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Dr. Michael Smith (Host): More people are diagnosed with skin cancer each year in the United States than all other cancers combined. One in five Americans will develop skin cancer by the age of 70. Welcome to The GW HealthCast. I'm Dr. Mike Smith and today’s topic, beating skin cancer. My guests are Dr. Vishal Patel and Dr. Joseph Goodman. Dr. Patel is an assistant professor of dermatology and director of cutaneous oncology at the GW Cancer Center. Dr. Goodman specializes in head and neck surgery specifically surgical oncology of the head and neck with functional reconstruction both are affiliated with The George Washington University Hospital. Doctor’s welcome to the show.

Vishal Patel, MD (Guest): Thank you.

Joseph Goodman, MD (Guest): Thank you.

Host: So, Dr. Patel, I’d like to start with you. I'm asking this question because I'm pretty sure that we probably have somebody listening right now that is worried about some changing mole or some skin lesions. So, the question is, what does skin cancer look like at the beginning?

Dr. Patel: Yeah, that’s a great question. That’s the difficult part of being a dermatologist is that it can look like anything. That may not be reassuring to patients, but it should be reassuring in that there’s a lot of things that look unusual and can be benign, but there’s a lot of things that may look unsuspecting to you and we want to pick up. The things that we do worry about that we like to tell our patients to keep an eye out for are lesions that are growing, changing, asymmetric. You may have heard of the ABCDE’s of melanoma. Those are lesions that are pigmented, that are asymmetric. Have irregular borders, darker colors. They are evolving, as we say, and they have a diameter bigger than the back of a pencil eraser head. Those are lesions we worry about specifically for melanoma.

There are other types of skin cancers, both common ones and uncommon ones that can present in a host of different ways. I tell patients that if you see something that’s new that you didn’t have before, you don’t recognize it, you have a partner that says, “That spot on your back, I just don’t remember seeing it there.” Or something that’s bleeding or irritating you, you want to have a dermatologist look at that so that we can properly evaluate it.

Host: I think it’s always good too. If somebody’s worried, go be seen. Don’t not be seen because you're embarrassed or something, right? Go ahead. If you're worried about something, go make that appointment. Dr. Goodman, can you maybe run through for us what… Because Dr. Patel eluded to that there’s different types of skin cancers. Can you kind of walk us through the different types of skin cancers, and just give us a nice high overview of those?

Dr. Goodman: Sure. Probably the most well known one is, of course, melanoma. Where the head and neck surgeon gets involved is usually at a point where we’re worried about it spreading to the lymph nodes. We can talk about that at any time later, but essentially, we can sample the lymph nodes through a variety of techniques. And help both with staging, which drives treatment decisions, and potentially even further surgery or reconstruction as needed.

Aside from melanoma, it’s important to know that squamous cell cancer is also a very common and potentially aggressive form of skin. That’s typically associated with sun exposure and it can be particularly prevalent in a high-risk population of immunosuppressed people. For instance, organ transplant folks. There are other types of cancers. Some of which can be aggressive, some of which are very rare. Dr. Patel is really probably the expert on that in terms of things associated with sweat glands and adnexal tumors. Then basal cell carcinoma is a very common one which is usually not that aggressive, but it can be locally pretty destructive.

Host: So, Dr. Goodman, you mentioned a little bit about staging. Walk us through, what is the workup? How are some of these lesions staged? When is a decision made to do a skin biopsy?

Dr. Goodman: Well I think, normally patients that refer to head and neck surgeons come in with either big and ugly tumors. They're sent by their primary care doctor. Maybe they’ve been neglected for a while or they’ve had a break in primary care, for instance. So, they’ve grown. They usually don’t come up overnight. They’ve been there for a while. Or sometimes there’s a neck mass. And in the workup of that neck mass, it’s determined that the primary source was from a skin cancer. Sometimes that history is remote. The skin cancer may have been removed years ago. But based on the fine needle biopsy of the neck node and some imaging and kind of a detailed history, we determine that in fact the primary was from maybe that resected skin cancer that superficially resected or potentially burned off. Somehow it was never determined that there was risk for it spreading to the neck. So, we get involved, I think the dermatologists get involved a little bit early. Typically for the primary site, the dermatologists are the ones who are going to be sampling and making that diagnosis.

Dr. Patel: I was going to say yeah. The skin biopsies that you're talking about. When we see patients early on, we take a small sample of their skin to first identify what type of skin cancer it might potentially be because that will help us drive treatment. I think what I wanted to let our listeners know about it is that the old way we used to practice skin cancer prevention and treatment was to biopsy a lot of lesions, and then we try to destroy everything superficially and reserve surgery for certain cases. Maybe on the head and neck or more high-risk tumors.

As we’re realizing now—some recent papers have really come out about basal cell, squamous cell, and melanoma—is that not only is the epidemic really rising, but we’ve probably underestimated those lesions that can be more aggressive than we first thought. Specifically, in squamous cell carcinoma. And that he number of deaths of those patients and bad outcomes may be more along the lines of melanoma and that we should treat it more aggressively.

What we’re trying to do here at GW, Dr. Goodman and myself, is approach all these patients from a very strategic and systematic way. So just doing the skin biopsy is not enough. We want to accurately stage them from the beginning, find those risk factors, and identify those patients who make look like they just have a lesion they’ve had for a while. It’s an innocuous typical squamous cell carcinoma or basal cell carcinoma or even a thin melanoma. But with proper staging from the beginning, we can then get them plugged into the head and neck surgeon, get them a lymph node biopsy early on to help prevent those poor outcomes and treat them so that they can get the best chance of cure the first time around and not worry about the terrible neck masses and things Dr. Goodman was talking about occurring later in life.

