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Cancer develops when healthy cells mutate and expand uncontrollably, generating a mass known as a tumor. A tumor might be malignant or noncancerous. A malignant tumor is one that can grow and spread to other regions of the body. A benign tumor is one that can develop but does not spread.
In some situations, skin cancer is more advanced and necessitates the care of a multidisciplinary team that includes a dermatologist, surgical oncologist, radiation oncologist, and medical oncologist. These doctors will consult with a patient and recommend the best course of action to treat the malignancy. When the operation to treat the malignancy is too substantial for an office setting, the surgical oncologist may recommend that it be performed in an operating room. In some cases, the team may propose radiation therapy and/or therapies involving medicine either orally or intravenously in lieu of or in addition to surgery.
WHAT ARE THE TYPES OF SKIN CANCER?
Skin cancer is classified into four types:
- Basal cell carcinoma: Basal cells are circular cells that can be seen in the lower epidermis. This type of cell is responsible for around 80% of all skin malignancies. Basal cell carcinomas are the name given to these types of malignancy. Basal cell carcinoma is most commonly found on the head and neck, but it can occur elsewhere on the skin. It is primarily caused by sun exposure or develops in people who were exposed to radiation therapy as children. This type of skin cancer normally grows slowly and spreads to other parts of the body only in rare cases.
- Merkel cell cancer: Merkel cell cancer is a rare, aggressive cancer that grows quickly. It begins in hormone-producing cells close beneath the epidermis, as well as in hair follicles. It is most commonly detected in the head and neck area. Merkel cell carcinoma is also known as neuroendocrine carcinoma of the skin.
- Squamous cell carcinoma: Squamous cell carcinoma: The majority of the epidermis is made up of squamous cells, which are flat, scale-like cells. These cells cause around 20% of skin cancers, which are known as squamous cell carcinomas. Because squamous cell carcinoma is mostly induced by sun exposure, it can appear anywhere on the skin. It can also appear on skin that has been burned, chemically injured, or exposed to x-rays. Squamous cell carcinoma is most usually detected on the lips, at scar sites, and on the skin outside the mouth, anus, and a woman’s vagina. Squamous cell carcinomas spread to other regions of the body in about 2% to 5% of cases.
- Melanoma: Melanocytes are dispersed cells that exist where the epidermis meets the dermis. These cells create melanin, the pigment that gives skin its color. Melanoma is the most deadly type of skin cancer and begins in melanocytes. It accounts for around 1% of all skin malignancies.
Basal cell and squamous cell carcinomas are occasionally clubbed together and referred to as keratinocyte carcinomas. This is due to the fact that they begin in a type of skin cell known as a keratinocyte. To separate keratinocyte carcinoma and Merkel cell cancer from melanoma, the term “non-melanoma skin cancer” is used in this guide.
Other rare kinds of skin cancer include cutaneous (skin) lymphomas, Kaposi sarcoma, skin adnexal tumors, and sarcomas, which are all categorized as non-melanoma skin cancers.
WHAT ARE THE SIGNS AND SYMPTOMS OF SKIN CANCER?
The following symptoms may be experienced by people with basal cell carcinoma, squamous cell carcinoma, or Merkel cell carcinoma. People with non-melanoma skin cancer may not exhibit any of these alterations. Alternatively, the origin of a symptom could be a medical disease other than cancer.
Skin changes are the most common warning symptom of skin cancer. Because each type of skin cancer manifests differently, it is critical to consult your doctor if you notice a change in your skin. The following are the skin characteristics that typically emerge.
Two or more of the following characteristics may be present in basal cell carcinoma:
- An open sore that bleeds, oozes, or crusts for several weeks.
- A reddish, raised patch of skin or an inflamed area that may crust or itch but rarely hurts.
- A hump that is shiny pink, red, pearly white, or translucent.
- A pink growth with a raised border and a crusty central indentation.
- A scar-like, white, yellow, or waxy patch with a smudged border.
Squamous cell carcinoma frequently crusts, bleeds, and manifests as:
- a warty growth
- A persistent, scaly red area with irregular edges that is prone to bleeding.
