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Prakash Chandran: We've all likely heard of skin cancer. But for those who haven't, it's an abnormal growth of skin cells. It's the most common cancer in the United States. And people in states with more sun exposure, such as Florida, are more at risk.

Today, I'm joined by Dr. Andrew Kelsey, a board-certified dermatologist and a fellowship-trained and board-certified Mohs surgeon and Shivani Patel, a board-certified physician assistant and dermatology specialist, both at Health First Medical Group. We're going to be talking about common skin cancer questions today.

This is Putting Your Health First, the podcast from Health First. My name is Prakahash Chandran. So Dr. Kelsey and Shivani, thank you so much for joining us today. I really appreciate your time. Shivani, I wanted to get started with you and just ask the basic question. I gave the textbook definition, but what exactly is skin cancer?

Shivani Patel: So in very simple words, every time we get exposed to sunlight or UV rays, it can basically damage some of the DNA inside our skin cells. And although our body really tries to repair this damage, as we continue to get this UV light, whether it be from tanning booths or from sun directly or from both in a lot of instances, the damage builds up over time and it can cause the cells to continue to grow and produce more abnormal cells and we end up getting what's called a skin cancer. This tumor essentially can grow deep. It can injure nerves underneath, blood vessels and anything else that lies in its path. And some types of skin cancers can also travel through lymph nodes and go to other organs in the body.

Dr. Andrew Kelsey: I think that's very well put. And it's also just important to note that skin cancer can affect anyone regardless of age, race, gender. Everybody's at risk, especially in a state with such intense sun like Florida.

Prakash Chandran: So Shivani, can you talk to us about the most common types of skin cancer?

Shivani Patel: Absolutely. So there are three most common types of skin cancers. And the type of skin cancer we get depend on where the mutations develop in the skin. So for example, if it starts in those thin flap cells on the very top layer of our skin, and they're called squamous cells, where the mutation start there, they turn into squamous cell cancer. When the mutations are in the basal cells, it gives rise to basal cell cancers. And similarly, if the mutations are in the skin pigment-producing cells, which are called melanocytes, they turn into melanoma.

Prakash Chandran: So Shivani, a lot of people may have heard about sun exposure as a risk factor, but can you go into more detail about the different types of risk factors for these three cancers that you're talking about?

Shivani Patel: Sure. Yes, absolutely. So the most common risk factor for basal and squamous cell and melanoma is the UV-damaged skin that's caused by sun or tanning beds. Then, the color of the skin, hair, and eyes also play a role. So we have skin that burns easily or rarely tans. Then, there's since sun-sensitive skin that freckles easily, the naturally blondes or the red-haired folks. We have the blue and green eyes that also play a risk factor.

So men are typically affected twice as much as females and basal cell cancers, for example, is far higher in persons ages 55 to 70 years old than in those that are 20 or younger. So basically, the older you get, the higher you have the risk factors for basal and for squamous cell cancers. The history of sunburns also play a very big role. We have a lot of patients who tell us they've had a lot of sunburns growing up. And when they're older, we start noticing a lot of skin cancers in that skin.

Living in an area that gets intense sunlight year round, such as Florida or California, people who are living at higher altitude, that's also a risk. If you have any type of skin cancer, a history of that, that itself is a risk of getting other skin cancers on the body. If you have a weak immune system, so for somebody who's taking anti-rejection medications after their organ transplant or if they're going through chemotherapy medications, that is a risk factor for a lot of cancers, especially squamous cell.

A lot of medical conditions can also cause an increased risk of developing basal cell cancer. So, medical conditions such as Gorlin syndrome and Rambo syndrome and there's several others. We have patients who have psoriasis and other skin conditions who go through what's called a PUVA treatment, which is the Psoralen and Ultraviolet A treatments. It's basically a light box. So studies have showed that if you have over a hundred sessions of these PUVA treatments, they are at increased risk of developing basal cell cancers. We see a lot of folks growing up, they had x-ray treatments for their acne, believe it or not. They don't do that anymore. But you know, those patients have a high risk of developing cancers on their face. The dialysis patients for kidney disease, they are at a higher risk of developing basal cell. There's arsenic in the food and water. There was also HIV folks. There are studies that are showing there's a higher risk of squamous cell cancer in those patients compared to normal population with no history of HIV. And also HPV infection also has an increased risk of squamous cell cancer developing.

