Skin Cancers

Basal Cell Carcinoma (abbreviated BCC or BCE for Basal Cell Epithelioma) is the most common type of skin cancer. It is 3–4 times more common than traditional cancers like breast, lung, colon, and others.

When your dermatologist or trained medical professional examines your skin, they are searching for precancerous growths (Actinic Keratoses and Atypical “moles”) and for non-spreading skin cancer like a Basal Cell Carcinoma. They are also checking to be certain that you do not have a more serious skin cancer, such as a Squamous Cell Carcinoma or a Melanoma. Your dermatologist or trained medical professional may use a lighted, magnifying device called a dermatoscope or dermascope to better evaluate your skin. Fortunately, most skin cancers are discovered early and can be successfully treated.

Remember that you are physically unable to examine many areas of your own body, including your back, buttocks, back of the thighs, and posterior scalp. Your dermatologist or trained medical professional literally “has your back” in searching for skin cancer. A camera phone may enable you to look at some of these areas. Early detection of skin cancer can save your life and that of a family member or friend.

Fortunately, Basal Cell Carcinoma (BCC), the most common cancer of any type, does not normally spread (i.e., metastasize) from its site of origin. However, BCC can enlarge and grow deeply into the skin, which can affect the surrounding skin structures. On the face, a BCC can damage the nose, ears, eyes, and mouth, resulting in partial or complete loss, scars, and disfigurement.

In contrast, the second most frequent skin cancer, Squamous Cell Carcinoma, can spread into your bloodstream(metastasize). The third most frequent skin cancer, Melanoma, is considered the most dangerous of all types of cancer due to its easy ability to metastasize.

RISK FACTORS FOR BASAL CELL CARCINOMA

Fair skin, light-colored hair (blonde or red), and fair eyes (blue, green, hazel, gray).
Excessive sun exposure.
History of severe sunburns.
Tanning bed, tanning booth, or sun lamp exposure.
Living in areas of intense sunlight (e.g., Florida, the Caribbean, near the Equator).
Medications that make you sensitive to sunlight (e.g., doxycycline, hydrochlorothiazide (HCTZ), naproxen, amiodarone, phenothiazine).
Underlying diseases that make you sensitive to sunlight (e.g., lupus erythematosus, collagen vascular disease, porphyria).
Inherited skin conditions that increase your risk of sun damage (e.g., xeroderma pigmentosum, epidermolysis bullosa, albinism).
Underlying immune disorder (e.g., AIDS, organ transplant patients, immunosuppressive drugs).
A family history of pre-cancerous Actinic Keratoses or skin cancer.

DIAGNOSIS OF BASAL CELL CARCINOMA

Your dermatologist or trained medical professional will examine your skin to look for suspicious growths. Basal cell carcinomas can have a variety of appearances, from a white or pink, translucent “bump” to a draining, non-healing “sore”. Basal Cell Carcinoma may also appear as a pink scar or even a brown spot.

To diagnose Basal Cell Carcinoma (BCC), your dermatologist or trained medical professional can perform a skin biopsy under local anesthesia at the time of your office visit. This is the only way to confirm the diagnosis of skin cancer. A skin biopsy procedure is fast, safe, and usually heals with minimal scarring.

If you have a suspicious growth, a small sample of skin is surgically removed (i.e. biopsied) under local anesthesia. This specimen is sent to a pathology laboratory for processing and examination under a microscope by a pathologist. A pathology report is usually available within 7-14 days. Your dermatologist or medical care professional will discuss your pathology report with you at the time of your next doctor’s visit. If a skin cancer diagnosis is found on your pathology report, treatment options will be discussed with you

A growth that does not heal or keeps recurring should be biopsied. After local anesthesia, a shave or scallop biopsy is performed with a scalpel and blade. The biopsy site is then “burned” (electrodessicated) with the probe of an electrosurgery unit. The specimen is sent out for pathology.

TREATMENT OPTIONS FOR BASAL CELL CARCINOMA

Even though Basal Cell Carcinomas (BCC) rarely ever spread elsewhere (i.e., metastasize), they can grow deeply into your skin, causing local tissue destruction. This may lead to the partial or complete loss of your nose, ears, lips, or eyes if not treated early on. Basal Cell Carcinomas can also cause scarring and other types of disfigurement. Your dermatologist or medical care professional can help you decide on the best treatment for your Basal Cell Carcinoma.

Treatment options for Basal Cell Carcinoma (BCC) depend on the location, size, type of BCC, and age of the patient. Your dermatologist or trained health care professional must consider many different conflicting factors. For example, many patients are sensitive to pain, do not like needles, or are taking blood thinners. These patients may prefer Superficial Radiation Therapy (SRT) [see (8)], as there are no needles, no pain, no risk of bleeding from blood thinners, and no interference with one’s lifestyle.

Other treatment factors are the location and type of skin cancer. If the base of the BCC is less than 1.0 cm (0.4 inches) in size, it is considered low risk; over 1.0 cm in size, it is high risk. If the BCC is located near an eye, ear, nose, mouth, or temple area, it is considered high-risk. A Superficial BCC is easily treated, while a sclerotic/fibrotic BCC may be larger than it appears and requires excision or Mohs surgery [see (5)]. A less invasive procedure, such as Superficial Radiation Therapy (SRT) [see (8)], may be preferred for elderly patients and for those with severe disabilities.

