Skin Cancer
Skin cancer is almost universal in Queensland and occurs to a slightly lesser extent in the rest of Australia. It is estimated that four out of every five people in Queensland will develop at least one skin cancer during their lifetime.
Although the 40-60 age group has the highest incidence, there is no age that is exempt. In recent years there has been an increase of diagnosis of skin cancer in the younger age groups, including teenagers. Therefore the advice is - if any unusual area develops on the skin and persists for more than three months, it should be regarded as a skin cancer until it is proved that it is not.
There are two important ingredients in the development of skin cancer: type of skin and sunlight. The skin type is inherited, and the most susceptible type is from Celtic forebears C fair skin with a reddish tinge, lots of freckles, and multiple moles. The best protective measure is to minimise exposure to sunlight, particularly in the first 20 years of life and especially between 10am and 3pm. Suitable clothing and protective creams help to reduce the effect of harmful UV rays, but protection is never absolute. Parents should make sure that children understand the harmful effect of sunlight and help the child to take adequate precautions against sun exposure.
There are three main varieties of skin cancer: BCC and SCC (non melanoma skin cancer) and melanoma. (Melanoma will be discussed fully in another Plastic Surgery Article).
Basal Cell Carcinoma (BCC):
About 80% of non-melanoma skin cancer is BCC. It can occur anywhere on the body surface, but more commonly on sun-exposed surfaces such as the face. The earliest sign can be a red flat area, a small nodule, a small spot that bleeds on rubbing with the towel, a small ulcer, or a scaly patch.
The natural tendency for any skin cancer is to increase in size C either in area or depth, so the longer it is present before being treated, the larger and deeper it will be. Treatment will therefore be more difficult and the consequent scarring will be more extensive. BCC usually does not spread to other organs of the body (metastasise) hence local treatment is usually curative. However to effect the cure, the tumour needs to be treated adequately either by non-surgical means or completely removed surgically. Any tumour cells left will continue to grow and form another lump. Before treatment by non-surgical means it is wise to have the tumour accurately diagnosed by microscopic examination or biopsied (a small piece taken under local anaesthetic for pathology). After surgery a pathologist should examine the piece removed for adequate removal in depth and at all edges.
Treatment for early lesions, such as hyperkeratoses, can be undertaken by non-surgical means including cryotherapy - freezing with carbon-dioxide snow or liquid nitrogen C or laser destruction. Efudix (5FU) cream is sometimes used in early stages, particularly over a wide area, but will not adequately deal with an established skin cancer. Radiotherapy is not usually recommended as primary treatment of non-complicated skin cancer, except in the very elderly or those patients who are medically unsafe for surgery. Surgical removal is necessary for tumours of appreciable thickness, in certain special sites as at the corner of the eye, or for recurrence after other methods of treatment. Small lesions are removed by excision and direct suture of the defect, leaving minimal scar. Removal of large areas of skin, or tissue in depth, will require some form of reconstruction by skin graft or local flaps. Most methods of treatment will result in some form of scarring, although the aim of any treatment method is to leave the least scar possible and plastic surgeons are trained to in this. Permanent cure should be achieved in over 95% of adequately treated BCC.
Squamous cell carcinoma (SCC):
Most of the above applies equally to SCC. About 20% of non-melanoma skin cancer is SCC. The difference is often only a microscopic one, as to the naked eye the two may look exactly the same. SCC tends to grow more rapidly, forms an ulcer sooner, starts as a scaly patch or nodule and can involve any skin surface, but is more common on the lip or ears. Treatment is the same as for BCC and as ever, should be undertaken early. The main difference with SCC is that it has the ability to metastasise, that is, spread to other parts of the body - via the lymph stream to glands draining the area, or via the blood stream to more distant parts such as the lungs, brain or liver. Glands involved may be in the neck (from tumours of the face), the groin (from tumours of the leg) or the axilla (arm-pit) from tumours of the arms or hand. Nevertheless, most SCCs are cured by adequate treatment at an early stage and less than 3% spread to other parts. They are treated in exactly the same way as BCCs but usually there is a recommendation for follow-up every few months for several years.
Kerato-acanthoma (KA):
This is a rapidly growing skin tumour, indistinguishable from SCC but not malignant. The exact diagnosis is made microscopically after removal of the tumour and the treatment is the same as for SCC. It does not spread to glands, but may recur locally. Diagnosis cannot be made on surface appearance as it looks exactly the same as the more dangerous SCC.
Rarer Cancers:
Other less common forms of skin cancer can be diagnosed microscopically after removal and in these cases special treatment such as radiotherapy or chemotherapy might be necessary. Sometimes a wider surgical removal is recommended for a particular tumour C for example, if it is considered to be very aggressive, to have unusual microscopic features or to be spreading along nerves or into deeper tissues. Merkel Cell tumour is one variety of aggressive skin cancer that grows quickly and looks much like other tumours in the early stages, but must be treated by both surgery and radiotherapy to try to prevent recurrence. Even with early and radical treatment a significant percentage of these tumours spread either to the lymph glands or throughout the body and can have a fatal outcome. This is another good reason why its important that the early tumour be removed for accurate microscopic diagnosis.
Pre-malignant skin conditions:
In Australia, unless early and effective sunlight protection is practised, sun damage to exposed skin is universal. This damage manifests in rough, scaly development of thickened areas, small non-healing areas, multiple freckles and moles, and colour and other changes in pre-existing moles.
Significant damage to skin or any changes you notice must be brought to the attention of your doctor so that early treatment can be sought, in most cases preventing a necessity for more extensive surgical treatment. You should not use applications to the skin that are scientifically unproven because apparent healing on the surface can occur with no curative effect on the deeper part of the tumour. Skin cancer is a cancer like any other and can kill if early and appropriate treatment is not undertaken.
Symptoms:
Any unusual skin condition that doesn't heal in four weeks, including: - Any sore, ulcer or scaly patch on the skin, or white patch on the lips that doesn't heal, - Any mole that seems to grow quickly - Any mole that changes shape or colour - Any mole that bleeds or repeatedly itches.
Snapshot:
- Most skin cancers are caused by over-exposure to the sun - They are the most common cancers in Australia - Australians have the highest rate of skin cancer in the world and it is growing - Melanoma results in about 700 deaths each year - About 125,000 Australians have skin cancer at the moment and do not know it - Most skin cancer can be prevented by protecting the skin from the sun - Nearly all skin cancers can be cured if detected and treated early.
Warning:
The Australian Society of Plastic Surgeons wishes to highlight the potentially damaging effects of ultraviolet radiation to the skin.
Back in 1993 Australians had more than 225,000 skin cancers excised by specialists. A total of 50,000 grafts and skin flaps where used for repair of the defects created by the excision of which more than half were associated with the face. And every year since, the incidence of skin cancer in Australian has grown.
These statistics make the surgical treatment of skin cancer one of the most costly forms of cancer to our society taking into the account medical costs and time away from work. The cost to the patient can be death.
This Society sincerely advises everyone and particularly young people to:
- Understand that unprotected exposure to ultraviolet rays is damaging and dangerous. - Avoid the sun as much as reasonably possible, especially in the middle of the day. - f out in the sun even for brief periods, apply a sunscreen SPF 15+ with particular care for your face, wear adequate protective clothing and broad-brimmed hats. - Know the signs of development of skin cancer and see your GP for early treatment.
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