Joey Host (Host): It is very common, but usually treatable. So, we're discussing skin cancer. Our guests from Novant Health's Cancer Institute, Dr. Peter Turk, Director of Surgical Oncology, and Dr. Logan Rhea, he's a medical-oncologist.

This is Meaningful Medicine, a Novant Health Podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, physicians offer tips to navigate medical decisions and build a healthier future. Thanks so much for joining us. I'm Joey Wahler. Hi there, Doctors. Welcome.

Peter Turk, MD: Hello, Joey.

Logan Rhea, MD: Thank you.

Host: I appreciate the time from you both. So first, I'm wondering what drew each of you to medicine and surgical oncology in particular? First, how about you, Dr. Turk?

Peter Turk, MD: Thank you, Joey. I love, when I was young, mowing lawns and doing things, seeing things accomplished. I'm fascinated by learning. And I think that has been the driving force of why I wanted to be a doctor. And I've been thrilled with surgical oncology because, in my career, it's been an amazing evolution in the management of patients' care. And we'll go into some of that today, but it's been astounding to see how much better we are doing, but also how much less we are doing to patients to get them cured. So, it has really been good parts relational, good parts educational, and a sense of joy in the accomplishment of treating these patients.

Host: And how about oncology for you, why that?

Peter Turk, MD: As far as cancer treatment, it is something that more so than taking out gallbladders or doing hernias. The patients become friends. It's relational and you're seeing them at one of the worst points in their life, and they want to trust you. And it's our job to get them through this in a way that they can, when we're done, be whole again. So, it is much more involved and much more layered than general surgery in and of itself.

Host: All right. And Dr. Rhea, Dr. Turk telling us that cutting grass was the start of his entrepreneurial spirit. How about you? What sparked your interest in medicine and oncology?

Logan Rhea, MD: Yeah, I always knew I wanted to help people. I always knew I wanted to try to make a difference in people's lives. And one of the things that really drew me to oncology in general is when I was in medical school, every single lecture on oncology, they were presenting brand new information that seemingly was hot off the press.

And in medicine, you really have to be a lifelong learner. And when you are really, really interested in something, it makes it a whole lot easier to become a lifelong learner. And so, I was always interested in the biology behind cancer. And I'm very fortunate to have had really great mentors early on in my medical journey. And so, it's always been very strongly the right thing that I felt that I was intended to do. And I've really enjoyed my time taking care of patients. And as Dr. Turk was alluding to, really forming rapport and relationships with them over the long term, it's always a difficult time in their lives. But if you can really make an impact and make that as beneficial for them and as positive for them as possible, it's really astounding.

Host: Both of you, obviously, have a great love for this, which is certainly an important part of it, if not the most important part. Dr. Turk, what are the most common types of skin cancer?

Peter Turk, MD: Well, by far, the most common is basal cell cancer. Again, that's sun-related cancer. There is about four million patients a year that get basal cell cancer. Extremely curable. Typically treated by a dermatologist alone, and very rarely do they see me or Dr. Rhea. It's a very unusual situation that it becomes advanced.

The second most common is squamous cell cancer. There's almost 2 million of those a year. Again, more commonly, very, very curable, as you had said, Joey, about skin cancers, and typically treated by dermatologists as well, unless it's very advanced. And then, we have surgical options and even immunotherapy options that, if we have time, Dr. Rhea can review those.

The one that's most known and most talked about is melanoma. There's only about 200,000 patients per year that get melanoma. Half of those are non-invasive melanoma. They're treated by dermatologists. We may see them. But definitely invasive melanomas, those are at risk for spread, is about 100,000 a year. And they are the ones that are the most deadly skin cancers. They are extremely curable if they're caught early. But if they are found after they've gone to lymph nodes, it's a 75% cure rate. If it's gone elsewhere in the body, the five-year survival is down to 35%. So, those are the three most common.