SURGICAL TREATMENTS

(1) Electrodessication and Curettage for Basal Cell Carcinoma

This is one of the most common ways to treat non-melanoma skin cancers like Basal Cell Carcinoma and Squamous Cell Carcinoma. This is sometimes abbreviated ED&C or EDC or EC or CE (electrodessication and curettage), F&C or FC (fulguration and curettage). Electrodessication is when the electrosurgery probe touches the skin area during treatment, while fulguration is when the probe is allowed to spark over the treatment area.

This treatment consists of local anesthesia followed by “burning” the skin with an electrosurgery probe (i.e., electrodessication and/or fulguration), then scraping the skin cancer area with a curette. This electrosurgery-curettage technique is usually repeated two or three times to destroy the underlying skin cancer. It works best for skin cancers that are small (i.e., less than 1.0 cm (0.4 inches) in
size.

Skin cancer is often treated with electrodessication (“burning” the skin cancer with the probe of an electrosurgery device), followed by curettage (scraping the base of the skin cancer with a curette). This is usually repeated 2–3 times.

(2) Excision of Basal Cell Carcinoma

Your dermatologist or medical professional can “cut out” (i.e., excise) your skin cancer under local anesthesia using a scalpel. The excised skin cancer is sent to a pathologist for processing and examination under a microscope to be certain that the skin specimen margins are free of skin cancer. Excision is usually performed on skin cancer that is over 1.0 cm (0.4 inches) in size. An area around the skin cancer of about 0.4 cm (0.2 inches) to 1 cm (0.4 inches) is usually required to completely excise (cut out) the skin cancer. Some skin cancer excisions are larger and may require moving normal skin over the cancer treatment site (skin flap) or detaching nearby skin to cover the surgery site (skin graft).

An atypical growth may be excised under local anesthesia. A drawing is made around the skin cancer, as seen in Photo 1. The size of the drawing is normally 4–10 mm around the growth to be certain that all of it is removed. In Photo 2, the growth is being excised (cut out), followed by stopping any bleeding with electrosurgery (heat applied by the probe of an electrosurgery device), as seen in Photo 3. The final step is to tie the skin together with sutures (stitches), as seen in Photo 4.

(3) Laser Treatment for Basal Cell Carcinoma

A laser is sometimes used to treat superficial skin cancer. Your dermatologist or medical professional may use a focused beam of light (laser) on an area under local anesthesia to destroy superficial non-melanoma skin cancers, Basal Cell Carcinoma, and Squamous Cell Carcinoma.

(4) Cryosurgery for Basal Cell Carcinoma

Cryosurgery treatment is occasionally used to treat skin cancer. Cryosurgery itself can cause scarring and, occasionally, disfigurement. Some dermatologists use cryosurgery for Superficial Basal Cell Carcinomas (BCC) and Squamous Cell Carcinomas (SCC) in elderly patients and in resistant BCCs and SCCs that have ill-defined borders or depth. Mohs surgery [see (5)] or Superficial Radiation Therapy (SRT) [see (8)] are usually preferred over cryosurgery.

This type of cryosurgery treatment consists of spraying liquid nitrogen in two freeze-thaw cycles of one minute each. The treated areas will become frozen and turn white. After two freeze-thaw cycles, the white color fades over several minutes. The treatment site then becomes red and swollen, and it may form a draining wound over several days or weeks. The area will take 4–6 weeks or longer to heal. For the best cosmetic result, gently cleanse the treatment site twice a day with mild soap and water, followed by the application of Vaseline or Aquaphor.

(5) Mohs surgery for Basal Cell Carcinoma

Mohs surgery is named after Fredric E. Mohs (1910-2002), who pioneered this procedure. This is considered the “Gold Standard” for skin cancer treatment. Mohs surgery is generally performed on high-risk areas around the eyes, ears, nose, or mouth, and for recurrent skin cancer. There is up to a 99% cure rate with Mohs surgery, which is superior to most other forms of skin cancer treatment. Superficial Radiation Therapy (SRT) [see (8)] also has a very high cure rate of 98–99%.

If you are referred to a Mohs surgeon, the Mohs surgeon will evaluate your skin cancer site. Your skin cancer will be removed in stages under local anesthesia, usually on the same day. A layer of skin is removed in each stage, and the tissue is examined under a microscope at an on-site laboratory. This is repeated until the skin cancer has been completely removed.

During your office visit to a Mohs surgeon, you will have to wait between each stage of your skin treatment for your skin specimen to be processed and evaluated under a microscope. Plan for your visit to a Mohs surgeon to take several hours or longer.

You may also be required to stay longer for reconstructive surgery after Mohs surgery if there is a large surgical wound created by your Mohs surgery treatment. Reconstructive surgery may include complex repair, a skin graft, or a skin flap. Alternatively, the wound from Mohs surgery may be repaired at a later date or may be allowed to heal naturally over 4-6 weeks.

