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Common Skin Cancers

The following information is derived from the Cancer Council of Victoria. They can be contacted for more information on www.cancervic.org.au or email enquires@cancervic.org.au or on the cancer helpline 131 120.

The commonest skin cancers are basal cell carcinoma (carcinoma is another word for cancer). These types of skin cancers are generally less serious than melanoma but are much more common and cause a great deal of unnecessary suffering (and sometimes death) if not controlled.

Most Australians develop one or more of these common skin cancers in their later years – resulting from our outdoor lifestyle. Many people feel understandable, shocked and upset when they are told they have skin cancer.

What is cancer?

Cancer is a disease of the body’s cells. Our bodies are always making new cells: so we can grow, to replace worn-out cells, or to heal damaged cells after an injury. This process is controlled by certain genes. All cancers are caused by changes (mutations) to those genes. Changes usually happen during our lifetime, although a small number of people inherit a changed gene from a parent.

Normally, cells grow and multiply in an orderly way. However, changed genes can cause cells to behave abnormally. They may grow into a lump (or tumour). These lumps can be benign (not cancerous) or malignant (cancerous).

Benign lumps do not spread to other parts of the body but can cause problems nearby which require treatment.

A malignant tumour (more commonly called cancer) is made up of millions of cancer cells. When cancer first develops, it is confined to its original site. If it is not treated, cancer cells may invade into surrounding tissue and spread to other parts of the body. When these cells reach a new site they may continue to grow and form another tumour at this site. This is called secondary cancer or metastasis.

The Epidermis contains three different types of cells: squamous cells, basal cells and melanocytes, each of which can turn cancerous. Skin cancers are named after the type of cell from which they start. The three main types of skin cancer are basal cell carcinoma, squamous cell carcinoma and – the most serious cancer – melanoma.

Melanoma

Melanoma develops in the melanocytes. It can occur anywhere on the body. It may grow quickly, and if it is not treated, may spread to other parts of the body to form new secondary cancers. For more information on melanoma see www.cancervic.org.au

Basal Cell Carcinoma

Basal cell carcinoma is the most common but least dangerous type of skin cancer. About 75% of skin cancers in Australia are basal cell carcinomas. They grow slowly over months or years and very rarely spread to other parts of the body. However if they are not treated, they may for an ulcer (a break in the surface of the skin); as this deepens, it may cause damage to tissue and organs nearby – for instance, the eyelids or nose.

Basal cell carcinomas occur most often on the head, neck or upper body, though they may appear on other parts of the body. They usually start as a small, round or flattened lumps that are red, pale or pearly in colour, and may also appear as a small area of scaly skin, similar to a patch of eczema.

If you have one basal cell carcinoma, you are likely to have other, either at the same time or in later years. Basal cell carcinomas are most common in people over 40 years, but also occur in younger adults. Basal cell carcinomas are easily treated it detected early.

Squamous Cell Carcinoma

Squamous cell carcinomas are less common than basal cell carcinomas but are potentially more dangerous. They grow more quickly, usually over weeks or months and may spread to nearby lymph nodes or other parts of the body if not treated promptly. They occur most often (but not only) on the head, neck and forearms. A squamous cell carcinoma looks like a read scaly spot, usually thickened, which may bleed easily or ulcerate after some time. It may be tender to touch. Squamous cell carcinomas rarely occur before 40 years of age.

Causes of skin cancer

Skin cancer and solar keratoses generally develop because of too much UV radiation from the sun and the other sources such as solariums or sunlamps. Skin cancer seems related to “short sharp shocks” of sunburn, particularly during childhood, as well as exposure to UV radiation over a number of years.

Each time your unprotected skin is exposed to UV radiation from the sun or other sources such as solariums, the UV radiation caused changes to take place in the structure of the cells. In particular, UV radiation damages your genes. Too much UV radiation causes the skin to become prematurely damaged, and the damage will worsen as long as your skin is exposed to UV radiation.

UV radiation also decreases the ability of the immune system in the skin to recognise and attack newly forming skin cancer cells, making it easier for them to grow.

Skin cancer is one of the few almost totally preventable cancers. The most important years for sun protection are during childhood and adolescence. Sunburn and over exposure to UV radiation during these years greatly increase the chance of melanoma and other skin cancers later in life.

How common is Skin Cancer?

Over 380,000 Australians are treated for skin cancer every year. This is the highest rate in the world. In Australia, skin cancer is the most common type of cancer. Over 95% of skin cancers are cured if treated early.