- An open wound that lasts for weeks
- A rough-surfaced elevated growth with a central depression
Merkel cell cancer is frequently manifested as:
- Skin lumps that are painless, firm, and shiny
- These lumps might be red, pink, or blue in color.
Some skin cancers travel down the nerves. If this occurs, it might produce itching, soreness, numbness, tingling, or the sensation that ants are crawling under the skin. A bulge or protrusion under the skin in regions such as the neck, armpit, or groin is another symptom.
Please consult your doctor if you are concerned about any changes you are experiencing. In addition to other questions, your doctor will inquire as to how long and how frequently you have been experiencing the symptom(s). This could include when you first saw the skin characteristic, how long it’s been there, and any other symptoms you’re having. This is done to assist in determining the cause of the condition, which is referred to as a diagnostic.
Most cases of skin cancer can be cured by removing the cancer with surgery or by utilizing a topical medication. In more complex circumstances, a multidisciplinary team of specialists will meet with a patient to discuss various sorts of therapy in order to establish a strategy that has the highest possibility of curing or treating this disease.
Relieving symptoms, especially in advanced skin cancer, will be an important aspect of cancer care and treatment. This is known as palliative care or supportive care. Once started, it is maintained throughout the course of treatment. Make an appointment with your health care provider to discuss your symptoms, especially any new or changing symptoms.
WHAT ARE STAGES OF SKIN CANCER?
Staging describes where the cancer is present, whether or not it has spread, and whether or not it is impacting other sections of the body.
Doctors utilize diagnostic tests to determine the stage of cancer, therefore staging may not be complete until all tests are completed. Knowing the stage assists the doctor in determining the best course of treatment and can help estimate a patient’s prognosis, or possibility of recovery.
Basal cell and squamous cell carcinoma staging
Basal and squamous cell carcinomas seldom spread to other areas of the body. On rare cases, a person’s lymph node(s) may be removed to determine if the cancer has spread, a condition known as metastasis. Lymph nodes are bean-shaped structures that aid in the fight against infection. Other tests to establish the degree of the disease, including as blood tests, chest x-rays, and imaging scans of the lymph nodes and nerves, liver, bones, and brain, may be recommended by the doctor, but this is uncommon.
Merkel cell cancer staging
The TNM method is used by doctors to describe the stage of Merkel cell carcinoma. Doctors use diagnostic test and scan results to address the following questions:
- Tumor(T): What is the size of the main tumor? Where can I find it?
- Node(N): Has the cancer spread to your lymph nodes? If so, where are they and how many are there?
- Metastasis(M): Is the cancer in other parts of the body? If so, where and how much?
The results are pooled to identify each person’s stage of Merkel cell carcinoma.
There are five stages: stage 0 (zero), stages I through IV, and level V. (1 through 4). The stage provides a common language for doctors to describe the cancer so that they can collaborate to determine the best treatments.
Stage 0: This is referred to as cancer in situ. Cancer cells can only be identified in the top layers of the skin. The malignancy has not spread and has not affected the lymph nodes.
Stage I: The primary tumor is 2 centimeters (cm) or less in width. The cancer has not spread to the lymph nodes or elsewhere in the body.
Stage IIA: The tumor has grown to be greater than 2 cm in size and has not migrated to the lymph nodes or other regions of the body.
Stage IIB: The tumor has spread to neighboring tissues such as muscles, cartilage, or bone. It has not spread to any lymph nodes or other parts of the body.
Stage III: Lymph nodes have been infiltrated by the cancer. The tumor might be of any size and has the potential to expand to surrounding bone, muscle, connective tissue, or cartilage.
- Stage IIIA: The tumor might be any size and has spread to adjacent tissues. The cancer has spread to surrounding lymph nodes, according to biopsies or surgery. The cancer has not spread to the rest of the body. Alternatively, there is no evidence of a tumor, but cancer was discovered in a neighboring lymph node during a physical or via imaging scans. A microscope was used to establish its presence.