NON-SURGICAL TREATMENTS OF BASAL CELL CARCINOMA

(6) TOPICAL TREATMENT FOR BASAL CELL CARCINOMA

Your dermatologist or medical professional may also use a topical
anti-cancer cream, gel, or solution for the treatment of small Superficial Basal Cell Carcinomas. Superficial Basal Cell carcinomas are on the skin surface and have not invaded deeper into the skin. Topical anti-cancer creams are able to reach these superficial lesions. Other types of Basal Cell Carcinoma, Squamous Cell

Carcinoma and Melanoma are deeper, where the anti-cancer cream may not reach. Consequently, the surface of the skin cancer may heal, while the deeper part of the skin cancer can enlarge and spread (metastasize).

Alternatively, an anti-cancer cream, gel, or solution may be used after previous skin cancer treatment in an effort to prevent skin cancer recurrence.

5-Fluorouracil (Eudex™, Tolak™) and Imiquimod Cream (Aldara™) are commonly used to treat small, Superficial Basal Cell Carcinomas. They are usually applied 5–7 days a week for 6–8 weeks or longer. Treated areas will become red, swollen, and may crust over before healing, about 3–4 weeks after discontinuing the anti-cancer cream therapy. Patients must avoid getting the anti-cancer medications in their eyes, as they can cause eye irritation or damage.

A new alternative anti-cancer medication is Klisyri™ (tiranibulin) ointment. Currently, Klisyri™ is only approved for the treatment of precancerous Actinic Keratoses. This ointment is applied daily for five days to pre-cancerous areas while avoiding eye areas. The treated areas become red, swollen, and may crust over before healing in 2–4 weeks.

It is currently unknown whether Klisyri™ will help Superficial Basal Cell Carcinoma or other types of skin cancer. Any treatment in the future will probably involve several treatment courses. Klisyri™ ointment is expensive unless covered by a discount coupon or by filing your prescription directly with a specialty pharmacy through your doctor’s office.

(7) BLUE OR RED-LIGHT TREATMENT FOR BASAL CELL CARCINOMA (also known as PHOTODYNAMIC THERAPY PDT)

Blue or Red-Light Therapy is sometimes used to treat single or multiple superficial non-melanoma skin cancers (e.g., Basal Cell Carcinoma and Squamous Cell Carcinoma.) This therapy should not be used for large or deep skin cancers or for Melanoma.

Therapy consists of the application of a special solution or gel to the treatment area at your doctor’s office. The solution or gel gets into the “nooks and crannies” of your skin and makes the skin sensitive to Blue and Red light. After waiting 1 hour for the face or scalp, or 2–3 hours for other body areas, the Blue Light Treatment is administered by a light stand for 10 to 16.5 minutes. Alternatively, Red Light Therapy can be administered with a smaller light stand. Red light from the smaller light stand is presently given for 10 minutes to 2 adjacent treatment areas (a total of 20 minutes). A larger Red Light Therapy light stand is pending approval.

After the Blue or Red-Light Treatment, your skin becomes red and slightly swollen. You should avoid sunlight and protect yourself from the sun for the next 24-48 hours, as you may have become sun-sensitive. Your skin will usually heal within a few weeks and be much softer and smoother. Repeat therapy every month for several months may be required, depending on how your Basal Cell Carcinoma responds to Blue or Red-Light therapy.

(8) SUPERFICIAL RADIATION THERAPY (SRT) FOR BASAL CELL CARCINOMA

Radiation therapy has been used to treat skin cancer since 1896. Treatment is based on Wilhelm Rontgen’s remarkable discovery of X-rays on November 8, 1895. Over the last century, radiation therapy has evolved. In the past 8 years, safe, reliable radiation machines have been developed that use tungsten instead of radioactive materials to treat Basal Cell and Squamous Cell Carcinomas.

Superficial Radiation Therapy (SRT) may be the preferred treatment method for patients who are afraid of needles or take blood thinners. SRT may also be the best choice for elderly patients or for patients with severe disabilities.

The Advantages of Superficial Radiation Therapy (SRT) for Basal Cell Carcinoma and Squamous Cell Carcinoma are:

No needles
No pain
No infection
No bleeding, even if you are taking blood thinners
No cutting
No downtime

SRT is the best treatment for areas on the hands and legs, as patients can continue their normal activities during superficial radiation treatment.

Wide treatment margins around your skin cancer are possible with superficial radiation therapy (SRT), which makes skin cancer recurrence less likely
Minimal or no scarring

The treatment site may heal with a slight loss of color or localized hair loss. The skin may recolor, and some hair may grow over time.

Superficial Radiation Therapy (SRT) usually gives the best cosmetic result compared to other treatment methods, particularly for non-melanoma skin cancers on the nose, ear, or mouth areas.
98% to 99% cure rate

This is among the highest cure rates of all skin cancer treatment methods.

SRT therapy is usually not used on children or patients with genetic disorders like basal cell nevus syndrome, xeroderma pigmentosum, albinism, or rare skin cancers that are resistant to radiation therapy. Mohs surgery [see (5)] is the preferred treatment for these less common cases.

TREATMENT FOR ADVANCED BASAL CELL CARCINOMA

Basal Cell Carcinoma rarely becomes invasive or spreads (metastasizes). There are several new drug therapies that may shrink or help control aggressive Basal Cell Carcinoma:

Cemiplimab-rwlc (Libtayo™ , which is administered intravenously)
Sonidegib (Odomzo™) or Vismodegib (Erivedge™) which are taken orally

These anti-cancer drugs can be used before surgery to shrink an advanced Basal Cell Carcinoma or after surgery on a Basal Cell Carcinoma resistant to surgery. Odomzo™ or Erivedge™ are commonly prescribed by your dermatologist. Your skin cancer treatment is monitored during regular dermatology visits.