Who is at risk?

Most Australians are at risk of sink cancer, but some more than others. They included people who:

• Are fair-skinned and don’t tan but go red in the sun
• Have freckles
• Were exposed to Australia’s sun as children
• Suntan or burn intentionally to make their skin appear browner
• Have a family history of skin cancer
• Work outdoors for long periods of time
• Use sunlamps, sunbeds and solariums

There is a greatly increased risk of squamous cell carcinoma if your immune system is lowered by drugs taken after an organ transplant.

Less common risk factors

If you take medicine that makes you more sensitive to sun exposure, take care to protect yourself. People who have received UV therapy for conditions such as psoriasis may also be as slightly higher risk. Ask your doctor if you are concerned about medicines you take. Other rare risk factors are overexposure – perhaps through heavy industrial use – to certain chemicals including coal tar, soot, pitch, asphalt, creosotes, paraffin waxes, petroleum derivatives and arsenic. Protective clothing should be warn if you handle these substances.

DIAGNOSIS

If you check your skin regularly, you will be able to identify early changes that could be skin cancer and get it checked by a doctor.

Skin cancer is not necessarily painful or itchy. If you notice anything unusual on your skin that is new or changing and does not go away within a couple of weeks, you should show it to your doctor.

How is skin cancer diagnosed?

Skin cancer is diagnosed by physical examination and biopsy. Your doctor will first examine the suspicious spot and will check other parts of your skin. A magnifying instrument (dermatoscope) may be used on suspicious spots.

Some people with lots of moles may be advised to have their skin photographed. This provides an ongoing “map” that is used for comparison of spots over time to see if they are changing.

It is a good idea for all adults to have an examination at least once to learn if they are at high risk of skin cancer. They may then be advised to have regular check-ups. Most people will be advised to regularly check their own skin, including their back, using a good light and partner or good sized mirror.

Biopsy

If your doctor suspects that you have a skin cancer and needs to confirm it, they will suggest that you have a biopsy.

This is a quick and simple procedure. It may be done by your local doctor, or you can be referred to a dermatologist or surgeon. The local doctor will give you a local anaesthetic and then use a scalpel to remove part or all of the spot and some of the surrounding tissue. You may have a stitch or stitches to help the wound heal.

The tissue that is removed is then sent to a laboratory to be examined under a microscope. It may take about a week for the result of you tests to be ready and a follow – up appointment may be arranged for you. This waiting period can be an anxious time and it may help to talk things over with a close friend or relative or your doctor.

Treatment

There are several ways to treat basal cell carcinoma and squamous cell carcinoma. In choosing the best treatment for you, your doctor will take into account a number of factors, including your age, general health, the type and size of the cancer, where it is on your body and what your want. The treatment choice will also depend on whether the cancer has spread anywhere else in your body, although this is unusual with common skin cancers.

Surgery

Most skin cancers can be simply cut out, along with a small area of normal skin from around the skin cancer. This is a simple operation that can usually be done in the doctor’s rooms under local anaesthetic. The wound is usually closed using stiches

If the cancer is large or spreading, you may need to be admitted to hospital to have a larger amount of skin removed to make sure all the cancer cells are removed. You may have a general anaesthetic for this. In most cases the wound can be stitched together and will heal as a straight scar.

Skin grafts or flaps

If a relatively large area of skin is removed, a skin graft may be required to cover the wound. For the graft, the surgeon will take a layer of skin from another part of your body and place it over the wound.

The other possibility is to do a “flap”, where the surgeon will cover the wound using a flap of skin near the wound. It is left attached at one end to provide blood supply. Most people, however, will be able to have the skin sewn up without a graft or flap.

After the operation

The wound will be covered with a dressing and left undisturbed for several days. You may also have dressings on any area from which skin was taken.

You may be uncomfortable for several days. If you have pain you doctor will prescribe painkillers for you.

If you have a skin graft, the area where the skin was grafted on may look unattractive immediately after the operation, but eventually it will heal and the redness will fade. There is a risk of infection, haematoma and scarring. Occasionally, the skin graft fails. If this happens, your doctor will advise you of the best next course of treatment.

Cryotherapy

If you have a solar keratosis or a common skin cancer that is small and not very deep, it may be possible to treat it by freezing it. This is known as cryotherapy. Liquid nitrogen is applied to the cancer to freeze it. This can cause a stinging or burning feeling.

Often people have some blistering and scabbing in the one to two weeks after treatment. It can take up to four weeks for the area to heal, and it may leave a pale scar. Areas treated on the leg can take longer to heal.

