques. They can be crusted and appear eroded and can commonly arise within a solar keratosis. More than 1 million cases of SCC are diagnosed in the U.S. every year (Skin Cancer Foundation, 2018).
Lastly, actinic keratoses (AKs) are the most common pre-cancerous skin growth that can develop into a SCC if left untreated. Similar to all other types, AKs are caused by exposure to UV light and, in rare cases, high exposures to x-rays. AKs can appear on sun-exposed areas, including the face, scalp, ears, shoulders, and legs. They resemble pink, scaly rough patches on the skin.
MedicalResearch.com: Which types of skin cancers are more dangerous – i.e. more likely to metastasize? Who is most at risk?
Response: All types of skin cancer can become dangerous if not diagnosed and treated early, but melanoma is the most deadly, as it becomes more invasive and metastasizes more often than other tumor types. While skin cancers can affect various types of people regardless of age or race, epidemiological studies show a role for genetic predisposition and sun exposure. Other factors that can increase a person’s risk for developing skin cancer are fair skin, sunburns, personal history of melanoma, family history of melanoma or dysplastic nevi, greater than 50 moles greater than 5mm in size, and greater than 5 dysplastic nevi (Wolff, Johnson, & Saavedra, 2013). Organ transplant recipients have a higher risk for developing SCCs as well.
MedicalResearch.com: What are some of the various treatment options for skin cancer? Do all skin cancers need to be treated with surgery?
Response: While Mohs surgery is considered the gold standard when it comes to nonmelanoma skin cancer and excision for melanoma, there are other treatment options. It is important to keep in mind that surgery may not be appropriate for all patients, especially those who may be high-risk. When reviewing the patient’s pathology report with the patient, I imagine that I am counseling a family member or friend. This allows me to find the best treatment option for them and their unique circumstance.
Following diagnosis, I discuss what treatment options are available for each patient and their unique circumstances. We discuss all of the important pros and cons to consider with each plan. In addition to Mohs surgery, there is Superficial Radiation Therapy (SRT), a non-surgical treatment option that is particularly beneficial for my surgically fatigued patients or patients who are not good surgical candidates. Patients who are very active or are on blood thinners often prefer a non-surgical option. Patients need to be made aware of the risks and benefits of each treatment. One treatment does not fit every skin cancer patient and dermatologists have the ethical responsibility to educate themselves and their patients about all available options.
MedicalResearch.com: What is the risk from actinic keratosis? Do all AKs need to be treated? How likely are AKs to turn into SCCs that may become invasive or metastasize?
Response: AKs, or precancers, have a risk for developing into SCCs if not treated, as discussed above. There is no way to determine which AKs will develop into SCCs, but 40-60% of SCCs began as AKs. If left untreated, SCCs may become invasive or spread to other areas of the body. This is why it is important to treat AKs. The more AKs a person has and the longer it takes to diagnose and treat them, the higher the person’s risk is for developing an SCC. Statistics show about a 10% lifetime risk of an AK turning into an SCC.
MedicalResearch.com: How do you decide the best treatment options for a particular patient? Can some tumors (i.e. BCCs, small SCCs, or lentigo malignas) be observed and followed, rather than aggressively treated, especially in the elderly or sick?
Response: When deciding the best treatment option for each patient, I look at their complete history. In addition to the tumor type and location, the patient’s lifestyle and limitations must also be considered. Are they physically active? Will they be able to adhere to post-operative wound care instructions? What medications, especially blood thinners are they currently taking or what other medical conditions do they have? Do they live a far distance from my office? These are all important factors when selecting a treatment plan.
Even for the very elderly, if the skin cancer is bothersome or painful to the patient and they would like it removed, I remove it. For elderly or sick patients, I look at their support system to see if they will have post-operative wound care. However, if the patient is not bothered by the skin cancer and their quality of life would not be improved with treatment and has a high risk of causing more morbidity than the cancer itself, then the best course of action would be to observe and follow-up with the patient.
MedicalResearch.com: Is there anything else that you would like to add? Any disclosures?
Response: I am a board-certified Dermatologist who offers both Mohs surgery and Superficial Radiation Therapy in my office. It is my ethical responsibility to make sure that I have all available tools in my toolbox to treat all different types of patients. I have extremely satisfied patients who trust me to help them make the correct decision on treatment modality.
American Cancer Society. (2018). Cancer facts & figures: 2018. Retrieved from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2018/cancer-facts-and-figures-2018.pdf
Wolff, K., Johnson, R.A., & Saavedra, A.P. (2013). Fitzpatrick’s color atlas and synopsis of clinical dermatology (7th ed.). McGraw Hill Education: New York, NY.
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