AVAILABLE TREATMENTS FOR SKIN CANCER

Mohs Surgery

Mohs surgery is a highly precise technique we use to treat certain skin cancers, most commonly basal cell carcinoma and squamous cell carcinoma. From a dermatologist’s perspective, its biggest advantage is that it allows us to remove the cancer layer by layer while examining each layer under the microscope in real time. This means we can confirm that all of the cancer has been cleared before the procedure is finished, while preserving as much healthy skin as possible. That is especially important on areas like the face, ears, scalp, hands, and other places where tissue preservation matters for both function and appearance.

For you as a patient, Mohs surgery is usually done in the office with local anesthesia, so you are awake but the area is numbed. The procedure can take several hours because each stage of removal is followed by careful microscopic review, and sometimes more than one stage is needed. Although that waiting can feel tedious, it is what makes the procedure so effective and gives it one of the highest cure rates for many common skin cancers. After the cancer is fully removed, we decide on the best way to repair the wound, which may involve stitches, a skin flap, a graft, or sometimes letting it heal naturally, depending on the location and size.

Superficial Radiation Therapy (SRT)

Superficial Radiation Therapy, or SRT, is a non-surgical treatment option we sometimes use for certain types of skin cancer, especially basal cell carcinoma and squamous cell carcinoma in carefully selected patients. From a dermatologist’s perspective, SRT uses low-energy X-rays that treat the cancer at the skin surface while limiting deeper tissue exposure. It can be a good choice for patients who want to avoid surgery, who are not ideal surgical candidates because of age or other medical conditions, or when the location of the skin cancer makes reconstruction more difficult. The goal is to destroy the cancer cells while preserving the surrounding tissue and maintaining a good cosmetic outcome.

For you as a patient, SRT is typically given over a series of short office visits rather than in a single procedure. The treatment itself is PAINLESS, but over time the skin in the treated area can become pink, irritated, dry, or crusted, somewhat like a gradual sunburn. Ultrasound is used to verify the cancers removal. I usually explain that SRT can be very effective for the right patient and the right tumor, but the best treatment choice depends on the type of skin cancer, its size and location, your overall health, and your personal preferences. Patients who take blood thinners or need minimal disruption to their daily routine, including work and other responsibilities, may find this option better suited for them.

SQUAMOUS CELL CARCINOMA (abbreviated, SCC)

ABOUT

Squamous Cell Carcinomas (SCC) are a common type of skin cancer that typically appears in sun-exposed areas of your body. SCCs are caused by the ultraviolet rays in sunlight. About one million people develop SCCs in the United States every year. This is about the same number of patients who develop traditional cancers each year in the United States (e.g., breast cancer, colon cancer, prostate cancer, and more).

When your dermatologist or trained health professional examines your skin, they are searching for precancerous growths, Actinic Keratoses, Atypical Nevi (atypical “moles”), and non-spreading skin cancer like Basal Cell Carcinoma. They are also checking to be certain that you don’t have a more serious skin cancer, such as a Squamous Cell Carcinoma or a Melanoma.

Your dermatologist or trained medical professional may use a lighted magnifying device called a dermatoscope to better examine your skin.
Fortunately, most precancerous growths, atypical “moles,” and skin cancers are discovered early and can be successfully treated.

Remember, you are physically unable to examine many areas of your own body, including your back, buttocks, back of your thighs, back of your neck, and back of your scalp. Your dermatologist or trained medical professional literally “has your back” in searching for skin cancer. A phone camera can sometimes help you examine these areas. Early detection ofskin cancer can save your life and that of a family member or friend.

Squamous Cell Carcinoma often develops from an untreated precancerous growth called an Actinic Keratosis. SCCs may also appear elsewhere on the body, including inside the mouth, on the lips, or on the genitals. These same areas are at high risk of the SCC spreading locally or internally (metastasizing). Mohs surgery is the preferred treatment in these areas.

Squamous Cell Carcinomas are more aggressive than Basal Cell Carcinomas. A SCC usually develops in sun-exposed areas on the face, neck, trunk, and extremities. As there is a risk of spreading locally or into the bloodstream (metastasizing), all SCCs should be treated and monitored.

SCC lesions may have many different appearances. Usually, they appear as a red bump that may be scaly or crusted over. An SCC growth may be non-healing, itching, or bleeding. It may appear to heal for a few weeks, but then recur at the same site. Generally, any suspicious area should be checked by your dermatologist or a trained medical professional.