- Stage IIIB: The tumor might be any size and has spread to adjacent tissues. The cancer has migrated through the lymphatic system, either to a regional lymph node near the site of origin or to a cutaneous site on the way to a lymph node, a process known as “in-transit metastasis.” These other lymph nodes may have been affected by metastases in transit. The lymphatic system is a component of the immune system that drains fluid from bodily tissues via a network of tubes or arteries.
Stage IV: The tumor has migrated to distant organs such as the liver, lung, bone, or brain.
HOW IS SKIN CANCER DIAGNOSED?
Because more than half of non-melanoma skin cancers are discovered by patients or family members, it is critical to bring any suspicious patch of skin to the attention of a clinician. Many tests are used by doctors to detect or diagnose cancer. They also perform tests to see whether the cancer has spread to another place of the body from where it began. This is referred as as metastasis. Doctors may also conduct tests to determine which treatments are most likely to be effective.
A biopsy is the only guaranteed way for a doctor to know if a part of the body has cancer in most cases of cancer. When selecting a diagnostic test, your doctor may take the following variables into account:
- The cancer type suspected
- Your symptoms and signs
- Your age and general well-being
- The outcomes of previous medical tests
Biopsy
Because non-melanoma skin cancer seldom spreads, a biopsy is frequently the only test required to diagnose and determine the stage, or extent, of the malignancy. A biopsy is the removal of a small sample of tissue for microscopic examination. The suspected skin lesion is excised during this procedure, usually after a local anesthetic has been given to numb the area. The doctor will also frequently remove a perimeter of healthy tissue around the tumor.
A pathologist examines the biopsy sample to establish whether or not it is a skin cancer. A pathologist is a medical professional who specializes in interpreting laboratory tests and assessing cells, tissues, and organs to identify disease.
Your doctor will go over the biopsy results with you. If the cancer was completely eliminated, no further therapy beyond the biopsy may be required. However, if cancer cells are discovered in the margins of the excised tissue, further therapy is usually advised.
WHAT ARE THE TREATMENTS OF SKIN CANCER
Different types of specialists frequently collaborate in cancer care to develop a patient’s overall treatment plan, which mixes many sorts of therapy. Dermatologists, surgeons or surgical oncologists, plastic surgeons, radiation oncologists, and medical oncologists may be among the doctors who treat non-melanoma skin cancer. This is referred to as a multidisciplinary team. Other health care professionals on cancer care teams include physician assistants, nurse practitioners, nurses, social workers, pharmacists, counselors, nutritionists, and others.
The following are descriptions of the most frequent types of non-melanoma skin cancer therapies. Your treatment plan will also include treatment for symptoms and side effects, which is an important aspect of cancer care.
The size and location of the skin cancer, potential side effects, and the patient’s preferences and overall health all influence treatment options and recommendations. Take the time to read about all of your treatment options, and don’t be afraid to ask clarifying questions. Discuss the aims of each treatment with your doctor, as well as what you can expect during treatment. These discussions are known as “shared decision making.” When you and your doctors collaborate to choose therapies that meet the goals of your care, this is referred to as shared decision making. Because there are many treatment choices for non-melanoma skin cancer, shared decision making is very crucial.
Surgery
During a medical procedure, the tumor and surrounding tissue are removed via surgery. Many skin malignancies are readily and swiftly removed from the skin through a simple surgical procedure. Occasionally, no extra treatment is required.
The surgical procedure employed is determined by the type of skin cancer as well as the size and location of the lesion. The majority of these operations begin with a local anesthetic to numb the skin. A dermatologist, surgical oncologist, general surgeon, plastic surgeon, nurse practitioner, or physician assistant can perform these in their clinic setting, rather than a hospital. Other treatments, such as larger broad excisions and sentinel lymph node biopsies, are carried out in a hospital operating room under local and/or general anesthesia. This is commonly used to treat Merkel cell carcinoma.
