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Cancer Medicine :: Skin Cancer (Non-Melanoma)

Skin Cancer (Non-Melanoma)

Treatment Options

This section outlines treatments that are the standard of care (best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. 

Treatment overview

In cancer care, different types of doctors often work together to create a patient's overall treatment plan that combines different types of treatments. This is called a multidisciplinary team.

Descriptions of the most common treatment options for skin cancer are listed below. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient's preferences and overall health. 

Surgery

Surgery is the removal of the tumor and surrounding tissue during a medical procedure. Many skin cancers can be removed from the skin quickly and easily in a simple surgical procedure, and often no further treatment is needed. Most of these surgical procedures use a local anesthetic to numb the skin and can be done outside of a hospital by a dermatologist (a doctor who specializes in diseases and conditions of the skin), general surgeon, plastic surgeon, nurse practitioner, or physician assistant. Different types of surgical procedures are used depending on the size of the cancer and where it is located.

Curettage and electrodessication. In this common procedure, the cancer is removed with a curette, which is a sharp, spoon-shaped instrument. The area can then be treated with electrodessication, which uses an electric current to control bleeding and kill any remaining cancer cells. Many people have a flat, pale scar after this procedure.

Mohs surgery. This technique involves removing the visible tumor, in addition to small fragments of the edge around the area where the tumor existed. Each small fragment is examined under a microscope until all cancer is removed. This is typically used for larger tumors, those in hard to reach places, and for cancers that have come back in the same place.

Freezing. Used most often on precancerous skin conditions, this procedure (called cryosurgery) uses liquid nitrogen to freeze and kill cells. The skin will later blister and shed off. This procedure will sometimes leave a pale scar. More than one freezing may be needed.

Laser therapy. A narrow beam of high-intensity light can destroy precancer that is located only in the outer layer of the skin.

Grafting. When a large tumor is removed, surgeons may use skin from another part of the body to both close the wound and reduce scarring.

Reconstructive surgery. Since skin cancer often occurs on a person's face, a reconstructive (plastic) surgeon or facial specialist may be part of your health care team. Before surgery begins, talk with your doctors about whether changes to your appearance are likely.

Radiation therapy

Radiation therapy is the use of high-energy rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. Radiation therapy may be used for skin cancer that is hard to treat with surgery, such as skin cancer that appears on the eyelid, tip of the nose, and ear; several treatments may be needed. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.

The side effects from radiation therapy may include a rash, dry or red skin, or a change in the color of the skin. Most side effects go away soon after treatment is finished. 

Topical chemotherapy

Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells' ability to grow and divide. For cancers located only on the top layer of the skin or to treat precancerous skin conditions, doctors may prescribe chemotherapy in a cream or lotion. These drugs are usually applied daily for several weeks. They may cause inflammation, which goes away once treatment is finished.

In addition to the topical chemotherapy that has been used for many years, some doctors are using imiquimod (Aldara), a topical immune response modifier, to treat early basal cell carcinomas, actinic keratoses (a precancer to squamous cell carcinoma), and very thin squamous cell carcinoma. Imiquimod is applied several times a week.

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. 

Recurrent skin cancer

Once your treatment is complete, talk with your doctor about the possibility of the cancer returning. Many people with one skin cancer later develop another skin cancer.

Sometimes, people feel worried or anxious about the possibility that the cancer will come back. 

If the skin cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options.

People with recurrent cancer often experience emotions such as fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. 

Metastatic skin cancer

In rare cases, non-melanoma skin cancer can grow deeper into the skin and can spread to other parts of the body. If cancer has spread to another location in the body, it is called metastatic cancer. Sites of a chronic inflammatory skin condition, mucous membranes (skin that lines the mouth, nose, anus, and a woman's vagina), and the lips are most susceptible to squamous cell cancer.

Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. 

Surgery alone is not effective to treat skin cancer that has metastasized. To control this distant spread, a person's health care team may recommend chemotherapy, radiation therapy, or immunotherapy. Immunotherapy (also called biologic therapy) is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to bolster, target, or restore immune system function.

In addition to treatment to slow, stop, or eliminate the cancer (also called disease-directed treatment), an important part of metastatic cancer care is relieving a person's symptoms and side effects. It includes supporting the patient with his or her physical, emotional, and social needs, an approach called palliative or supportive care. People often receive disease-directed therapy and treatment to ease symptoms at the same time.