Host: So why do some patients develop more aggressive forms of skin cancers and others don’t. Have we learned what those risk factors are?

Dr. Patel: Yeah. We definitely have learned a lot just in the last about three years has been a host of [inaudible] in evidence coming from some great cancer centers. We’ve known for some time—Dr. Goodman made a mention to this—that if you're immunosuppressed, you may have an organ transplant, a stem cell transplant, you may be on medications. There’re medications that we didn’t even realize were so immunosuppressive. But all patients hear and see all the adds on TV about biologic drugs for psoriasis or rheumatoid arthritis or Crohn’s disease. Those are all drugs that modulate the immune system. Our immune system is constantly working to prevent skin cancers from forming since we’re walking around getting hit by UV rays all day long. So those patients are at a much higher risk of developing skin cancers. We urge those patients and family members of those patients to push them to see the dermatologist regularly, so they can get screened more aggressively and have preventative treatments, topical treatments, light therapy treatments to prevent those skin cancers from forming in the first place.

There’s some medications that patients take that can also put them at risk. Medications that make you susceptible to the sun. What we call phototoxic medications. Then there’s inherent risk factors into the tumor. They just tend to grow. They may be genetically more predispositioned because the tumor’s aggressive or the patient has genetic mutations. Such as the MCR1 related in melanoma, which is what gives patients that red hair, which is associated with melanoma. Or genetic mutations with blue eyes and skin colors that being more lighter than other ones. That puts you at risk for more skin cancers as well as more aggressive ones.

Host: Dr. Goodman, when you are referred patients, how important, especially with the aggressive malignancy, to follow a team approach? I know that George Washington University Hospital is well known for a multidisciplinary approach to many diseases, including cancer. So, can you walk us through what is involved in the workup and the treatment of some of these aggressive cancers?

Dr. Goodman: Yeah, for sure. It depends on where the initial diagnosis was made. That’s obviously the first step whenever there’s a concern. That’s either a concern from the patient or a concern from the physician. So initially there’s got to be a tissue biopsy done of some kind. Sometimes that’s done by the dermatologist through a shave biopsy or a punch biopsy or whatnot. Sometimes there’s an excisional biopsy that’s required that’s a little bit more extensive. Sometimes a fine needle aspiration biopsy can be done subcutaneous nodules or lymph nodes.

Once the actual tumor etiology is discovered, then the staging process really is tailored around each subtype. So, for melanoma, it will be different than squamous cell, et cetera. We always want to make sure if it’s a type of cancer that does go to the lymph nodes—which is most cancers except for maybe basal cell, although very rarely that can metastasize—we want to get some sort of an anatomic study of the lymph nodes. Usually a CAT scan, MRI, or sometimes an ultrasound. If there’s concern for further spread, if it’s a larger tumor or more aggressive tumor, sometimes a PET scan can be helpful staging the patient for any metastatic disease. That would look at the entire body.

Host: Yeah, this is a fascinating topic. I think what I’d like to at this point is ask both of you in summary what do you want people to know about skin cancer? Dr. Patel, we’ll start with you.

Dr. Patel: What I’d like the listeners and family members to know about skin cancer is… You said it very aptly in the beginning of the show that skin cancer, it’s really an epidemic that’s on the rise. Just from the host of things we do, the way we live our lives and vacation and grow up in the sun, we’re realizing that we have a larger number of patients who are going to have problems with skin cancer down the line. That may be related from the actual skin cancer they have or may be related to other healthcare problems they have, and then later have a complication in the form of a skin cancer that is more aggressive. So, for those patients and those family members, we want you to get screened here at the dermatology department. Get screened regularly and your dermatologist will determine how frequently that would need to be. Whether that’s once a year, twice a year, or whatnot based on your risk factors.

Also, it’s really important I tell all my patients, you're part of the healthcare team. We see you in a snapshot, just one picture at a time once a year. It’s not like going to the dentist where you can just see a cavity and find it once a year. We need your help to self-monitor, to be sun protective, and have partners that can look at you and say these are lesions that are new and different. You need to have them taken care of. Then also to realize that skin cancer, it’s identifying the ones that are going to have poor outcomes, what we call high risk lesions. That’s really where we get really interested.

That’s what you want a provider to do is to really risk assess you as of whether or not you're high risk so that you can then get plugged in to all the specialists that work together. Like here at GW with the head and neck surgery, radiation oncology, medical oncology, and dermatologic oncology so that we can approach you early on, even before the lesions rear its ugly head so that you can have aggressive preventative therapies, and then you can get adjuvant therapies—or therapies added on to surgery later on—so you get the best outcomes period. It’s a team approach of which the patient is the MVP of the team.

Host: Dr. Goodman, what would you like people to know?

Dr. Goodman: Yeah, no. I want to piggyback on that because I think that’s the main point that we’re trying to get across for treatment of skin cancers here at GW MFA is that multidisciplinary team approach. So early lesions are very well managed and followed by the dermatologist. That’s usually the point of entry for any area of concern. Once it gets to my level or to the point where you need adjuvant treatments beyond just the simple excision and reconstruction, you get the oncologist on board, the radiation oncologist on board. Potentially we engage our pathology colleagues to help us to actually analyze the slides, the tissue itself. The radiologist of course. You know the neuroradiologist for head and neck in particular are very capable of telling us where potential sites of metastasis or more advanced disease may be.

So, we have a tumor board format essentially where these cases are presented, and all members of the team are in the same room and we discuss what the standard of care would be, treatment options of the patient. These patients are followed by all members of the team.

Host: Dr. Patel and Dr. Goodman, I want to thank you guys for the work that you're doing at GW University Hospital and also thank you for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Goodman or Patel or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment. I'm Dr. Mike Smith. Thanks for listening.