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The Danger Behind Nonmelanoma Skin Cancers

Say the words “skin cancer,” and the most serious form, melanoma, is likely to be the first thing to come to mind. Melanoma is responsible for the vast majority of skin cancer–related deaths but accounts for only 1 percent of all skin cancers diagnosed.

In fact, basal cell carcinoma and squamous cell carcinoma are the most commonly diagnosed forms of skin cancers. Although rarely fatal and highly curable when caught early, they, like melanoma, require prompt treatment.

“The reality is, although they’re not as deadly as melanoma, nonmelanoma skin cancers can be disfiguring and lead to a long list of other serious complications if left untreated,” says Beth McLellan, M.D., director of oncodermatology at the Montefiore Einstein Center for Cancer Care and an assistant professor at Albert Einstein College of Medicine. “For example, basal cell carcinomas can cover wide areas and grow deep—damaging skin and bone—and cause ulcerations that lead to chronic wounds, which can then become infected. If basal cell develops in the eye area, it can threaten vision. Squamous cell carcinoma on the head and neck can grow deep enough to affect the nerves and underlying bone and cartilage.”

Though metastasis (the spreading of cancer to other parts of the body such as the lymph nodes) is rare for nonmelanoma cancers, it does occur. Metastatic disease affects less than 1 percent of basal cell carcinoma patients and up to 5 percent of squamous cell carcinoma patients.

According to some research, a personal history of these cancers can also signal an increased risk for other types of cancer, including breast and lung cancers for women and an increased risk of melanoma for both genders. “In other words, nonmelanoma cancers are not growths you want to ignore,” McLellan says.

Signs of skin cancer

An estimated 2 million or more Americans will be diagnosed with nonmelanoma cancers this year, according to the National Cancer Institute. Nonmelanoma cancers appear as an abnormal change, sometimes subtle, to an area of the skin. Signs of basal cell carcinoma and squamous cell carcinoma may include:

■ A rounded, pink, or skin-colored growth with visible blood vessels or brown or black spots, which may sink in the center like a crater and ooze, become crusty, or bleed easily.

■ A shiny pink or red and scaly growth, which may look like an eczema patch.

■ A waxy, hard, pale growth, which may resemble a scar with no definitive edges.

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■ A nonhealing sore.

■ A mole that has changed in appearance.

■ A flattened, reddish scaly patch.

Also, a small, rough patch of skin; a painful or itchy growth; or a dry, scaly patch on the lips may be a precancerous lesion called actinic keratosis.

The risk for developing nonmelanoma cancer is thought to be related to the amount of time your skin is exposed to the sun over your lifetime. According to the American Cancer Society, you’re more likely to develop basal cell carcinoma or squamous cell carcinoma if you tend to engage in outdoor recreation such as going to the beach, spend time in the sun wearing a bathing suit, live in a sunny area, or have a history of sunburns (the more sunburns, the higher your risk).

Some research suggests that you’re also at high risk, especially for melanoma, if you’ve spent intermittent periods in intense sunlight. People who use tanning beds also have an increased risk of skin cancer.

Skin cancer risk increases as you age—adults ages 55 to 75 are 100 times more likely to develop basal cell carcinoma than persons younger than 20. And having a fair complexion or a tendency to burn easily also increases the odds. But people with dark skin can develop skin cancer, too.

Other risk factors for skin cancer include a family or personal history of any form of skin cancer; a history of radiation therapy; exposure to certain UV light treatments, such as PUVA for psoriasis; a weakened immune system; exposure to arsenic (sometimes found in well water and insecticides); smoking tobacco; a history of trauma to the skin or severe burns (such as those caused by heat, chemicals, or electricity); and human papillomavirus.

Nonmelanoma skin cancers most often develop in areas frequently exposed to the sun, such as the head, neck, backs of the hands, legs, arms, shoulders, or trunk. Squamous cell carcinoma may appear in unexpected places, such as in the mouth (particularly among smokers and drinkers), on the lips, and in the genital area. African-Americans are more apt to develop squamous cell carcinoma in areas that don’t see the sun, such as the anus. But anyone, regardless of skin color or ethnicity, can develop nonmelanoma cancers.

Treating common skin cancers

A skin biopsy, which involves removal of part or all of the growth for analysis, is the only way to know for sure whether a growth is cancerous. If a biopsy shows the presence of cancer, your treatment options will depend on the type of cancer; its location, size, and stage; treatment side effects such as scarring; and your age, overall health, and skin cancer history. Your doctor should also consider your personal treatment preference and your ability to comply with any self- treatment and follow-up.

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In some cases, your doctor would have already removed the entire growth for a biopsy, and no further treatment is needed. If not, your doctor may recom- mend one of two primary surgical methods to treat basal cell carcinoma and squamous cell carcinoma:

1. Surgical excision is used to remove both low- and high-risk tumors. The procedure can be performed using local anesthesia in an outpatient setting. Surgical excision typically results in a one- to two- week healing period and will leave a scar.

2. Mohs micrographic surgery, a more time-consuming and costly procedure than surgical excision, is typically reserved for tumors that have an increased risk of recurrence and are in highly visible areas such as the face. Mohs is performed over several hours by a highly skilled surgeon while you’re under local anesthesia. Because Mohs preserves more tissue than excision, it leaves less scarring.

Your doctor may also recommend one or more other treatments in addition to or instead of surgery:

■ Radiation therapy used as a primary treatment is typically reserved for patients over age 60 who can’t tolerate surgery or who have tumors that can’t be surgically removed because of their size or location.

■ Curettage and electrodessication involves scraping away the tumor and using electricity to kill any remaining cancer cells.

■ Photodynamic therapy uses a combination of a chemical applied to the lesion and a special light directed at the treatment site to destroy cancer cells.

■ Topical prescription creams, ointments, or gels can be applied directly to an early-stage growth or lesion. Such prescriptions contain either a mild chemotherapy drug or a drug that boosts the immune system to destroy the cancer.

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■ Cryotherapy harnesses the power of liquid nitrogen to freeze and destroy cancerous cells. It’s used on small, non- invasive, low-risk lesions.

■ Targeted therapy in oral drug form may be prescribed in extremely rare cases when basal cell carcinoma metastasizes and can’t be surgically removed or treated with radiation.

Because skin cancer recurrence is most common in the first few years after treatment, it’s crucial to see your doctor regularly, which can be as often as once a month.

Keeping skin cancer at bay

Overall, the prognosis for basal cell carcinoma and squamous cell carcinoma when caught early is excellent, with five-year cure rates at greater than 90 percent.

Survival rates drop dramatically with metastasis, however: For squamous cell carcinoma, only 25 to 35 percent of patients are alive at five years if the cancer metastasized to the lymph nodes (the survival rate drops to less than 10 percent if there are distant metastases), and less than 20 percent are still alive at 10 years. Basal cell carcinoma that has spread also has a poor prognosis; average survival time after diagnosis of metastasis may be anywhere from 10 months to slightly more than seven years.

“The good news is that many nonmelanoma skin cancers can be prevented with some simple measures: Using and reapplying sunscreen often, avoiding midday sun, wearing a hat to protect your face and scalp, covering up your arms and your legs, and avoiding tanning beds,” McLellan says. “This is a case where a little bit of prevention goes a long way.”

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