Skin cancer is the most common cancer in the United States and the world with over 3 million cases in the US alone. Approximately 95% of skin caners in the US are one of two types: Basal Cell Carcinomas and Squamous Cell Carcinomas. Melanoma makes up about 4% of skin cancers in the United States, but is the cause of about 75% of skin cancer deaths. The remaining 1% of skin cancer is made up of a large number of skin cancers all occurring very rarely.
Patients often ask what is the difference between basal cell carcinomas (BCC) and squamous cell carcinomas (SCC).
Basal cell carcinomas are the most common skin cancer and originate from the hair follicle. That is why we do not find basal cell cancers on the palms or soles where we do not have hair follicles. Squamous cell carcinomas come from the epidermal lining of the skin. Therefore, we can find SCC on any skin lining, even the palms and soles, unlike BCC. Basal cell carcinomas rarely ever cause death or travel to the lymph nodes, but they can cause significant local destruction, mutilation, and functional deficits if they are allowed to invade local anatomic structures such as the eye, nose, ears, or nerves resulting in facial paralysis. They are slow growing, but grow faster the larger they are.
Squamous cell carcinomas can arise from a precursor or ‘pre-cancer’ called the Actinic Keratosis (AK) or from out of nowhere (de novo). This is why dermatologists place such an emphasis on treating the rough spots on patients’ sun-exposed locations in order to prevent them from progressing to cancer. Squamous cell carcinomas are more dangerous than basal cell carcinomas in that they can metastasize to the lymph nodes, brain, lungs, or liver causing death. While this is a rare event, it is important to treat squamous cell carcinomas early when they are easier to treat and carry a lower risk of metastasis to other organs.
There are many treatments for skin cancers. An appropriate and patient-specific treatment plan should be discussed with your dermatologist. Ultimately, treatments for skin cancer can broadly be thought of as existing in two categories: non-blinded and blinded.
‘Non-blinded’ skin cancer treatments refer to the careful examination of the margins of the tissue to ensure that the cancer has been removed. There are only two procedures that can be considered ‘non-blinded’. The first and most effective of all treatments is Mohs Surgery.
Mohs Surgery, developed by the late Dr. Frederich Mohs, uses a technique where 100% of the surgical margin can be evaluated. This is the only technique where the entire surgical margin is evaluated. All other treatments either do not evaluate the margins or evaluate a lesser amount. Mohs Surgery is reserved for skin cancers that occur on certain body locations, are of a certain size, carry with it some increased risk based on their appearance under the microscope, or other extenuating circumstances (including, but not limited to a young patient, immunosuppression, recurrence, in a burn scar, etc). Mohs surgery allows the surgeon to take less tissue than what would normally be required because of the ability to evaluate 100% of the margin and therefore conserves more of the patient’s skin than other procedures. The processing of the tissue can take about an hour, which can often cause significant wait times in the office. Mohs surgery by definition refers to the surgeon acting as both the surgeon and the pathologist.
Mohs surgery offers the highest cure rates of any other treatment, 95-99%, when done by a Mohs College fellowship-trained surgeon. All clinical trials validating Mohs Surgery cure rates were done studying Mohs College fellowship-trained members. Mohs College members can be found here (http://acms.execinc.com/edibo/SurgeonFinder). If your surgeon is not found on this site, then they have not done a one-year dedicated fellowship.
Once the skin cancer is removed, the most cosmetically acceptable reconstruction is performed. Mohs College fellowship-trained Mohs surgeons have undergone an intensive one-year training not only learning the surgical removal and evaluation of skin cancer, but also have tirelessly trained in the most advanced reconstruction techniques available. Furthermore, Mohs College members are required to frequently attend national conferences in order to maintain their fund of knowledge on the most cutting edge surgical removal and repair techniques.
In very rare instances, collaboration with a non-dermatologist surgeon is required (plastic surgeon or ENT).
For more information on what to expect during Mohs surgery at Skin Wellness Physicians, please click here: XXXXXXMOHSSURGERYXXXXX.
The other non-blinded treatment option is simple excision, which involves taking out the tissue in a non-Mohs technique. This is appropriate and used often for smaller skin cancers on the trunk and extremities. Under these circumstances, this treatment offers high cure rates with good cosmetic outcomes. While the margins are evaluated, only a fraction of the margins are evaluated when compared to Mohs surgery or none of the margins when discussing ‘blinded’ treatments below.
‘Blinded’ skin cancer treatments refer to treatments that do not check the margins of the skin cancer such as: radiation therapy, ED&C, photodynamic therapy, and topical therapies. The treatments are based on clinical trials that determine how much or how little should be treated based on multiple factors. Most treatments are blinded. A very good treatment with high cure rates in some instances is radiation therapy. There are several different types of radiation treatments that vary in cost, treatment number, and side effects. If your dermatologist has recommended radiation therapy for your skin cancer, then the details of these options will be discussed with your radiation oncologist.
“Scraping and burning” or known professionally as ED&C for electrodesiccation and curettage is a good option in some circumstances, but can often lead to prolonged wound healing times and less than ideal scars. These cure rates range from 70-85%
Photodynamic therapy will be discussed elsewhere, but involves the use of a medicine placed on the skin that is preferentially absorbed in pre-cancer or skin cancer cells where it is metabolized into high-levels of a light-sensitive compound that we make in our body naturally, but at very low levels. This resultant chemical then makes the pre-cancer or skin cancer cells very sensitive to bright light, particularly blue or red light. After a calculated incubation period, patients are exposed to a blue or red light depending on the goal of the therapy (pre-cancer or skin cancer), after which a percentage of the target cells will have been destroyed. This often requires multiple treatments and carries with it some downtime. At times, your physician at Skin Wellness Physicians may recommend combining this method with surgery in order to improve both the surgical experience and cosmetic outcome for your skin cancer treatment. For more information on Photodynamic Therapy at Skin Wellness Physicians, please click on XXXXXPDTXXXXX.
Topical therapies can be utilized at times, but these treatments often carry the lowest level of success. While they may be good options in poor surgical candidates, they often carry with them lengthy treatment protocols and significant skin reactions. However, when used as a pre-treatment to skin cancer surgery (i.e. Mohs surgery). Topical therapies can often reduce the extent of surgery by shrinking the cancer and thus making the surgery less extensive or invasive with better cosmetic outcomes.
In very rare instances, the treatment of skin cancer will require systemic therapies. These are often utilized in very rare circumstances and require a careful and detailed discussion with your dermatologist or oncologist.
At Skin Wellness Physicians we are committed to maintaining up-to-date treatment options with the most advanced skin cancer treatments and techniques. As these skin cancer treatments progress, so will our commitment to the best care for you.