Prakash Chandran: So there seemed to be a lot of risk factors that you just mentioned. One of the biggest being the UV damage. I don't feel like there's any hard and fast rule that I've heard, but it's always unclear, like how much time you should spend outside exposed to those UV rays; when you need to put on sunscreen, I feel like people only do that when they go to the beach. Can you just talk at a high level around reducing the risk of skin cancer and if there's any hard and fast rules that people should be following?

Dr. Andrew Kelsey: Yeah, that's a great question. So sunscreen has come a long way over the last 20 years or so. There weren't even really good sunscreens until probably the '90s. Basically, everybody should be wearing sunscreen. And the American Academy of Dermatology recommends we use what are called physical blockers rather than the chemical blockers. These actually, thankfully, are safe for the water ,safe for the reef. You want to be wearing broad-spectrum sunscreen that protects against UVA and UVB, and that'll be printed right on the bottle. And the recommendation is to use at least SPF 30. Try and find something that's water-resistant because down here in Florida, whether you're sweating or participating in water activities, that will help the sunscreen last through that water exposure.

Generally, between 10:00 AM and 2:00 PM, the sun rays are the strongest and that's when you want to seek shade or try and stay inside. And then, lately, there's been this awesome fashion trend towards the sun-protective clothing, which is just another way to sort of layer on protection. So the combination of avoiding the peak sunrays, wearing proper sunscreens and wearing sun-protective clothing, combined it's sort of the best you can do to avoid that primary risk factor, which sun-exposure.

Prakash Chandran: So Shivani, I want to talk about skin cancer detection through screening. Can you talk about who should be getting screened and why it's so important?

Shivani Patel: So skin cancer is the most common cancer in the United States with millions of cases diagnosed each year. It is also one of the most preventable cancers and highly treatable when found early. So basically, skin cancer screenings are extremely important. Any adult who has never had one should really consider scheduling a full body skin check to establish a baseline and to discuss whether and how often regular skin checks are necessary.

Anybody who's had a history of any type of skin cancer or precancerous skin lesion, anybody who's had melanoma or has a first-degree relative with melanoma, anybody with a large number of abnormal moles, abnormal-appearing moles on their body should really get a cancer screen. Anybody who's used tanning beds in the past or currently using, hopefully not, but if they're still using it, they should definitely have the cancer screening done. Blistering sunburns growing up, they should get it checked. And then, history of significant sun exposure through activities, such as golfing. We see a lot of golfers here in Florida. Boating, surfing, landscaping, construction, any of those things, they should really get their skin examined at least once a year.

And the only other thing, organ transplant recipients, you know, also recommended. A lot of their nephrologists, for example, will recommend -- going back to what we discussed earlier, dialysis patients are at increased risk of basal cell cancer, so probably good for them to get it checked as well.

Prakash Chandran: Okay. So really one of the main takeaways here is that every adult should be getting screened to get that full body skin analysis and set a good foundation for staying healthy moving forward or detecting things early. At that appointment, can you walk us through what someone can expect?

Shivani Patel: So during a total body skin exam appointment, patients are often asked to remove their clothing and put on a gown. There is a lot to look at when it comes to skin and every provider has a pattern that they follow. I always start with my patient's back and I systematically make my way to the front while looking at all of the skin. Bright lights will always help with good skin exam and so does the use of dermatoscope that allows to look at the details within a skin lesion. So I always recommend patients wear their hair down, so I'm able to look through their scalp. I'll have the ladies remove any makeup, nail polish for their appointments. I can do a good thorough exam of their face and nails as well, because skin cancers can occur in any of these places, even under the nails.

I recommend that they don't wear any lotions or creams so we can feel like the good texture of the skin. They're encouraged to bring a list of areas or lesions that they may have concerns over, anything that they notice changes to, I always have them write them down. And as I do my skin exam, if I find any suspicious lesions, I always mark them for a biopsy. And skin biopsy is essential for these spots and it's the only way to know whether they have a skin cancer.

