What's New in Skin Cancer Treatment

8/10/2019 What's New in Skin Cancer Treatment

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SKIN CANCER

THE EPDIMIC AND THE UPDATE

Ali Hendi, MD

Private Practice

Clinical Assistant Professor

Georgetown University, Washington DC


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SKIN CANCER

OVERVIEW

STATS

TYPES

CAUSES TREATMENT

UPDATE

EPIDIOMIOLOGY

TREATMENT

PREVENTION


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Skin Cancer Facts

Skin cancer is the most common form of cancer in the United States.

One in five Americans will develop skin cancer in the course of a lifetime.

More than 20 Americans die each day from skin cancer, primarilymelanoma (the deadliest form of skin cancer). One person dies ofmelanoma almost every hour.

Melanoma accounts for about three percent of skin cancercases, but it causes more than 75 percent of skin cancerdeaths.
http://www.skincancer.org/adserver/adclick.php?bannerid=1&zoneid=1&source=&dest=/


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What is Skin Cancer?

Skin cancer is a malignant condition that begins with theuncontrolled growth of abnormal cells typically in the toplayer of the skin.

There are two broad categories of skin cancers: melanoma(MM)and non-melanoma skin cancers(NMSC). Both can

occur when skin DNA damaged by ultraviolet radiation (UVR)is not properly repaired by the immune system.

Melanomacan start when the protective pigment cellsthat give skin its natural color become malignant. This can

be due to UV exposure or other damage. NMSCcan occur when the DNA of the keratinocytes, the

main cell type in the skins top layer, is damaged by UVR.


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What Causes Skin Cancer?

Ultraviolet Radiation (UVR)UVR is a proven human carcinogen.

Up to 90% of all non-melanoma skin

cancers are caused by exposure to

the suns harmful UV rays.

Tanning

First exposure to tanning beds in

youth increases your chances of

developing melanoma by 75 percent,

and indoor tanners have an increasedrisk of all skin cancers.


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Who is at Risk?

A person with a parent or sibling diagnosed

with melanoma has a 50% greater chance

of developing the disease than those without

a family history of melanoma.

People with fair skin, light eyes and light hair

are at higher risk of developing skin cancer.

Skin cancer occurs infrequently but is mostdeadly for African American, Latino and

Asian populations due to a low early

detection rate.

People of all ethnic groups and skin types can be affected.


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Precancers or Precursors to CancerActinic Keratosis

Actinic keratosis (AK), also known as solar keratosis, isthe most common precancer.

Up to 10 percent of AKs become squamous cellcarcinomas (SCCs) within two years, and 40-60 percent of

SCCs begin as untreatedAKs.

Dysplastic Nevi

Dysplastic nevi, also known as atypical moles, are largebenign moles that can resemble melanoma.

People with dysplastic nevi are at an increased risk ofmelanoma. The larger the number of atypical moles, thegreater the risk.


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Actinic Keratosis: What to Look For

Small crusty or scaly bumps or horns thatarise on or beneath the skin surface.

Often red, but may be tan, pink, or a

combination of colors.

Sometimes itch; can also become

inflamed and occasionally bleed.

Usually grow from 1/8 1/4 (2mm

4mm), but can be larger.


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Types of Skin Cancer

There are three main types of skin cancers:

Basal cell carcinoma (BCC)

Squamous cell carcinoma (SCC)

Melanoma


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Basal Cell Carcinoma

The most common form of skin cancer, affectingabout 1 million Americans each year.

More men than women are affected, but BCC is

becoming increasingly common among women.


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BCC: What to Look for

An open sorethat bleeds, oozes or crusts

and remains open for weeks.

A shiny bumpor nodule that is pearly ortranslucent and is often pink, red or white.

A reddish patchor irritated area.

Sometimes crusts; it may itch or hurt.

A pink growthwith an elevated rolledborder and a crusted indentation.

A white, yellow or waxyscar-like area,often with poorly defined borders.

An Open Sore

A Reddish Patch

Scar-Like Area


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Squamous Cell Carcinoma (SCC)

Squamous Cell Carcinoma (SCC) is the second most

common skin cancer, affecting more than 250,000

people each year.