Sometimes more than one treatment is needed to remove the cancer or keratosis completely.

Curettage and cautery

This procedure is also known as electrodesiccation and curettage. If you have only a small basal cell carcinoma, your doctor may simply scrape it off under local anaesthetic using a small instrument called a curette. The doctor may then use cautery to control any bleeding and to destroy any remaining cancer cells. Cautery involves using a needle to pass a very mild electric current into the area. This technique commonly leaves a pale scar.

Radiotherapy

Radiotherapy treats cancer by using radiation to kill the cancer cells. It is given by machines that target intense beams of radiation onto the cancer.

Radiotherapy is not often used to treat early skin cancers, but it is valuable in situations where surgery could be difficult or disfiguring. It may also be used if a person is medically unfit for surgery. The main role for radiotherapy is to complement surgery in the treatment of locally advanced skin cancers and those that have spread to nearby lymph nodes. The treatment is often divided into several doses, given over two to six weeks depending on the severity of the problem. It is painless and only takes a few minutes for each treatment.

Side effects of radiotherapy

Sin in the treatment area may become red and sore after two or three weeks of treatment. From the start of your treatment, you will need to take care washing and avoid shaving the area or wearing clothing that can rub. Check with your doctor or nurse before using any talcum powders and lotions. Ask a member of your radiotherapy treatment team for a cream to ease any burning sensation.

Chemotherapy cream

This is the treatment of cancer with anti-cancer drugs. The drugs work by killing cancer cells.

If topical chemotherapy is used in skin cancer treatment, a cream containing a medication called 5-flurouracial (Efudix) is applied directly to the skin. It is used every day, often for several weeks. The skin in the area may become red and inflamed, but this will only be temporary and there are usually no other side effects. The advantage of this treatment is that you can do it at home, there are no injections and usually there is not scar. However, it is only recommended for shallow cancers.

Immunotherapy

This involves stimulating the body’s immune system to fight the skin cancer more vigorously. It is a promising new way of treating solar keratoses and some basal cell carcinomas.

A cream containing the drug imiquimod is applied to the cancer. It boosts the immune response in the area where it is applied. The treatment is taken for about six weeks. It causes reddening and sometimes scabbing of the affected skin, which may be present for up to three months. The skin settles down after treatment with no or little scarring.

Prognosis

More than 99% of people with basal cell carcinoma and squamous cell carcinoma are cured. The prognosis is good for most skin cancers that are found and treated early.

After your treatment for common skin cancers is complete, your doctor may want you to have regular check – up for a time to make sure there is no cancer remaining and that treatment has been successful.

Once you have had one skin cancer, you are at increased risk of developing another one. If you notice any changing or new spots, or are worried between appointments, it is a good idea to tell your doctor as soon as possible.

You will need to talk with your doctor about your own prognosis. Your medical history is unique, so you will need to discuss with someone who knows your medical history what you can expect and the treatment options that are best for you.

Do solar keratoses need treatment?

You may be advised to have a solar keratosis removed because your doctor feels it is at risk of becoming a squamous cell carcinoma. Or you may want to have one removed because of its appearance, or symptoms it is causing.

If you want a solar keratosis removed, the options are similar to those described above for common skin cancer: cryotherapy, cautery, chemotherapy cream or immunotherapy.

A solar keratosis may respond to a simple to a simple moisturiser and keeping it out of the sun. Most are easily treated with freezing (cryotherapy). If your doctor is not sure whether the spot is a skin cancer or a solar keratosis, a piece may be cut out and sent to a laboratory for diagnosis (biopsy).

Protecting your skin

Whenever UV radiation levels reach 3 (moderate) and above, sun protection is required. At that level UV radiation is intense enough to damage the skin and contribute to the risk of skin cancer. In Victoria from September to April, UV radiation levels are 3 and above for most of the day. Particular care should be taken between 10am and 2pm (11am and 3pm daylight saving time) when UV radiation levels reach their peak.

The SunSmart UV Alert is issued by the Bureau of Meteorology when the UV Index is forecast to reach 3 and above. It is reported in most daily newspapers and some television and radio weather forecasts across Australia.

To protect against skin damage and skin cancer when the UV level is 3 and above, use a combination of five sun protection measures:

• Seek shade
• Wear clothing that covers as much skin as possible
• Wear hats that protect the face, ears and neck
• Wear wrap-around sunglasses that meet the Australian Standard 1067 (sunglasses category 2,3 or 4)
• Use SPF 30+ broad spectrum, water resistant sunscreen, and reapply it every two hours.