Non-melanoma skin cancer surgeries and procedures include:
- Curettage and electrossication: The skin lesion is removed with a curette, which is a sharp, spoon-shaped device, during this popular surgery. An electric current is then used to control the bleeding and eliminate any leftover cancer cells in the area. This is known as electrodessication. After healing from this operation, many patients have a flat scar.
- Wide excision: This entails removing the tumor as well as some healthy skin and soft tissue around it, known as a margin. The amount of tissue removed is determined by the type and size of the skin cancer. When a huge tumor is removed, the incision may be too large to seal, so doctors may close the wound with skin from another region of the body. This is known as a skin graft.
- Mohs micrographic surgery: This procedure, also known as complete margin assessment surgery, entails removing the visible tumor as well as small fragments around the edge of the tumor’s location. Each small fragment is examined under a microscope until the malignancy has been eliminated completely. This is normally reserved for larger tumors, those located in the head and neck region, and cancers that have returned in the same location.
- Reconstructive surgery: Because skin cancer frequently develops on the face, a reconstructive (plastic) surgeon may be a member of the health care team. When doctors arrange treatment, they take into account how the treatment may affect a person’s quality of life, such as how the person feels, looks, talks, and eats. Before undergoing any skin cancer surgery, consult with your doctor to see whether you can change your appearance and if there are any functional issues that must be considered while building a treatment plan.
- Sentinel lymph node biopsy: This surgical method, also known as SLNB, sentinel node biopsy, or SNB, is frequently utilized in the treatment of Merkel cell carcinoma. It assists the doctor in determining whether the cancer has spread to the lymph nodes. When cancer spreads from its origin to the lymph nodes, it passes through the lymphatic system. The first lymph node into which the lymphatic system empties is known as a sentinel lymph node. Because cancer can begin anywhere on the skin, the sentinel lymph nodes will be located differently for each patient, depending on where the disease began. To locate the sentinel lymph node, a dye and a harmless radioactive material are injected as close to the site of the tumour as possible. The material is tracked all the way to the sentinel lymph node. The doctor then removes one or more of these lymph nodes to look for cancer cells, leaving most of the remaining lymph nodes in the area intact. These are delivered to a pathologist, who examines the lymph nodes and writes up a report. If no cancer cells are identified in the sentinel lymph node(s), no additional lymph node surgery is required. A sentinel lymph node that contains cancer cells is referred to as a positive sentinel lymph node. This indicates that the disease has spread and that extra therapy, possibly additional surgery, may be required.
Before undergoing surgery, consult with your health care team about the potential adverse effects of the procedure. In general, surgery can cause pain, scars, numbness, skin stretching, wound difficulties, infection, and cosmetic alterations to the area where the surgery was conducted.
Radiation therapy
The use of high-energy rays or other particles to eliminate cancer cells is known as radiation therapy. A radiation oncologist is a doctor who specializes in the use of radiation therapy to treat cancer. Radiation therapy may be used instead of surgery for skin cancer that is placed in a difficult-to-treat location, such as the eyelid, tip of the nose, or ear. It is also utilized by some people who want to prevent surgical scarring. Finally, radiation therapy may be indicated following surgery, particularly for lymph nodes involved in the malignancy, to help prevent the skin cancer from returning.
In the case of Merkel cell cancer, radiation therapy is frequently administered following surgery for stage I and II illness. This is known as adjuvant therapy.
External-beam radiation therapy, which delivers radiation from a machine outside the body, is the most prevalent method of radiation treatment. A radiation therapy regimen, or schedule, typically consists of a predetermined number of treatments administered over a predetermined time period. To eradicate the malignancy, several treatments may be required. Brachytherapy is a less prevalent method of radiation treatment for skin cancer. The radiation source is placed very close to or inside the skin cancer.
Radiation therapy is not advised for patients with necessitated basal cell carcinoma syndrome.
Radiation therapy side effects may include a rash, skin infections, itchy or inflamed skin, or a change in skin tone. These side effects, however, can typically be avoided by applying a corticosteroid or antibiotic to the skin. If adverse effects occur, they usually resolve within a few weeks of the end of treatment.
