Skin Cancer - Non Melanoma

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What is Skin Cancer (Non-Melanoma)?

Skin cancer is the most common of all cancers, with doctors finding skin cancer in about one million Americans each year. Reducing exposure to ultraviolet (UV) radiation from sunlight can prevent most skin cancers. If skin cancer is found early, it can usually be cured by relatively simple surgery. Skin cancer is responsible for less than 1% of all cancer deaths.

The skin, the body's largest organ, protects against infection and injury and helps regulate body temperature. The skin also stores water and fat and produces vitamin D. Skin is made up of two main layers: the epidermis (outer layer of skin) and the dermis (inner layer of skin).

Types of skin cancer

Cancer begins when normal cells change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body). There are three main types of skin cancer:

Squamous cell carcinoma. Most of the epidermis is made up of flat, scale-like cells called squamous cells. Approximately 20% of skin cancer resembles these cells and is called squamous cell carcinoma. This type of cancer is mainly caused by sun exposure, but it can appear on skin that has been burned, damaged by chemicals, or exposed to x-rays.

Basal cell carcinoma. Cells in the lower epidermis are round cells known as basal cells. About 80% of skin cancer develops from this type of cell that has been exposed to the sun and is called basal cell carcinoma. Basal cell carcinoma most often forms on the head and neck.

Melanoma. Where the epidermis meets the dermis, there are scattered cells called melanocytes, which produce the melanin that gives skin color. Melanoma starts in melanocytes, and it is the most aggressive of the three types of skin cancer. The rest of this section describes basal cell and squamous cell skin cancers.

Squamous cell carcinoma and basal cell carcinoma are known as non-melanoma skin cancers, to distinguish them from melanoma, which arises from very different cells and is treated differently.

Typically, non-melanoma skin cancer can be treated with relatively simple surgery. If the cancer is very small, cryosurgery (freezing) or laser surgery may be used.  Squamous cell carcinoma also rarely spreads, but it is more likely to spread than basal cell carcinoma.

Risk Factors and Prevention

A risk factor is anything that increases a person's chance of developing cancer. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The following factors may raise a person's risk of developing skin cancer:

Exposure to sunlight/UV radiation. Ultraviolet B (UVB) radiation causes sunburn and plays a role in the development of basal and squamous cell cancers. Ultraviolet A (UVA) penetrates the skin more deeply and contributes to photoaging (premature aging of the skin) or wrinkling. The role of UVA in the development of non-melanoma skin cancer is suspected, but not yet certain. People who live in areas with year-round, bright sunlight (which includes both UVA and UVB) or at high altitudes have a higher risk of developing skin cancer, as do those who spend significant time outside or on a tanning bed (which emits mostly UVA).

Fair skin. Less pigment (melanin) in skin offers poorer protection against UV radiation. People with light hair and light-colored eyes who have skin that tans poorly or freckles, or those who burn easily, are more likely to develop skin cancer.

Gender. Rates of skin cancer in older white men and younger women have increased in recent years.

Age. Most basal cell and squamous cell cancers typically appear after age 50, but cancers may appear earlier in individuals with sun-damaged skin. In recent years, the number of skin cancers in people age 65 and older has increased dramatically.

A history of sunburns or fragile skin. Skin that has been burned, sunburned, or injured from disease has a higher risk of skin cancer. Squamous cell and basal cell cancers occur more often in people with higher lifetime exposure to the sun or other sources of UV radiation.

Individual history. People with weakened immune systems or those who use certain medications (such as immunosuppressive drugs, certain steroids, and drugs that make the skin sensitive to light) have a higher risk of developing skin cancer, particularly squamous cell cancer. People with some rare genetic conditions, such as xeroderma pigmentosum, nevoid basal cell carcinoma syndrome, or albinism have a much higher risk of developing skin cancer.

Previous skin cancer. People who have had any form of skin cancer have a higher risk of developing another skin cancer. Thirty-five percent (35%) to 50% of people diagnosed with one basal cell cancer will develop a new skin cancer within five years. Therefore, people who have had one skin cancer need ongoing, follow-up care to watch for additional cancers.

Precancerous skin conditions. Lesions called actinic keratoses (rough, red or brown scaly patches on the skin) or Bowen's disease are usually more common in areas exposed to the sun. Such areas can change into squamous cell cancers in some people. Bowen's disease in non-sun-exposed areas may be related to arsenic exposure. Use of sunscreens may decrease the risk of actinic keratoses.