Dr. Andrew Kelsey: So just to touch on something that Shivani brought up, she mentioned this device called a dermatoscope, which has absolutely revolutionized the way that we diagnose skin cancer over the last 20, 25 years. It's this very bright light connected to a magnifier. And after years of training, you get very good at picking up on patterns underneath this microscope or this magnifying device. And it has significantly decreased the number of biopsies it takes to find a skin cancer. In other words, it makes us a lot better at finding skin cancer.

Prakash Chandran: Yeah. So that's absolutely fascinating that that type of technology exists. But even with it, if you do discover a lesion that requires a biopsy, Dr. Kelsey, can you tell us what people can expect as they're getting one done or after one is taken?

Dr. Andrew Kelsey: Sure. So, the primary advantage of being dermatology providers who have a lot of experience or board-certified dermatologist is not all biopsies are created equal. Generally speaking, you have to have an idea of what you're looking for. So as Shivani mentioned, different skin cancers occur in different parts of the skin. And so in order to find that skin cancer and not, you know, have a biopsy essentially go to waste, you have to make sure you're sampling the right spot. We photograph the lesion very close up so we can see what it looks like. We numb the skin with a little local numbing medicine. It feels like a pincher or a rubber band snap. And then, using the proper tool, we sample the skin lesion and you're left with a little bit of Vaseline and a Band-Aid, which you take care of for three or four days. That skin then gets sent off to a dermatopathology lab, where it is studied by trained dermatopathologists to interpret what the cells look like and report back on what the actual findings are, whether it's a skin cancer or something else.

Prakash Chandran: And how long does it typically take for a patient to get an answer back after that process happens?

Dr. Andrew Kelsey: That can vary depending on the complexity of the lesion. Typically, it's somewhere in the neighborhood of about two weeks.

Prakash Chandran: Okay. So you mentioned that not all biopsies are created equal. So, Dr. Kelsey, if something is found, what are the different treatment modalities that are available based on what you find?

Dr. Andrew Kelsey: So there's a menu of treatment options ranging from surgery, of which Mohs surgery is one type. There are other procedures or other ways of removing the skin cancer. Then, there are things like chemotherapy, whether we're talking injectable chemotherapy or chemotherapy cream. There's even things like radiation, which could be done for certain types of skin cancers on the correct location in the right patient.

Prakash Chandran: Now, you mentioned Mohs surgery, and I know that you're a board-certified Mohs surgeon. I've heard about it before. I've heard that it's the gold standard treatment. Can you talk a little bit more broadly about what Mohs is and why that's the case?

Dr. Andrew Kelsey: Sure. Great question. So Mohs surgery is named after the founder, Dr. Frederic Mohs, who pioneered this treatment in the '40s and '50s. And the way that Mohs surgery works is we map out the skin cancer that we can see on your skin. We numb it up using that same local numbing medicine. So there are no risks of general anesthesia, and we remove that skin cancer that we see with our eyes. And while the patient's waiting, we process that skin in our lab and I'm able to look under the microscope for the skin cancer cells. If we see any, we know exactly where that corresponds to on our patient and we go back and get it. We repeat this process until the entire tumor has been removed and the advantage of doing it this way, there are multiple advantages, but primarily, because we're using a microscope, we're able to chase out just the skin cancer cells and leave all of the patient's normal, healthy skin alone. And because we check every little piece of skin that we take, this is how we achieve what has been widely published as the highest cure rate for certain types of skin cancer.

Prakash Chandran: You know, it's pretty amazing to hear the technology and innovation that has happened in this field. Not only in the detection side, weeding out those false positives, but as you're saying, also in the surgery side and really being as accurate as possible and not effecting other healthier skin around the area in question. So Dr. Kelsey, I know that you are personally fellowship-trained, but why is it so important to have a fellowship-trained Mohs surgeon?

Dr. Andrew Kelsey: So all board-certified dermatologists, in order to get there, go through a residency where there is a minimum exposure to Mohs surgery, and those who have an interest in skin cancer in additional surgical training, then apply for fellowship, which is one to two years of additional training at a university typically with a master Mohs surgeon, and the fellowship is a highly supervised year covering hundreds and hundreds of surgical cases where the fellow learns how to remove the tumors correctly, how to interpret the slide under the microscope, and it's a reconstructive fellowship as well. So practicing all of those, you know, fancy reconstructions we have to do to try and make these skin cancers a distant memory. In my case, my training also included a lot of high-risk skin cancers, so I'm pretty comfortable in managing skin cancers, both surgically and medically when necessary.