Other local therapies
Doctors may employ photodynamic treatment, cryotherapy, or laser therapy to treat precancerous skin problems or cancerous lesions situated exclusively in the top layer of the skin.
Photodynamic therapy (PDT): This is a combined therapy for actinic keratoses. First, a topical drug known as aminolevulinic acid (Levulan) is applied to locations having a high number of actinic keratoses. The region is then subjected to a particular light-emitting equipment for a few minutes to several hours. Because aminolevulinic acid causes skin sensitivity, the process might be uncomfortable. Your doctor may advise you to take pain relievers before to the treatment. Furthermore, the chemical makes the skin extremely sun sensitive, thus it is critical to limit sun exposure and to wear protective eyewear, clothing, and sunscreen for a few days following the treatment. The skin will be quite inflamed for a few days, but the actinic keratoses will go as the sensitivity subsides.
Freezing: Liquid nitrogen is used in this method, also known as cryotherapy, to freeze and eliminate aberrant cells. It is most commonly used to treat precancerous skin problems. When the liquid nitrogen is first administered to the skin, it will sting, and then the skin will blister and shed. It is possible that more than one freeze will be required. This surgery may result in a scar.
Laser therapy: A narrow beam of high-intensity light can eradicate precancerous skin problems that are only found in the skin’s outer layer.
Chemotherapy
Chemotherapy is the use of medications to eradicate cancer cells, typically by preventing the cancer cells from growing, dividing, and proliferating. These medications are often applied to the skin every day for several weeks in the treatment of skin cancer. This is known as topical therapy. These drugs may cause skin inflammation or irritation, which will subside once the treatment is completed.
Topical diclofenac (Solaraze), fluorouracil (Efudex), and ingenol mebutate (Picato) are licensed for the treatment of precancerous actinic keratoses, with fluorouracil providing better outcomes in terms of efficacy and time until new precancers arise. During therapy, all of these lotions might produce irritation, burning, redness, and stinging. These symptoms normally fade away shortly after treatment is finished. Because these creams do not leave scars, many doctors use them to treat the face or other regions where a person’s look may be compromised.
Topical imiquimod (Aldara), which stimulates the immune system, may be advised for tiny basal cell tumors that are not on the face. For 6 to 12 weeks, the cream must be administered once a day, five days a week. The Food and Drug Administration (FDA) has also approved topical fluorouracil for the treatment of very thin basal cell carcinomas. It should be administered twice a day for three to six weeks. This treatment is likely to cause some discomfort and redness in the location of the basal cell carcinoma.
Targeted therapy
Targeted therapy is a type of cancer treatment that targets specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This method of treatment inhibits cancer cell growth and spread while limiting damage to healthy cells.
Cancers do not all have the same objectives. Your doctor may do tests to determine the genes, proteins, and other components in cancer cells in order to find the most effective treatment. This enables clinicians to provide the most effective treatment to each patient whenever possible. Furthermore, research studies are continuing to learn more about specific molecular targets and new treatments aimed at them.
Vismodegib (Erivedge) and sonidegib (Odomzo), both FDA-approved hedgehog pathway inhibitors, are FDA-approved medications for big (also known as advanced) basal cell tumors that cannot be treated with surgery or radiation therapy. They inhibit the PTCH1 genetic mutation, which appears to be responsible for the formation of basal cell carcinoma. In many patients, this therapy reduces or stabilizes tumors. Hair thinning, muscle cramps, weight loss, dry skin, and loss of taste are the most common side effects of this medication.
Discuss with your doctor the potential side effects of a certain medicine and how to manage them.
Immunotherapy
Immunotherapy, also known as biologic therapy, is intended to increase the body’s natural defenses against cancer. It employs components created by the body or in a laboratory to enhance, target, or restore immune system activity.
For non-melanoma skin cancer, the FDA has approved three immunotherapy medicines.
- Cemiplimab (Libtayo): This immune checkpoint inhibitor works by inhibiting the PD-1 pathway. It is licensed for the treatment of metastatic or locally advanced squamous cell carcinoma, as well as metastatic or locally advanced basal cell carcinoma. Cemiplimab’s most common side effects are lethargy, rash, and diarrhea. It can also produce serious and perhaps fatal adverse effects, including as issues with the lungs, intestines, liver, hormone gland, skin, and kidneys.