RISK FACTORS FOR SQUAMOUS CELL CARCINOMA

Squamous Cell Carcinoma occurs in all races, regardless of their skin color. It is more common in fair-skinned individuals. People who use tanning beds, tanning booths, or sun lamps are also at greater risk of developing skin cancer. See if you or your family have any of these Risk Factors:

Fair skin, light-colored hair (blonde or red), and fair eyes (blue, green, hazel, gray)
Excessive sun exposure
History of severe sunburns
Tanning bed, tanning booth, or sun lamp exposure
Living in areas of intense sunlight (e.g., Florida, the Caribbean, near the Equator)
Medications which make you sensitive to sunlight (e.g. ,doxycycline, hydrochlorothiazide (HCTZ), naproxen, amiodarone, phenothiazine)
Underlying diseases that make you sensitive to sunlight (e.g., lupus erythematosus, collagen vascular disease, porphyria)
Inherited skin condition that increases your risk of sun damage (e.g., xeroderma pigmentosum, epidermolysis bullosa, albinism).
Underlying immune disorders (e.g., AIDS, organ transplant patients, immunosuppressive drugs)
A family history of pre-cancerous Actinic Keratoses or skin cancer

Resources from the American Academy of Dermatology and the American Society for Dermatologic Surgery were consulted for this section.

DIAGNOSIS OF SQUAMOUS CELL CARCINOMA

To diagnose a Squamous Cell Carcinoma (SCC), your dermatologist or trained medical professional performs a skin biopsy under local anesthesia at the time of your office visit. This is the only way to confirm the diagnosis of skin cancer. A skin biopsy procedure is fast, safe, and usually heals with minimal scarring.

TREATMENT OPTIONS FOR SQUAMOUS CELL CARCINOMA

Treatment for Squamous Cell Carcinoma (SCC) depends on the location, size, type, and age of the patient. Squamous Cell Carcinoma, like Basal Cell Carcinoma, can cause disfigurement due to local invasion and destruction of underlying skin structures. SCC also has the potential to spread locally or into your blood stream (metastasize). It is important that you receive appropriate treatment for your SCC. Your dermatologist or medical professional can help you decide on the best treatment.

Many conflicting factors are considered when making a treatment recommendation for skin cancer. If the base of the SCC is less than 1.0 cm (0.4 inches) in size, it is considered low-risk. If the lesion base is over 1.0 cm (0.4 inches) in size, it is high-risk. If the SCC is located near an eye, ear, nose, mouth, or temple area, it is considered very high risk. If the SCC is poorly differentiated, there is a greater risk of skin cancer recurrence or metastasis. Your dermatologist or medical care professional can help you decide on your best treatment option.

SURGICAL THERAPIES

(1) Electrodessication and Curettage Treatment for Squamous Cell Carcinoma

Electrodessication and Curettage are two of the most common ways to treat non-melanoma skin cancers like Squamous Cell Carcinoma. This is sometimes

abbreviated ED&C or EDC or EC or CE (electrodessication and curettage), F&C or FC (fulguration and curettage). Electrodessication is when the electrosurgery probe touches the skin cancer area, while fulguration is when the probe is allowed to spark over the treatment area.

This treatment consists of local anesthesia followed by “burning” the skin with an electrosurgery probe (i.e. electrodessication and/or fulguration), then scraping the skin cancer area with a curette. This electrosurgery-curettage technique is usually repeated two or three times to destroy the underlying skin cancer. It has a cure rate of 95% or higher for skin cancers that are low risk (i.e. less than 1.0 cm or 0.4 inches in size).

Treatment is usually covered by Medicare, Medicaid, and insurance carriers, minus any deductible or co-payment required by your insurer. If you have a second insurance policy (“secondary insurance”), this will usually cover your co-payment.

Skin cancer is often treated with electrodessication (“burning” with the probe of an electrosurgery unit), followed by curettage. This is usually repeated 2–3 times.

(2) Excision of Squamous Cell Carcinoma
Your dermatologist or medical professional may cut out (i.e., excise) your skin cancer under local anesthesia using a scalpel. The excised skin cancer is sent to a pathologist for processing and examination under a microscope to be certain that the skin specimen margins are free of skin cancer. Some skin cancer excisions are large and may require a second surgery to cover the skin cancer treatment site with adjacent normal skin (a skin flap) or adjacent detached normal skin (askin graft). Excision usually requires cutting around the skin cancer with a 0.4 cm (0.2 inches) to 1 cm (0.4 inches) margin. Excision has a 95% or higher cure rate for low-risk skin cancer (1 cm or 0.4 cm in size) but does not do as well with high-risk skin cancer (over 1 cm or 0.4 cm in size).

(3) Cryosurgery for Basal Cell Carcinoma
Cryosurgery treatment is occasionally used to treat skin cancer. Cryosurgery, itself, may cause scarring and occasionally disfigurement. Some dermatologists use cryosurgery for Superficial Basal Cell Carcinomas (BCC) and Squamous Cell Carcinomas (SCC) in elderly patients and in resistant BCCs and SCCs which have ill-defined borders or depth. Mohs surgery [see (5)] or Superficial Radiation Therapy (SRT) [see (6)] are usually preferred over cryosurgery.

CRYOSURGERY UNIT
Cryosurgery is commonly used to treat pre-cancerous growths (Actinic Keratoses).
It is rarely used to treat non-melanoma skin cancer (e.g. Basal Cell Carcinoma and Squamous Cell Carcinoma).

(4) Laser Treatment for Squamous Cell Carcinoma in situ
A laser is sometimes used to treat Superficial Non-Melanoma Skin Cancer. Your dermatologist or medical professional uses a focused beam of light (laser) under local anesthesia to destroy superficial non-melanoma skin cancer (e.g., Squamous Cell Carcinoma or Basal Cell Carcinoma).