Prakash Chandran: So as we close here today, I'd love to ask, given all of your experience, what are the primary things you know to be true about reducing the risk of skin cancer? And Shivani, we'll start with you.

Shivani Patel: There are a couple of different things the patients should do to reduce the risk of skin cancers. They can protect their skin from the sun. So while many people feel that the damage has already been done, protecting their skin from sun can prevent further skin damage and may allow for a body to repair some of the existing damage. And for these reasons, we always recommend for them to protect their skin from sun every day, even in winter, even on a cloudy day. And when they're outdoors during the day, they should seek shade and try to avoid being outdoors when the sun is strongest between 10:00 and 2:00. When it's cloudy, rainy, snowy day, wear sunscreen that offers broad spectrum sunscreen, SPF 30 or higher. Water-resistant sunscreens are great. They should apply this every day, even if they're spending a few minutes outside. I tell my patients, even if you're outside checking mail, next thing you know, you're talking to your neighbor for a few minutes and the sun damage adds up. When they're going outside, they should put a wide brimmed hat on, sunglasses all the time. Whenever possible, wear long sleeves, pants, shoes, socks, cover yourself up. Never ever use a tanning bed or indoor tanning equipment. The indoor tanning is not any safer than the sun. And the UV rays from tanning beds tend to be stronger than the sun's UV rays and it dramatically increases the risk of getting skin cancer.

Keep all of your dermatology appointments. Your dermatology provider will let you know how often they need to see you for the skin cancer screening. Patients should always learn how to examine their own skin for signs of skin cancer. And the purpose of skin self-exam usually recommended once a month is to find skin cancers early when it's most treatable and unlike other internal cancers, skin cancer is something that they can actually see and monitor. So they should really make appointments to see their dermatology providers, but also do their skin exams.

There are some great videos and handouts that they can get from aad.org, which is the American Academy of Dermatology website. And it teaches the patients how to do their own self-skin exam. There are handouts where they can put the lesions, the sizes, they can monitor it monthly, and these are the type of things that they can bring in for their routine skin exams with us that we can discuss.

Prakash Chandran: Well, Shivani. I think that is really great advice. And Dr. Kelsey, I will give you the last word. Given all of your experience, what's one thing you know to be true that you'd like to share with our audience today?

Dr. Andrew Kelsey: Oh man, to only pick one. I guess my one final thought, let's make it two final thoughts, is number one, I totally agree with Shivani. I mean, medicine has come a long way in terms of finding cancerous growths early. It's very common to do breast cancer screenings, colon cancer screening, cervical cancer screenings. It's very common. But skin cancer is the most common cancer in America by a long shot. And it's just not yet the norm to get your skin checked. As Shivani very eloquently described earlier, it's a very simple thing to do and at least get a baseline, figure out what your risk might be and determine if this is something that you should be doing regularly.

And then my second final thought is if you have to have some kind of surgery, like Mohs surgery to remove a skin cancer, it's not so bad. I mean, we've come such a long way. We can cure these cancers with a 99% accuracy in many cases and then put things back together like we were never there. So I'm finding it nice and early, finding it nice and small gives us the best shot of providing awesome cure rates like that with the smallest possible scar.

Prakash Chandran: I think that is the perfect place to end that. Thank you both so much for your time today.

Dr. Andrew Kelsey: Thank you.

Prakash Chandran: That was Dr. Andrew Kelsey, a board-certified dermatologist and a fellowship-trained and board-certified Mohs surgeon, and Shivani Patel, a board-certified physician assistant and dermatology specialist, both at Health First Medical Group. Thanks for listening to Putting Your Health First. To schedule your annual skin check or to learn more, visit hf.org/dermatology. You can also visit the resource that Shivani mentioned, aad.org, that's the American Academy of Dermatology. Thank you again for listening. My name is Prakash Chandran, and we'll talk next time.