There's also a Merkel cell cancer, which it's best known because Jimmy Buffett died of it. It's a very unusual cancer that is similar to melanoma. It's typically advanced and typically hard to cure.

Host: Gotcha. So Dr. Rhea, what are some of the early warning signs people should be looking for when it comes to skin cancer? I know myself, I've had it multiple times where, for me, and I know for many others, it appears as a zit-- to use the medical term-- not, right? And it's one that just won't go away. It seems like it's about to heal and then it kind of goes back to where it was. And so, it's kind of a never-ending cycle, and that's one sign, isn't it? Kind of a blemish-looking mark that just won't heal, right?

Logan Rhea, MD: Right. And of course, there are a lot of different ways that some of these skin lesions can present. And one thing I always tell patients is you know your body best. You're the one who's seeing it a lot more often than anybody else's. And so, taking an inventory of things that seem a little bit abnormal, seem to be out of place when it compares to the rest of your skin.

Certain particular things that people should be taking note of are there new moles or growths on their skin that they didn't really recognize before. Kind of taking a mental tab of it and seeing is that changing a little bit over time. One thing that we know about moles is if they are changing, that's usually slightly concerning that there could be some other process going on. Are they getting bigger? Are they changing color? Is it actually kind of regressing a little bit, getting paler, or are there any other types of odd things like bleeding coming from the lesion that seems to be difficult to actually heal? It just constantly scabs over and then constantly starts to bleed again.

And ultimately, as you were mentioning, some of these lesions look simply like zits or they look just like little rashes on the skin, or red patches or scaly areas. Some of them appear like very small ulcers. And so, bringing it to the attention of either your primary care provider, if you already have a dermatologist, those are going to be important about having them evaluated before they become something more invasive.

Another thing for melanoma more specifically is that we do have a little mnemonic that we use to help us understand things that are a little bit more concerning from a melanoma perspective. And it's called the A-B-C-D-E rule. And really, it's A, asymmetry, one half doesn't really match the other; B border, the edges are raised or they're Irregular; C, color, the colors are changing, or there's multiple colors within the mole itself; D, diameter, so if anything's larger than a pencil eraser, which is about six millimeters, that's usually a little bit more concerning; and E, evolution, is it changing over time? Because that's going to be something that's really a marker that something within that is not normal. And so, those are five useful tips for a skin lesion or a mole and we can use those to know what to tell your providers about.

Host: Yeah. Great acronym for people to keep in mind.

Peter Turk, MD: Yeah. To follow up with Dr. Rhea, they are a wonderful algorithm to use. But about one out of 20 melanomas that we see that are referred from dermatologists, either the patient or the dermatologist will say, "I didn't think this was anything." Oftentimes the patient says, "This is something I'm worried about," and dermatologists are not always fully aware what it is. That's why shave biopsies, which is the standard way to diagnose, is absolutely the right thing to do. Melanomas don't read the dictionary or Google. And they're not all black and tarry and different colors. Some are pinkish, some are just very subtle. So, it's a treacherous disease. And that's where knowing your body, as Dr. Rhea mentioned, is critical.

Host: Yeah, sometimes taking a look beneath the surface-- in this case, literally the surface of the skin is the only way to find out, right, Dr. Turk?

Peter Turk, MD: Yes.

Host: So, Dr. Turk, how big of a role do family history and genetics play in someone's risk for developing skin cancer? What if, for instance, you've got that extremely fair skin complexion like myself and your parents and grandparents did as well?

Peter Turk, MD: So, yes, I'm a perfect example of that: blonde hair, blue eyes, and fair skin. Definitely, there's a strong predilection as opposed to say an African American person, they still can get melanomas, rarely get skin cancers. But for the most part, if they are from Celtic or Irish background, they are of highest risk. We'll say yes about the genetic risk. Genetics play, at most, 10%. Ninety percent, it's ultraviolet light, either by the sunshine or by tanning booths, are the biggest cause.