Between two and 10 percent of SCCs spread to

distant tissues and organs. SCC causes about 2,500

deaths per year.


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SCC: What to Look For

A wart-like growththat crusts and occasionally

bleeds.

An open sorethat bleeds and crusts, persisting

for weeks.


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SCC: What to Look for

An elevated growthwith a central depression thatoccasionally bleeds.

A persistent, scaly red patchwith irregular borders

that may crust or bleed.


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Melanoma

Melanoma is the deadliest form of skin cancer, butwhen caught early is almost always curable.

Moles with certain characteristicsthe ABCDEsareearly warning signs of melanoma.


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Melanoma: Ais for Asymmetry

An asymmetricalmole has sides that do not match.

A symmetrical, benign mole An asymmetrical melanoma


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Melanoma: Bis for Border

The borders of melanomas tend to be uneven, with scalloped or notched

edges.

A benign mole with an even border A melanoma with uneven borders


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Melanoma: Cis for Color

Melanomas are often multicolored, in shades of brown or black,

or even red, white or blue.

A benign, solid colored mole A multicolored melanoma


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Melanoma: Dis for Diameter

Melanomas are usually bigger than a pencil eraser(1/4 or 6mm) in diameter.

A small, benign mole A melanoma


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Melanoma: Eis for Evolving

Common moles look the same over time. Keep an eye out for

moles that evolveor change in any way.

Before

An evolving malignant mole

After


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Treatment of Skin Cancers

Depending on the degree of advancement and the type of skin cancer,several treatment options are available, including:

Mohs Micrographic Surgery

Excisional surgery

Curettage and electrodesiccation Topical Medications

Photodynamic Therapy (PDT)

Radiation

Cryosurgery

Laser Surgery

Chemotherapy

Biotherapy or Immunotherapy


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WHATS NEW/ UPDATE

EPIDIOMIOLOGY

TREATMENTS

PREVENTION


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EPIDEMIOLOGY

2014 ACS STATS EPIDMIC OF SKIN CANCER

3.5 Million NMSC in 2 Million people in US

Melanoma rates have been increasing for the last 30 years

76K new Melanoma cases / year and 10K deaths /yr from

MM- 2:1 M:F Life time risk of MM

2%- Whites (1/50)

0.1% Blacks (1/1000)

0. 5% Hisptanics (1/200)

Melanoma is the MOST COMMON form of cancer in 25-29 yrold and 2ndmost common in 15-29 yr

www.AAD.organd www.SkinCancer.org
http://www.aad.org/http://www.aad.org/


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SKIN CACNER IN UNDER 40 POPULATION

A 2005 study found that basal cell carcinoma and

squamous cell carcinoma are increasing in men and

women under 40. In the study, basal cell carcinoma

increased faster in young women than in young men Melanoma in Caucasian women under 44 has

increased 6%


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COST OF SKIN CANCER

INCREASING RAPIDILY

CONSITENT WITH INCREASING RATES OF SKIN

CANCER AND EARLY DETECTION INITIATIVES

NEW BREAKTHROUGHS FOR ADVANCED

MELANOMA WHICH ARE VERY $$


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TREATMENT

Local Destruction EDC / Cryosurgery

IMMUNOTHEARAPY Imiquomod

STANDARD SURGERY- Wide local excision

MOHS MICROGRAPHIC SURGERY-

Gold Standard Fastest growing procedure in medicine

New frontiers


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Local Destruction

Effective for SuperficialNMSC

EDC- aka scraping

Cryosurgery- aka freezing Cure rates 81-96%


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Immunotherapy

Imiquomod Cream

FDA approved for AK and superficial NMSC

Cure rate- 75-85%

Can conceal deep portions of a skin cancer

Not as effective as initially hoped


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Standard Surgery- Wide Local Excision

Visible tumor is cut out in shape of football with hope ofgetting it all- aka clear margins

Only 1% of actual margin examined

Pathology reportclear marings based on a smallsampling


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Mohs Micrographic Surgery

Most accurate surgical treatment for skin

cancer

100% of tissue margins looked at by surgeon

who performs the pathology before

reconstruction


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Mohs Surgery: Procedure

Tissue removed just


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Tissue inked and mapped


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Sections color coded for orientation