From May to August, UV radiation levels in Victoria are usually low (below 3). Therefore, sun protection measures are not necessary during these months unless you are in alpine regions, or near highly reflective surfaces like snow or water.

Research into skin cancer

Researchers are continually looking for new, simple ways of preventing and treating skin cancer.

No method, other than avoiding UV radiation exposure, has been shown to prevent skin cancers.

With regard to treatment, a lot of attention is being paid to drugs and vaccines that stimulate the body’s immune response, and enhances its natural (but weak) ability to kill cancer cells.

Another newer approach is photodynamic therapy. This involves injecting or putting on the skin a chemical that is activated to kill cancer cells when the chemical is exposed to a certain kind of light. See Photodynamic Therapy.

You may want to ask your doctor about research and new treatments, including new treatments being tested in clinical trials.

GLOSSARY

The following list contains the meaning of words commonly used by doctors and other health professionals when discussing skin cancers.

Anaesthetic – a drug given to stop a person feeling pain. A “local” anaesthetic numbs the skin only; a “genera” anaesthetic causes temporary loss of consciousness.

Basal cell carcinoma – cancer arising from basal cells of the skin.

Basal cells – round cells that lie below the outer squamous cells of the epiderms in the skin.

Benign – not cancerous. Benign cells are not able to spread like cancer cells.

Biopsy – the removal of a sample of tissue from the body, for examination under a microscope, to assist diagnosis of a disease.

Carcinoma – cancer that begins in the tissue that lines the skin and internal organs.

Cautery – a method of destroying small areas of tissue using a small electric current, which is applied through a needle and which burns the skin cells.

Cells – the “building blocks” of the body. A human is made of billions of cells, which are adapted for different functions. Cells are able to reproduce themselves exactly, unless they are abnormal or damaged, like cancer cells.

Cryotherapy – the use of extreme cold to freeze and destroy unwanted cells.

Dermis – one of two main layers that make up the skin. The dermis is the second layer, which contains the roots of hairs, glands that make sweat, blood and lymph vessels and nerves.

Epidermis – one of two main layers that make up the skin. The epidermis is the surface layer, which contains basal cells, squamous cells and melanocytes.

Genes – the tiny factors that control the way the body’s cells grow and behave. Each person has a set of many thousands of genes inherited from both parents.

Haematoma – an accumulation of blood in the tissues that clots to form a solid swelling.

Immune system – one of the body’s defence systems, designed to protect us against anything it recognises as “foreign”, for example bacteria, viruses, transplanted organs and tissues, cancer cells and parasites.

Lymph vessels – part of the lymphatic system. Lymph flows through these vessels, which run throughout the body, carrying cells that help fight disease and infection. Lymph nodes filter the lymph to remove bacteria and other harmful agents, such as cancer cells.

Malignant – cancerous. Malignant cells can invade normal tissues and spread (metastasise) to other parts of the body.

Melanocytes – cells in the epidermis and elsewhere that produce melanin.

Melanoma – cancer of the melanocytes. The cancer usually appears on the skin, but may affect the eye and mucous membranes. Excessive exposure to UV radiation contributes to the development of melanoma.

Metastases – also known as ”secondaries”. Tumours or masses that develop when cancer cells break away from the original (primary) cancer and are carried by the lymphatic and blood systems to other parts of the body.

Mutation – a change in the genetic material of a cell or the change this causes in an individual.

Prognosis – an assessment of the course and likely outcome of a person’s disease.

Secondary cancers – cancer metastases.

Skin graft – a piece of skin that is taken from one are of the body to replace skin that has been lost from another area because of surgery or disease.

Solar keratoses – red or brown scaly areas that may appear on the skin that is exposed to sunlight. Often called sunspots.

Squamous cell carcinoma – cancer arising from squamous cells.

Squamous cells – flat skin cells that make up the epidermis and cover surfaces in the body. Squamous skin cells contain keratin, a protective substance that resists heat, cold and the effects of many chemicals.

Tissue – a collection of similar cells.

Tumour – a new or abnormal growth of tissue on or in the body.

Ulcer – a break in the skin that won’t heal and may be inflamed.

Ultraviolet (UV) radiation – the part of sunlight that causes sunburn and skin damage. Ultraviolet radiation is invisible and does not feel hot. Other sources of UV radiation include solariums, sunlamps and sunbeds.

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