But there are "melanoma" families. That's why we always ask family history. If they have a mother, a father, a grandparent that had melanoma, we definitely look at them more closely. Because now we're learning the genetics of melanoma, but there are melanoma families or people who have dysplastic moles. You know these people. And dermatologists have difficulty because they have multiple moles all over the body. How can you see one changing mildly? Oftentimes, for these patients, the dermatologist will take pictures of all parts of their body, so they can look three months separate or six months separate, and they'll know for sure what's changing.

Host: Dr. Rhea, we hear a lot of course about sun exposure dangers. Fortunately, it seems we hear more about it in recent years than years ago. So, how can we best protect our skin on a daily basis? What are a few of the main tips you can give us?

Logan Rhea, MD: Of course. So, one is just avoid any unnecessary excess exposure to the sun where you can. As you had mentioned, sun exposure and, as Dr. Turk had mentioned, specifically the UV radiation that the sun emits really increases your risk for all skin cancers, but certainly more invasive skin cancers like melanoma.

When you are out in the sun, I certainly encourage you to wear things like sunscreen. I always explain to patients some of the differences between different types of sunscreen. So, there's sunblock and sunscreen. Sunblock, you think of those mineral sunscreens containing elements like zinc. They're a little thicker chalkier, kind of leave your skin looking a little bit more white and chalky afterwards. And those are things that are actually blocking the ability for UV radiation to be absorbed in your skin. Sunscreens start to filter out some of the more harmful UV radiation. And those are the ones that you'll see more commonly in the aerosolized form, in those spray cans. And of course, there's all sorts of different brands, more generic brands, more luxury brands. But at the end of the day, some sunscreen is going to be better than no sunscreen.

You'll see numbers on all of those containers, whether it's a bottle or a spray can, and that's talking about the sun protection factor or SPF. And really, what it's trying to gauge and tell you is how much filtering is happening from that sunscreen. So, anything with a single digit, there's not quite as much happening, but you certainly are still getting some protection. Once you're about 30 or higher, you're getting very negligible differences between SPF 30, 45, 50, 70, 100. But ultimately, our recommendations are for SPF 30 sunscreens. And really, those are going to be best utilized when you're going to be out in the sun for more than 10, 15 minutes. And they should be reapplied about every 90 or 120 minutes, or every hour and a half in two hours. And so, those are going to be the ways that you can kind of protect yourself while you're out in the sun.

Certainly, avoiding tanning beds if you can. Obviously, most people who grew up around the time that I did, tanning beds were pretty popular. I went to school in Wilmington. So, a lot of people wanted to be tan year round. But as we get older, we understand a little bit more about the significant risk factors that they provide to us if we certainly have one or multiple exposures to them.

And then, think about the times when you don't really know you're having excess sun exposure. One example I give constantly is that if you're going to get skin cancer on the face, it's most often on the left side of your face. As you're driving in your car, the sun is typically beaming into you on that left side. Most people don't really think about those types of exposures. Tints on windows and things, they try to filter out as much of that excessive radiation as possible, but there's still going to be some that gets through there. So really considering maybe a morning moisturizer or lotion for your face that contains some sort of SPF, just as you're walking out that door and starting your morning commute, it can actually go a long way in the long term.

Peter Turk, MD: The Australians figured this out much before we did. It was the 1950s when we realized the UV exposure caused skin cancer and including melanoma. Australians, as you may think, most of them are from Northern European descent. There are not many clouds in Australia, and they love their outdoor sports, so it truly was an epidemic.

And so, they started a program in the 1980s. It was called Slop! Slap! Slop on the sunscreen and slap on a hat. And they've also advanced that to wraparound sunglasses. I wouldn't have thought about it originally, but you can get a lot of skin cancer around the eyes, and that is a very helpful additive as well in that setting.