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Mohs Lab


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Sections embedded for horizontal sectioning


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Sections processed and read by Mohs surgeon


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Pathology read by surgeon and mapped


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Only small area with tumor re-excised


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Process continued until no tumor at margins


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Cure Rates for Skin Cancer

Mohs Surgery 98-99%

Standard excision 90-92 %

Destruction 81-96 %

Topical 75- 85%


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Mohs Surgery: Benefits

Has highest cure rate (98-99%)

Entire margin evaluated the same day

Fewer recurrences

Leaves the smallest surgical defect possible

Allows for less complicated reconstruction (i.e. 2ndintention)

Cost effective treatment Out patient setting and local anesthesia

One of the fastest growing procedures demonstrating its

universal acceptance(BCC and SCC)


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Mohs Surgery- New Frontiers

Immunohistochemistry- IHC

Specific cell markers that light up under

microscope

Improve accuracy further for hard to see skin

cancers

Melanoma

Extramammary Pagets disease


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Melanoma in situ Normal Sun Exposed Skin

Mohs Surgery for MM with IHC


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Mohs Surgery for Melanoma

Current data very promising

Prospective trial with 5 yr. follow up- ongoing,

data out in 2018

Not yetin guidelinesexc. for LM subtype

Only of fellowship trained Mohs surgeon

perform Mohs for MM


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Mohs Surgery- Training

Additional 1-2 year Fellowship afterdermatology residency

Mohs surgeons with fellowship training

belong to American College of Mohs Surgery(ACMS)

Not all doctors who perform Mohs surgery

have done a fellowship!!

www. ACMS.org


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OTHER TREATMENTS- UPDATE

VISMODEGIB Oral medicine for BCC- 2012

Not curative, palliative

Cost: $8,600/month SENTINEL LYMPH NODE BIOPSY (MM)

Most recent data (MSLT-1) shows no survivalbenefit

For staging purposes only

not proven to be effective as hoped

U U O SKIN CANC


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FUTURE OF SKIN CANCER

TREATMENT

GENE EXPRESSION PROFILING

To stratify risk of recurrence

Non-invasive-

tissue from the surgical removal of the cancer is used

Not yet mainstream

Very promising


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PREVENTION

NEW SUNSCREEN LABELING GUIDELINES

SUNCREEN INNOVATIONS ACT



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FDA regulationeffective June 2012

Set standards for sunscreen labeling

Broad-spectrum only if blocks UVA and UVB

and SPF 15 or higher


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NEW SUNSCREEN LABELING

GUIDELINES

Banned terms: waterproof, sweatproof,

sunblock, instant protection, and SPF 50

or higher (unless data provided )

Allows water resistance: 40 or 80 min based

on standard testing only


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TANNING AND SKIN CANCER

More people develop skin cancer because of

tanning than develop lung cancer because of

smoking

More than419,000 cases of skin cancer in theUS each year are linked to indoor tanning

Sustaining 5 or more sunburns in youth

increases lifetime melanoma risk by 80percent



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NEW REGUATIONS

As of September 2, 2014, ultraviolet (UV)

tanning devices will be reclassified by the FDA

from class I (low to moderate risk) to class II

(moderate to high risk) devices. UV radiation is a known CARCINOGEN

World Health Organization


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SUNSCREEN INOVATIONS ACT

Signed by President Obama on Nov. 26, 2014

Allows the FDA to prioritize and approve moreeffective sunscreen ingredients

On the market in another country for 5 yrs 8 mo. Deadline for FDA to a make a decision

FDA no longer needs to issue a regulation in orderto approve an ingredient

More options for consumers

Longer lasting UV protection


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SKIN CANCER

OVERVIEW STATS

TYPES

CAUSES TREATMENT

UPDATE

EPIDIOMIOLOGY TREATMENT

PREVENTION


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Thank You

Ali Hendi, MD

Private Practice

Clinical Assistant Professor

Georgetown University, Washington DC

Email: [email protected]

www.MohsSurgeryMD.com
mailto:[email protected]:[email protected]

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