(5) Mohs Surgery for Squamous Cell Carcinoma
Mohs surgery is named after Fredric E. Mohs (1910-2002), who pioneered this procedure. Mohs surgery is considered the “Gold Standard” for non-melanoma skin cancer treatment. It is generally performed on high-risk areas around the eyes, ears, nose, or mouth areas and for recurrent skin cancer. There is up to a 99% cure rate with Mohs surgery, which is superior to most other forms of skin cancer treatment. Superficial Radiation Therapy (SRT) also has a very high cure rate of 98–99%.

If you are referred to a Mohs surgeon, the Mohs surgeon will evaluate your skin cancer site. Your skin cancer will be removed in stages under local anesthesia, usually on the same day. A layer of skin is removed in each stage, and the tissue is processed and examined under a microscope at an on-site laboratory.

This is repeated until the skin cancer has been completely removed. During your office visit to a Mohs surgeon, you will have to wait between each stage for your skin specimen to be evaluated under a microscope. Plan for your visit to a Mohs surgeon to take several hours or longer.

You may also be required to stay longer after your Mohs surgery if there is a large surgical wound created by your Mohs surgery treatment. This wound may be allowed to heal naturally over 4–6 weeks. Alternatively, complex repair or a skin graft/skin flap are used to cover the Mohs surgery site.

NON-SURGICAL TREATMENTS FOR SQUAMOUS CELL CARCINOMA

(6) SUPERFICIAL RADIATION THERAPY (SRT) FOR SQUAMOUS CELL CARCINOMA

Radiation therapy has been used to treat skin cancer since 1896. Treatment is based on Wilhelm Rontgen’s remarkable discovery of X-rays on November 8, 1895. Over the last century, radiation therapy has evolved. In the past 8 years, safe, reliable radiation machines have been developed that use tungsten (used in light bulbs) instead of radioactive materials to treat Basal Cell and Squamous Cell Carcinomas.

Sensus Healthcare™ is a pioneer in radiation therapy and manufactures the Sensus SRT 100™, 100+™, and Vision™ radiation machines for skin cancer treatment. SRT uses superficial radiation, which does not penetrate deeply into your skin. In contrast, the hospital radiation machines treat below-the-skin surfaces for breast cancer, colon cancer, prostate cancer, and other internal cancers. For this reason, superficial radiation therapy (SRT) has few side effects compared to hospital radiation machines.

Several companies have recently developed radiation machines for the treatment of non-melanoma skin cancer (i.e., Basal Cell Carcinoma and Squamous Cell Carcinoma.) A comparison of these different radiation machines is not available at this time.

The advantages of Superficial Radiation Therapy (SRT) are:

No needles
No pain
No infections
No bleeding, even if you are taking blood thinners
No cutting
No downtime. SRT is the best treatment for skin cancer on the hands and legs. Patients will be able to continue their normal activities during superficial radiation treatment (SRT).
Wide treatment margins around your skin cancer site make skin cancer recurrence less likely.
Minimal or no scarring. The treatment site may heal with a slight loss of color or local hair loss. The skin may recolor, and some hair may re-grow over time.
Superficial Radiation Therapy usually gives the best cosmetic result, particularly for non-melanoma skin cancers on the nose, ear, or mouth areas.
98-99% cure rate: This is among the highest cure rates of all skin cancer treatment methods.

SRT therapy is usually not used on children. It is also not recommended for patients with rare skin cancer disorders, genetic disorders like xeroderma pigmentosum and albinism, or rare skin cancers that are resistant to radiation therapy. Mohs surgery [see (5)] is the preferred treatment in these cases.

(7) Chemical Treatment for Squamous Cell Carcinoma

Traditional Chemical Treatment is NOT recommended for an initial Squamous Cell Carcinoma except in unusual circumstances. Topical chemical creams, ointments, and solutions do not penetrate deeply enough into the skin

An anti-cancer cream or ointment of solution like 5-Fluorouracil 5% or Imiquimod 5% is sometimes used to treat sites that have already been treated for skin cancer. They are also sometimes used with elderly or non-compliant patients. One treatment regimen is to apply 5-Fluoruracil 5% cream twice a day for 6–8 weeks or longer, depending on the response to treatment. Alternatively, Imiquimod 5% cream is applied twice a day for 16 weeks or longer, depending on the response to treatment.

TREATMENT FOR ADVANCED SQUAMOUS CELL CARCINOMA

Most Squamous Cell Carcinomas can be successfully treated if diagnosed early. Squamous Cell Carcinoma can invade underlying skin structures as well as spread (metastasize) to other areas of the body. There are a number of new drug therapies that may shrink or help control advanced Squamous Cell Carcinoma:

Cemiplimab-rwlc (Libtayo™ ) and Pembrolizumab (Keytruda™) which are administered intravenously. These drugs can be used before surgery to shrink an advanced Squamous or Basal Cell Carcinoma or after surgery to treat skin cancer that is resistant to surgery.

TREATMENT FOR ADVANCED SQUAMOUS CELL CARCINOMA

AVAILABLE TREATMENTS FOR SKIN CANCER

Mohs Surgery

Superficial Radiation Therapy (SRT)

MELANOMA AND PRE-MELANOMA

ABOUT

Melanoma is considered the most dangerous of ALL types of cancer due to its easy ability to spread into the bloodstream to other areas of the body (i.e., metastasize). However, if Melanoma is diagnosed early, the cure rate can be 100%.