Finally, just be careful when you're out in the sun. It should be before 10:00 or after 4:00 PM. So, 10:00 in the morning or after 4:00 PM, much less risk for sun exposure and some damage from the sun. I saw some study that said women 30 years and younger, they saw a group of 63 of them that had melanoma before age 30. Ninety-seven percent of them had used the tanning beds. So, that is something that is profound in its impact. It is 10 to 15 times as strong as the sun. So again, tanning beds are going to be your worst enemy.

Host: Wow. Eyeopening numbers for sure there. Dr. Rhea, if someone is diagnosed with skin cancer, what does the typical treatment journey look like in a nutshell? And how do specialists like the two of you work together during that process?

Logan Rhea, MD: Of course. So, a lot of the times, it's a patient bringing forward something to one of their doctors, whether it's their primary care doctor or their dermatologist, or sometimes caught just on a general screening skin examination by one of those providers as well.

Typically what starts is, as Dr. Turk had mentioned, a shave biopsy where we're essentially just scooping off the more superficial layers of the skin of that abnormal area. And then, it's being looked at under the microscope from a pathologist to really see if there are more aggressive features or features consistent with skin cancer. Depending on what type of lesion is ultimately identified by that pathology helps to determine the next best steps.

For the most part, if something like a basal cell carcinoma or a squamous cell carcinoma is discovered, usually, the dermatologist themself is actually doing maybe a little bit more of an excision if the margins of that shave biopsy still had some cancer cells in them, but they usually don't have to take too much skin. They don't have to take big chunks away. With melanoma, it's a little bit different. They're referred then to a surgeon like Dr. Turk, who will perform something called a wide local excision. With melanoma, we know that there can be skip lesions or satellite lesions where there can be small areas of additional melanoma in the skin layers that aren't contiguous, they don't actually connect with each other. So, taking a wider margin is very important.

And depending on the true size of the melanoma, there may be something called a sentinel lymph node biopsy that's performed where a lymph node is also removed and analyzed under the microscope to see if melanoma is involved. One of the reasons that we worry about melanoma is that unlike basal cell carcinomas or squamous cell carcinomas, it doesn't necessarily grow outward. It grows down. Down into the deeper layers of the skin, where we have more blood vessels, where we have more lymphatic vessels, which you can really think of as highways to other parts of the body. And that's why we treat melanoma when it's found, even when it's early, a lot more aggressively than some of these other cancers.

Dr. Turk, I'll let you quickly talk a little bit more about wide local excision and sentinel lymph node biopsy, and then I can take it back from there.

Peter Turk, MD: Sure. We'll go back to 1907. Dr. William Hanley. He said we needed two-inch margins around melanoma, when you think about this, a hundred years ago, they were terrible. These are bleeding masses. They take them down to the muscle, and they would also take all their lymph nodes out. We definitely have improved upon that.

Again, in all of surgery, we're trying to do less and less and do just as well. So, the rule is if it's a non-invasive melanoma, which means it's in the epidermis, not into the skin itself, We have to get five-millimeter margins, which is less than quarter of an inch margin, not a big concern. Thin melanomas, we advance that to one-centimeter margins. So, it's still something we can close without too much deformity.

The thickness is the biggest concern, if it's thicker than 0.8 millimeter, but you think about that, that's probably 20 sheets of paper. That needs to be evaluated with the lymph node removal as well. That's what Dr. Rhea had mentioned is the sentinel lymph node biopsy. This is where we, instead of taking several lymph nodes out and cause complications from that, leg swelling or arm swelling, depending on where it is in a long-term recovery, we can inject a little radioactivity, a little blue dye right around the melanoma. And it will track the lymph system and tell us which one or two lymph nodes the cancer would go to first. We take those one or two lymph nodes out if they're clear. Great news. We now know that even if there is is cancer in the first one or two lymph nodes, we don't take the others out, but we definitely would move them toward further management because if it is in the lymph node, it's a higher risk for being elsewhere. And that's where we get Dr. Rhea involved for making sure it's nowhere else, and then what do you do to help prevent it from coming back somewhere else.