If disease-directed treatment is not successful, this may also be called advanced cancer. This diagnosis is stressful, and it may be difficult to discuss. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families.

Side Effects

Most often, non-melanoma skin cancer can be treated with relatively simple surgery, with the main side effect being possible scarring of the skin. Talk with your doctor about what scarring or other side effects you can expect before surgery begins. If the person treated for skin cancer is experiencing pain from surgery, he or she should speak with a pain management specialist to find ways to manage pain.

If the skin cancer has spread at the time of diagnosis, which is rare, cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects occur.

Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatment you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and your overall health. Common side effects for each treatment option are described in detail within the Treatment section.

Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health care team. Also, be sure to communicate with the doctor about side effects you experience during and after treatment. Care of a patient's symptoms and side effects is an important part of a person's overall treatment plan; this is called palliative or supportive care. It helps people with cancer at any stage of illness be as comfortable as possible. 

Be sure to talk with your doctor about the level of caregiving you may need during treatment and recovery, as family members and friends may play an important role in the care of a person with skin cancer. 

In addition to physical side effects, there may be psychosocial (emotional and social) effects are well. For many patients, a diagnosis of skin cancer is stressful and can bring difficult emotions. Patients and their families are encouraged to share their feelings with a member of their health care team, who can help with coping strategies.

After Treatment

After treatment for skin cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. An important part of follow-up care is routine screening for new additional skin cancers, including whole body skin examinations by a health care professional. This is because many people treated for one skin cancer later develop other skin cancers. Also, people treated for skin cancer are encouraged to talk with their doctors about following a healthy diet that includes foods containing antioxidants such as vitamins E and C and selenium.

Sun protection is essential to help prevent other skin cancers. Many people who are treated for skin cancer lead an active, outdoor lifestyle, but it is very important to take steps to protect yourself from further skin damage. Participating in outdoor activities before 10:00 AM or after 4:00 PM and wearing long sleeves, pants, sunscreen, sunglasses with UV protection, and a hat will protect against further skin damage. 

For most skin cancers, the surgery removes only a small part of the skin, so there is little need for rehabilitation. However, in some cases, there may be some need for rehabilitation services if surgery was more extensive. People who have surgery, particularly multiple surgeries, on their face may have a substantially altered appearance. Rarely, the eyelid may be altered. The eyelid may not close well, and the person may need to use drops to moisten the eye. In those rare cases when extensive facial surgery is necessary, the person will need support and possibly the help of a caregiver during treatment and recovery. Some of these surgeries are multi-stage and may require prolonged absence from work or other activities.

Rarely, when radiation therapy is used, there is the possibility of a second cancer, which may not appear for more than 10 years after treatment. Chemotherapy is used extremely rarely in advanced disease. It is unlikely that the chemotherapy for advanced disease would have common late effects. It is important to note that chemotherapy is not curative for advanced squamous cell carcinoma and is unlikely to cause leukemia.

People recovering from skin cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level.

Latest Research

Doctors are working to learn more about skin cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

Photodynamic therapy. Photodynamic therapy is the use of a cream or other medication that may be combined with light or laser therapy to remove identified skin lesions.

Topical medications for actinic keratoses. Ongoing clinical trials of topical medications (creams or lotions) for use on actinic keratoses are being studied to prevent second cancers.

Imiquimod for superficial squamous cell cancer and basal cell cancer. As explained in Treatment, imiquimod is a type of immune response modifier in which the body uses its own immune system as a method of treatment. Research is ongoing to learn more about imiquimod's uses.

EGFR inhibitors for advanced or metastatic squamous cell carcinoma. Many squamous cell carcinomas express epidermal growth factor receptor (EGFR), a tumor protein that helps cancer cells grow. Several clinical trials are investigating whether drugs that inhibit EGFR are effective against advanced or metastatic disease.

“Hedgehog pathway” inhibitor for advanced basal cell carcinoma. Researchers are studying the use of a “hedgehog pathway” inhibitor (GDC-0449) in treating people with these cancers who have the PTCH1 genetic mutation, which contributes to the uncontrolled growth of basal cell carcinoma. 

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current skin cancer treatments, in order to improve patients' comfort and quality of life.

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