- Pembrolizumab (Keytruda): This is yet another PD-1-targeting immune checkpoint inhibitor. It can be used to treat Merkel cell cancer that has spread or has returned following treatment. Pembrolizumab can also be used to treat squamous cell carcinoma that has spread or returned after treatment and cannot be cured with surgery or radiation therapy. Fatigue, discomfort, decreased appetite, itching, diarrhea, nausea, rash, fever, cough, shortness of breath, and constipation are frequent side effects of pembrolizumab.
- Avelumab (Bavencio): Avelumab inhibits the PD-L1 signaling pathway. It is approved for the treatment of persons aged 12 and up who have Merkel cell cancer that has spread to another section of their body. Avelumab commonly causes fatigue, discomfort, diarrhea, nausea, rash, appetite loss, and edema owing to fluid buildup. Kidney issues, anemia, intestinal blockage, and infection are also common in some people.
Different forms of immunotherapy might result in a variety of adverse effects. Skin rashes, flu-like symptoms, diarrhea, and weight fluctuations are all common adverse effects. Immunotherapy can sometimes cause the immune system to attack healthy cells, which can lead to negative effects. Consult your doctor about the potential adverse effects of the immunotherapy that has been prescribed for you.
Metastatic or advanced skin cancer
Although it is unusual, non-melanoma skin cancer can spread to another portion of the body from where it began. Doctors refer to this type of cancer as metastatic cancer in these cases. If this occurs, it is advisable to consult with specialists who have treated similar cases in the past. Different doctors may have differing views on the optimal conventional treatment strategy. Clinical trials are another possibility.
Skin cancer that has spread beyond the skin cannot always be removed surgically. Unresectable cancer is cancer that cannot be removed surgically. A person’s treatment strategy may include chemotherapy, radiation therapy, and/or targeted therapy to control distant spread. Palliative treatment will also be essential in order to alleviate symptoms and negative effects.
Basal cell carcinoma: If surgery or radiation therapy are unable to treat metastatic basal cell carcinoma, targeted therapy may be a possibility. Vismodegib and sonidegib are hedgehog pathway inhibitors that have been approved by the FDA. These medications inhibit the PTCH1 genetic mutation.
Squamous cell carcinoma: Because metastatic or unresectable squamous cell carcinoma of the skin is uncommon, treatment strategies frequently employ treatments that have proven effective in persons with squamous cell carcinoma of the head and neck that did not begin on the skin. Taxanes, such as docetaxel (Taxotere) or paclitaxel (a generic medication), and platinums, such as carboplatin or cisplatin, are commonly used in chemotherapy (both available as generic drugs). Fatigue, low blood cell counts, rashes, diarrhea, and changes in sensation at the tips of the fingers or toes are the most common side effects of these medications.
Based on findings from individuals with head and neck squamous cell carcinoma, many targeted therapies, similar to chemotherapy regimens, may be employed for some persons with squamous cell carcinoma. Cetuximab (Erbitux), panitumumab (Vectibix), and erlotinib are examples (Tarceva). None have been authorized by the FDA for squamous cell skin cancer.
Immunotherapy has become the usual therapeutic option for persons with metastatic and unresectable squamous cell carcinoma. Cemiplimab and pembrolizumab, both PD-1 inhibitors, can be used to treat this condition.
Merkel cell cancer: Immunotherapy with avelumab or pembrolizumab is typically used to treat metastatic Merkel cell carcinoma. Clinical trials may make other immunotherapy medicines available. To alleviate symptoms and side effects, chemotherapy, surgery, and/or radiation therapy may be performed.
A diagnosis of metastatic cancer is extremely stressful and challenging for the majority of people. You and your family are encouraged to express your feelings to doctors, nurses, social workers, and other members of the health care team. It may also be beneficial to speak with other sufferers, such as through a support group.
