Transcription:
Skin Cancer: Cutaneous Lymphoma and Melanoma

Melanie Cole (Host): Skin cancer is the most commonly diagnosed cancer, and in most cases, it’s not life-threatening, nor does it spread to other parts of the body. The exception is melanoma, the rarest and most aggressive form of skin cancer. According to the American Cancer Society, more than 5 million non-melanoma skin cancers are diagnosed each year while melanoma will be diagnosed in approximately 76,000 people. Although melanoma is potentially deadlier, if caught and treated earlier, it has a very high cure rate. My guest today is Dr. Christiane Querfeld. She’s the Chief of the Division of Dermatology and the Director of Cutaneous Lymphoma Program at Toni Stephenson Lymphoma Center at City of Hope. Welcome to the show, Dr. Querfeld. Tell us a little bit about – let’s start with non-melanoma skin cancers. What are we looking for? People are out in the sun; they see little dots show up on their body, what should we be looking for?

Dr. Christiane Querfeld (Guest): Non-melanoma skin cancers are the most common ones and usually comes out when patients are older. That’s accumulative sun incidents on the skin. The skin doesn’t forget. What you look for is really some red, scaly lesions, and they can be sometimes crusted, they can be sometimes sore, and can grow. Mostly those lesions come in sun-exposed areas – the face is very common, the head and mane mostly if they have some hair-loss, ears, arms, and legs.

Usually, lesions that are precursors can be actinic keratosis. They are not cancerous yet, but they are on the edge of becoming cancer. This is very easy to treat. Dermatology has some treatments now -- immune modulating treatments can be applied topically as a cream. Also, cryotherapy is an option, though it’s to keep in check. Some other treatments are photodynamic therapies where a remedy will be applied to the skin that sensitizes the cancerous cells to light and then patients have light exposure. It’s called Blue Light. Patients look the following two days like they had a severe sunburn, but it actually really treats the whole area.

When we’re talking about skin cancer -- something like Field Cancerization – even if we have a cancer and we take out the cancer, the area is not completely healthy. There’s still some atypical keratinocytes or lesions that is technically not cancer, but cancer can develop again. That’s why when you have a skin cancer; you likely develop another cancer. What’s very, very important is -- even at this stage, developed skin cancers is sunscreen. Sunscreens protect from developing too many skin cancers and protecting the skin from getting too much sun exposure. Even if you’re outside all day, you should apply it multiple times. It’s really the most important thing we can do for prevention.

Melanie: What about melanoma? People hear about melanoma; they’re afraid of that word. Tell us what we should be looking for if we are concerned, and who is at risk for melanoma.

Dr. Querfeld: There are several types of melanoma. The patients at risk – younger patients, are at risk who have a genetic predisposition. It runs in families. But in older patients, it can really be associated with sun exposure, and this is mainly on the head and the face where patients get most of the sun. There are patients in general who are at risk – sun exposure has been the highest risk factor associated, but not everything is really related to the sun. We haven’t really fully discovered what causes melanoma. If it’s related to the sun, the protection is very easy, sunscreens. What patients should look for is any dark spot that’s enlarging, any mole that’s irregular, any mole that’s bleeding, or any mole that shows different colors, is growing, is enlarging, and have irregular borders.

Melanie: Do you think people should be giving themselves checks? Should we see a dermatologist? How often?

Dr. Querfeld: It depends. I would say a regular skin check at least once a year. If patients have many moles, then it may be really advantageous to see a dermatologist more than once – twice a year. And it depends, if you had already atypical moles removed, it would be really great to see twice a year, a dermatologist.

Melanie: And now we’re talking about lymphoma and cutaneous lymphoma – and when people hear lymphoma, right away they think a systemic disease, a cancer that’s in the lymph system – but, cutaneous lymphoma is a little bit different and related to skin cancer. Explain how that is related.

Dr. Querfeld: Cutaneous lymphoma is a blood cancer that comes to the skin. It’s not technically a skin cancer, and while we know cutaneous lymphomas are a specific type of lymphoma, we have not found a cause why these lymphomatous cells really home in the skin. We know that if it’s detected very early – in an early stage of cutaneous lymphoma patients have a favorable prognosis. There is a risk of about 10, 15% that those patients may have progression, meaning the lymphoma can then spread from the skin to inside the body – or into lymph nodes.