Logan Rhea, MD: Right. And as we look at those samples under the microscope, there are certain features that then prompts a referral to someone like me, a medical-oncologist, to talk about similar treatments. And even if there's no lymph node involvement, if it's a particularly deep or invasive melanoma or if there are very high risk features, things like ulceration that are prominent on the pathology sample.

If there's ever a lymph node that actually shows melanoma cells in it as well, it's always appropriate to have a medical-oncologist review the case. And ultimately, what we're going to be doing is talking about the risks and benefits of certain additional therapies, but also staging. What staging really means is doing additional scans to see if there's any concerns that melanoma has left even those lymph nodes and gone to other places.

And so, we typically are doing things like PET CT scans, which are specialized scans that use a radio-contrasted sugar to go to places in the body that are taking up more sugar or fuel than they should as well as an MRI of the brain. Because, unfortunately, melanoma can go all the way up to the brain and not have any other areas of involvement in other places of the body. And so, using those tools, we then come up with a treatment plan for a patient to either start treatment to help reduce the risk of melanoma coming back, typically in the form of immunotherapy infusions, or we're starting treatments to help reduce the burden of melanoma, also typically in the realm of immunotherapy infusions. But there's a few different options in that scenario.

And one thing I'll just quickly say is that immunotherapy is a little bit different from chemotherapy. You think of chemotherapy as more of a toxin going directly and killing cancer cells. Immunotherapy actually utilizes the body's immune system to help fight off cancer cells. And melanoma, historically, because of the toxicity from UV radiation is a very immunogenic or immune-sensitive type of cancer, and these treatments were actually created for melanoma. People won the Nobel Peace Prize in Medicine for creating them and now have applications in over 20 different types of cancer. So, a very exciting time to treat cancer in general.

But we're making really great strides in helping reduce patients' risks of their melanoma coming back at distant sites, as well as helping them to live longer and sometimes many, many years even with melanoma that spread to places like the lungs, the liver, the brain.

Peter Turk, MD: One of the early cures that is not well known is Jimmy Carter in 2015 had melanoma that was in his liver and in his brain, and they did some surgery. But for the most part, it was immune therapy and he was absolutely cured of that disease, and survived 10 more years. So when it works, it can work extremely well.

Host: Another interesting nugget from Dr. Turk on the historic side, the historical side. We certainly appreciate that. And finally, for you, Dr. Turk, as if the great information the two of you have given us already isn't enough, how about one final piece of advice for those joining us who may still be thinking, hopefully not, "Skin cancer isn't something that I have to worry about," what do you want them to know about the disease that maybe people just don't understand enough?

Peter Turk, MD: We've talked about mostly Caucasians, people with light complexion that can get melanoma. And again, melanoma being the one that is potentially deadly. But one out of 40 Caucasians or whites get melanoma, but one out of a thousand African Americans get melanoma. They don't get it typically on the skin. They get it as called acral melanoma. They get it on the soles of their feet, the palms of their hands, and under the fingernails. Bob Marley is a great example of somebody who died of melanoma that was on the sole of his foot.

So to know that for patients that are Caucasian, their five-year survival is 98% with melanoma. With African Americans, it's much less than that because they're not caught early. They're not typically thought of as something bad. You have a little nodule on the sole of your foot or the palm of your hand or under your nail bed, that absolutely needs to be evaluated as well.

Host: Well, folks, we trust you are now more familiar with skin cancer. We've learned about the ABCDEs and the three S's as well, plus some great history-related information from Dr. Turk as we said too. Doctors, keep up all your great work and thanks so much again.

Peter Turk, MD: Thank you, Joey.

Logan Rhea, MD: Thank you for having us.

Host: Absolutely. We appreciate the time again. And to find a physician, please do visit novanthealth.org/services/cancer. For more health and wellness information from Novant Experts, please visit healthyheadlines.org. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. Thanks so much again for being part of Meaningful Medicine, a Novant Health Podcast.