Melanoma arises in the pigment-producing cells of your skin, called melanocytes. Melanocytes give your skin its color. Melanocytes are located in the base layer of the epidermis. The epidermis is the outermost layer of your skin and is just the thickness of a piece of paper.

Over 50% of the time, Melanoma develops as a new growth, not in an existing “mole.” It is important to have your skin checked regularly by a family member, a dermatologist, or a trained medical professional.

You should realize that you are unable to see many areas of your body, including your back, buttocks, back of your thighs, back of your neck, and back of your scalp. Your dermatologist or trained medical professional literally “has your back” in searching for skin cancer. They may use a lighted, magnifying device called a dermatoscope or dermascope to better evaluate your skin. Fortunately, most Melanomas are discovered early and can be successfully treated.

A camera phone may assist you in your self-inspection of these areas. Remember, early detection of a melanoma can save your life and that of a family member or friend. Over 100,000 people develop melanoma in the United States each year and 10,000 die from it.

WHAT “MOLES” SHOULD BE CHECKED?

Any mole that is growing rapidly or changing in shape or color
Any mole that bleeds or oozes
Any growth that is itching, painful, or bleeding
A streak (usually brown or black) that appears in a fingernail or toenail
Any non-healing “sore” or growth

Resources from the American Academy of Dermatology and the American Society for Dermatologic Surgery were consulted for this section.

RISK FACTORS

Many Melanomas can be prevented by protecting your skin from the sun. Sunscreens with a Sun Protection Factor (SPF) of 30 or higher are very effective in blocking the harmful ultraviolet rays of the sun. Protecting yourself from the sun and wearing sun-protective clothing also helps to prevent Melanoma as well as pre-cancerous growths (Actinic Keratoses) and non-melanoma skin cancer (e.g., Basal Cell Carcinoma and Squamous Cell Carcinoma).

If you have a family history of Melanoma, your risk of developing it is increased. A family history of non-melanoma skin cancer also puts you at greater risk of Melanoma.

Risk factors for developing Melanoma are similar to those of pre-cancerous growths like Actinic Keratoses and cancerous growths like Basal Cell Carcinoma and Squamous Cell Carcinoma. See if you or your family have any of these Risk Factors:

Fair skin, light-colored hair (blonde, red), and fair eyes (blue, green, hazel, gray)
Excessive sun exposure
History of severe sunburns
Tanning bed, tanning booth, or sun lamp exposure
Living or lived in areas of intense sunlight (e.g. Florida, the Caribbean, near the Equator)
Medications which make you sensitive to sun light (e.g. doxycycline, hydrochlorothiazide (HCTZ), naproxen, amiodarone, phenothiazine
Underlying diseases that make you sensitive to sunlight (e.g., lupus erythematosus, collagen vascular disease, porphyria)
Inherited a skin condition that increases your risk of sun damage, such as xeroderma pigmentosum, epidermolysis bullosa, and albinism.
Underlying decreased immunity due to AIDS, organ transplants, and/or Immunosuppressive medications)
A family history of pre-cancerous Actinic Keratoses or skin cancer
Strong family history of melanoma or a history of multiple atypical (dysplastic) “moles,” sometimes as many as 50 or more.

Resources from the American Academy of Dermatology and the American Society for Dermatologic Surgery were consulted for this section.

DIAGNOSIS

A Melanoma may appear on the skin with no precursor growth over 50% of the time. People are reminded to “Remember their ABCs” for diagnosing an Atypical “Mole” (known medically as an Atypical Nevus or Dysplastic Nevus) and for diagnosing Melanoma.

An Atypical / Dysplastic nevus is considered a Pre-Melanoma. Some Pre-Melanoma growths will change into melanoma over a period of time.
If you notice the following ABCDEF changes in growth, consult your dermatologist or trained medical professional.

A is for an Asymmetrical appearance
B is for an irregular Border
C is for an atypical brown, tan, black Color or Multi-color. In some instances, the atypical growth may appear pink or have no color. This is called an Amelanotic Melanoma. This is a rare type of Melanoma that is often diagnosed late due to the lack of color changes.
D is for the Diameter or size of the lesion. Although most Melanomas are 0.6 cm (about 1/3 inch) or more in Diameter when they are diagnosed, some melanomas may be only the size of a pencil mark.
E is for Evolving. A growth that is changing in size, shape, color, or elevation should be biopsied. Also, if the growth is itching, oozing, bleeding, or crusting, it should be biopsied.
F is for Funny-Looking. This is included in the ABCs of melanoma detection, as it helps guide whether to do a skin biopsy. If all the skin lesions appear “funny-looking,” then this pattern may be normal for an individual. But if a growth does not look like it belongs with other skin growths, it should be biopsied. This is known as the “ugly duckling sign”.

Melanoma can occur in all people, regardless of their skin color. People of color develop melanoma in areas where they get little sun exposure. 60–75% of all melanomas in people of color are found on their hands, soles of the feet, and nail areas.