Melanie: Would we spot it? Would a dermatologist be the person to spot cutaneous lymphoma?

Dr. Querfeld: Yes, the dermatologist would be the first person to see if something wrong is on the skin. Usually, dermatologists are trained for this specific disease. We know that cutaneous lymphoma can mimic a lot of skin conditions. It can mimic psoriasis, and it can mimic eczema. What dermatologists do is they take a skin biopsy – this will be evaluated by a skin pathologist that has expertise training in evaluating skin pathologies.

Melanie: And then, are there treatments for cutaneous lymphoma? What are you doing at City of Hope?

Dr. Querfeld: We have the all standard treatment options available at City of Hope, and we have investigational therapies. Immunotherapies have now developed for many, many cancers, and as well as for cutaneous lymphoma. For early stages, we have skin-directed regimens that are certain types of light therapies as well as an immune-modulating agent. Usually, it’s applied as a cream or an ointment. We do have systemic therapies if the disease is more widespread or very resistant to the skin-directed therapies. We start, usually with the standard treatment, and if things are not helping to clear all cutaneous lymphoma lesions, we opt for other treatments we have available. Immunotherapies, biologic therapies are usually the way to go. The advantage of it is that those therapies attack the pathway that’s dysregulated in those malignant blood cancer cells.

Melanie: Dr. Querfeld, back to skin cancer for a minute – you’ve mentioned sunscreen a couple of times – just explain to listeners what you really want them to know about skin cancer and sunscreen. As a dermatologist, you can tell them that sunscreen is great for them, but they don’t always know what the numbers mean, and whether 70 is better than 50, so explain a little bit about sunscreens and what we should be doing with them to use them correctly.

Dr. Querfeld: Sunscreens, yeah, it’s a lot – my patients are asking me a lot of questions – what type of sunscreens they usually should use and what SPF factor, sun-protectant factor, they should use. On a general basis, there are two types of sunscreens. One is a chemical, and one is a physical blocker. A physical blocker is usually with particles, such as Zinc or Titanium Oxide. When those are applied to the skin, they block immediately. A chemical sunscreen is a substance that gets absorbed into the skin, and it takes about 20 to 30 minutes to work before you can actually go outside and be protected. Those chemical blockers sometimes can cause allergies, so I usually tend to recommend more the physical blockers, but it depends on the patient’s preference.

Both work similarly strong if it’s SPF 30, so they should protect the skin 95%, okay? If you have an SPF factor of 50, that’s 99%. SPF70 and 100 – 100 is really absolute 100%, and there’s not much of a difference between SPF 50 and 70. On a general basis, SPF 30 and higher, the skin is really protected. Anything that’s lower, I would not recommend.

Melanie: And when they say waterproof, are they really waterproof?

Dr. Querfeld: You have to reapply it, so they are waterproof, but only for a short time. I tend to recommend patients to reapply after an hour if they’re really at the beach. Even if they’re not in the water, patients have to reapply sunscreens. What I sometimes see the danger of using a high SPF 50 or 70, patients think they are all protected throughout the day, but they are not, so you have to reapply. Usually, I tend to recommend to reapply multiple times throughout the day if they really spend the time outside all day. I also recommend to apply the sunscreens really early in the morning. Some patients tell me, “Well, I’m not outside, and I’m just driving,” but even when you’re driving you to get the sun – the UVB actually – or UVA comes through the windows, and you need to apply sunscreens to be protected.

Melanie: Wrap it up for us, then, with your best advice about skin cancer, preventing skin cancer, and melanoma, checking our bodies and seeing a dermatologist.

Dr. Querfeld: Yes, I would recommend if you don’t have an increased risk, start out very young and to see a dermatologist once a year, to apply sunscreens every day, and if you have already a skin cancer, you should follow-up with your dermatologist more closely. Even skin cancers cured by excising or removing it, however, there are some patients who have a weakened immune system, and then the skin cancer can take off and be quite nasty. If so, City of Hope, we have the advantage that we work closely with our oncologists and other disciplines like surgery, where we have a plan together for patients who have really very serious skin cancers.

Melanie: Thank you, so much, Dr. Querfeld, for being with us today. You’re listening to City of Hope Radio, and for more information, you can go to CityOfHope.org, that’s CityOfHope.org. This is Melanie Cole. Thanks, so much for listening.