Human papillomavirus (HPV). Research indicates that infection with this virus is a risk factor for squamous cell carcinoma, particularly if the person's immune system becomes suppressed. HPV is most commonly passed from person to person during sexual activity. There are different types, or strains, of HPV, and some strains are more strongly associated with certain types of cancers.

Prevention

Reducing exposure to sunlight and other sources of UV radiation lowers the risk of skin cancer. This is important for all age groups, but is especially important for people who have risk factors for skin cancer. Sun damage is cumulative, meaning it builds up over time. Steps to reduce sunlight exposure and help prevent skin cancer include:

Preventing sunburn

Limiting or avoiding sun exposure between 10:00 AM and 4:00 PM

Wearing sun-protective clothing and a hat that shades the face, neck, and ears. Clothes made of fabric labeled with UPF (UV protection factor) may provide better protection. UV-protective sunglasses are also recommended.

Using sunscreen with a sun protection factor (SPF) of 15 or higher throughout the year and reapplying it at least every two hours, especially after heavy perspiration or being in the water

Avoiding use of sun lamps, tanning beds, or tanning salons

Examining skin regularly (examinations by a health care professional and self-examinations).

Symptoms and Signs

People with basal cell or squamous cell carcinoma may experience the following symptoms. Sometimes, people with non-melanoma skin cancer do not show any of these symptoms or signs. Or, these symptoms may be caused by a medical condition that is not cancer. The skin features that people with basal cell or squamous cell carcinoma frequently develop are listed below. If you are concerned about a symptom or skin feature, please talk with your doctor.

Changes in the skin are the main warning sign for skin cancer. Each type of skin cancer can appear differently, so it is important to talk with your doctor when you notice a change in your skin.

For basal cell cancer, two or more of the following features may be present:

An open sore that bleeds, oozes, or crusts and remains open for several weeks

A reddish, raised patch or irritated area that may crust or itch, but rarely hurts

A shiny pink, red, pearly white, or translucent bump

A pink growth with an elevated border and crusted central indentation

A scar-like, white, yellow, or waxy area, often with a poorly defined border

Squamous cell cancer can often crust, bleed, and appear as:

A wart-like growth

A persistent, scaly red patch with irregular borders that may bleed easily

An open sore that persists for weeks

An elevated growth with a rough surface and a central depression

Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you've been experiencing the symptom(s) and how often.

If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

Early detection: Finding skin cancer early

Earlier detection and recognition of skin cancer is the key to improving the chance for successful treatment. Recognizing early warning signs of skin cancer and doing regular self-examinations of your skin will help find skin cancer early when the disease is highly curable.

Examinations should be performed in front of a full-length mirror in a brightly lit room. It helps to have another person check the scalp and back of the neck. In people with fair skin, non-melanoma skin cancer most often begins on skin that has frequently been exposed to the sun. However, in people with darker skin, squamous cell carcinoma occurs primarily in areas infrequently exposed to the sun, such as the lower legs.

Include the following steps in a skin self-examination:

Examine the front and back of the entire body in a mirror, then the right and left sides, with arms raised.

Bend the elbows and look carefully at the outer and inner forearms, upper arms (especially the hard-to-see back portion), and hands.

Look at the front, sides, and back of the legs and feet, including the soles and the spaces between the toes.

Part the hair to lift it and examine the back of the neck and scalp with a hand mirror.

Check the back, genital area, and buttocks with a hand mirror.

Talk with your doctor if you find any of the following:

A growth on the skin that matches any symptom listed above

New growth on the skin

A suspicious change in an existing mole or spot

A sore that doesn't heal within two weeks

Diagnosis

Doctors use many tests to diagnose cancer and find out if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. A biopsy is the removal of a small amount of tissue for examination under a microscope. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:

Age and medical condition

Type of cancer suspected

Severity of symptoms

Previous test results

Because basal cell and squamous cell cancers rarely spread, a biopsy is often the only test needed to both diagnose and find out the stage (extent) of cancer. Your doctor will review the results of the biopsy with you. No further treatment beyond the biopsy may be necessary if the entire cancer is removed. However, if the cancer is present at the edges of the tissue (called the margin) taken during the biopsy,additional treatment will usually be necessary.

Stages

Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and whether it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery).

Basal cell and squamous cell rarely spread. On rare occasions, the patient's lymph nodes (tiny, bean-shaped organs that help fight infection) may be removed to determine if the cancer has metastasized. The doctor may perform other tests, including blood tests, chest x-rays, and imaging scans of the liver, bones, and brain, but this is uncommon.

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