**The Bottom Line is that All suspicious growths should be biopsied.**

TREATMENT OPTIONS FOR PRE-MELANOMA AND MELANOMA

Treatment for Pre-Melanoma or Melanoma depends on its size, depth, and location. If the Pre-Melanoma (known as an Atypical Nevus or Dysplastic Nevus) is “severely atypical,” it should be excised with a 0.4 cm (about a 0.2 inch) margin. Mild or moderate atypical/dysplastic nevi usually require no further treatment.

If your Melanoma has NOT penetrated below the skin surface, it is known as “Melanoma in Situ” or “STAGE 0”. These tumors are usually excised with up to a 1.0 cm margin around the Melanoma in Situ with a 100% cure rate.

Melanoma that has penetrated through the top layer of skin, known as the epidermis, into the underlying dermis is considered “STAGE I.” These lesions carry a good prognosis with a wide surgical excision with 1 cm or larger margins.

The majority of Melanomas are treated by simple excision with no need for further cancer treatment. Mohs surgery is currently being evaluated for Melanoma treatment.

If the Melanoma has penetrated through the epidermis more than 0.8 mm (Breslow’s level) into the dermis, the tumor is classified as “STAGE II”. At this point, patients are usually referred to a Melanoma Clinic for a sentinel lymph node biopsy and a wide surgical excision.

TREATMENT FOR ADVANCED MELANOMA

When Melanoma spreads into the lymph nodes (STAGE III) or to more distant parts of the body (STAGE IV), it is considered advanced, and additional treatments are required. Due to recent breakthroughs in treatment, the 5-year survival rate of patients with advanced Melanoma is now about 50%.

IMMUNOTHERAPY FOR ADVANCED MELANOMA

Medications that boost the immune system are known as immunotherapy drugs. These include:

Pembrolizumab (Keytruda™) [infused intravenously for STAGE IIB, and STAGE IIC after melanoma surgery to prevent tumor progression; this therapy has been very promising].

Pembrolizumab (Keytruda™) [infused intravenously for STAGE III and STAGE IV patients]

Pembrolizumab (Keytruda™) and Sotigalimab (humanized IgG1 monoclonal antibody) [infused intravenously for STAGE IV patients]

Ipilimumab (Yervoy™) [infused intravenously for STAGE III and IV patients]

Nivolumab (Opdivo™) [infused intravenously for STAGE III and STAGE IV patients]

Nivolumab (Opdivo™) and Relatlimab are infused intravenously for STAGE IV patients. This protocol is preferred by some oncologists.

Nivolumab (Opdivo™ and ipilimumab (Yervoy™) (combination [infused intravenously for STAGE IV patients]) haveshown promising results.

Talimogene laherparepvec [T-VEC] (Imlygic™) is injected into the tumor for STAGE III and STAGE IV patients

MELANOMA VACCINE

A recent study using Moderna, Inc.’s personalized cancer vaccine with Keytruda™) immunotherapy showed 79% of high-risk melanoma patients were alive and cancer-free at 18 months, compared to 62% receiving immunotherapy alone.

Historically, earlier immunotherapies were the first FDA-approved drugs, but they are not as beneficial as the newer therapies listed above.

Interferon alfa-2b (Intron A™) [infused intravenously or injected subcutaneously or intramuscularly for high-risk STAGE II and STAGE III patients]

Pegylated interferon alfa-2b (Pegintron™), Interleukin-2 (Proleukin™/ aldesleukin) [infused intravenously for STAGE IV patients.]

TARGETED DRUG THERAPY FOR ADVANCED MELANOMA

New targeted therapies for advanced Melanoma are all taken by mouth.
They target a defective, cancer-producing version of the gene called BRAF.
About half of Melanoma patients have this mutant gene. Only patients with the mutant gene will benefit from Targeted Drug Therapy.

Targeted oral drug medications for Melanoma include:

Nivolumab (Opdivo™) and ipilimumab (Yervoy™) intravenously, followed by the oral drugs, dabrafenib (Tafinlar™) and trametinib (Mekinist™) This combination is superior to other drug combinations for patients with advanced BRAF V600 metastatic melanoma. The results have been very encouraging.

Dabrafenib (Tafinlar™), oral medication

Trametinib (Mekinist™), oral medication

Combination of Dabrafenib (Tafinlar™) and Trametinib (Mekinist™) for STAGE III and IV patients

Vemurafenib (Zelboraf™) and Cobimetinib-(Cotellic™) combination for STAGE IV patients

Encorafenic (Braftovi™) and binimetinib (Mektovi™) combination for STAGE IV patients

Atezolizumab (Tecentriq™)-cobimetinib (Cotellic™)-vemurafenib (Zelboraf™), combination for patients with BRAF V600 mutation-positive melanoma

These advanced Melanoma treatments are covered by Medicare, Medicaid, and other insurance carriers, minus any deductible or co-payment required by your insurer. If you have a second insurance policy (“secondary insurance”), this will usually cover your co-payment.

RADIATION THERAPY FOR ADVANCED MELANOMA

Early studies show that experimental radiation therapy with some medications may be beneficial.

Resources from the American Academy of Dermatology and the American Society for Dermatologic Surgery were used for this section.

Skin Cancers

BASAL CELL CARCINOMA

SQUAMOUS CELL CARCINOMA

MALIGNANT MELANOMA