Skin changes are part of normal aging, but sometimes changes to the skin provide us with early warning of impending medical problems.
Sun exposure is the main risk of skin cancer, especially frequent sunburns in childhood. In addition to wrinkles, there are other common skin changes due to sun exposure. There are four main sun-related changes to keep an eye on.
Perhaps the most common skin change is seborrheic keratosis, or SK for short. These are not felt to be premalignant but are a marker of sun exposure in general. They have a brown, waxy, “stuck on” appearance. These are generally associated with aging – they are often called ‘wisdom’ spots – and they do run in families.
The most ‘benign’ form of skin cancer is basal cell carcinoma. These usually occur only in sun-exposed area and have the appearance of a non-healing, reddish ulcer with curled up edges – like a small volcano. They are slow growing and can be cured with early local excision alone. The Victorian name for these was ‘rodent’ ulcers because it was believed that mice might have chewed on the skin.
The next somewhat more aggressive skin cancer is squamous cell cancer of the skin. These also generally occur only in sun-exposed areas such as the scalp, nose, cheeks and ear tips and are slow growing. They are flat, reddish scab-like plaques – basically, “a scab that never heals”. If left untreated for a long time, these can spread to lymph nodes, rarely other places in the body. Caught early, local removal is all that is needed.
The most feared skin cancer is malignant melanoma. These are generally blackish moles that grow over time and in some cases at very early stages they can spread (metastasize) throughout the body. There is a worldwide epidemic of melanoma, especially in high sun areas such as Australia, South Africa and the Southwest United States where fair-skinned people have settled and are not able to fight sun exposure.
Learn more about the different types of skin cancer.
Standard chemotherapy is minimally effective in the treatment of melanoma; however, there has been an amazing amount of progress in the treatment of melanoma over the last 5 years with the explosion of immune therapy.
In the past, the observation was made that on rare occasion melanoma tumors would spontaneously regress on their own after a period of inflammation and vitiligo (white skin) around the tumors. Also in many cases, inflammatory white cells called lymphocytes were seen inside of tumors. In the 1980s, at the National Cancer Institute, Dr. Rosenberg started experimenting with growing tumor infiltrating lymph cells in the lab and re-injecting them into patients. For the first time, a few complete responses with the disappearance of all disease were seen in some patients and the responses were durable, or long-lasting. Further studies demonstrated that immune hormones such as interferon and interleukin-2 were somewhat effective in treating melanoma.
Over the last few years, the precise understanding of the process of immunity in melanoma has been revealed. Many melanoma tumors, (and other cancers, including lung and kidney cancers) have been found to cloak themselves from the immune system by secreting proteins around the tumor cells (CTLA-4 and PDL-1). This makes the tumor cells invisible to the immune system.
The new drugs that block the cloaking mechanism are called “immune-check-point” inhibitors. There are more than the initial three drugs on the market — ipilimumab (Yervoy), nivolumab (Opdivo) and pembrolizumab (Keytruda) — and many more to come. Depending on the setting, these can lead to complete responses in 20% -50% of patients and survivals in the 2-3 year range or longer. Our former president, Jimmy Carter was treated for brain metastasis from melanoma with one of the drugs and is now in complete remission almost a year later.
At the end of the day, prevention is still the key to preventing skin cancer. Moderate sun exposure is okay; 30-60 minutes per day and not at high-noon in the summer. Simple measures include covering up, wearing a hat with a brim and applying sunscreen – 30 SPF or better.
If you suspect a change in your skin is problematic, early recognition and evaluation by your primary care doctor or dermatologist is recommended. Based on the stage of cancer and other factors, your treatment options might include surgery, immunotherapy, targeted therapy, chemotherapy or radiation therapy.
Dr. Christopher Seidler is the medical director for The Cancer Center at Harrington. He was formerly an Associate Clinical Professor of Medicine, Department of Hematology/Oncology at UMass Medical Center and has won the Susan Komen Research Award, among many other accomplishments.
