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Prakash Chandran: Melanoma is a very serious skin cancer. And in the past decade alone, the number of new invasive melanoma cases diagnosed annually increased by 31%. Just in 2022, an estimated 7,000 people will die of melanoma. And today, we'll learn about what causes it and how you might prevent it. Let's talk about it with Dr. Scott Albert, a surgical oncologist at St. Joseph's Health.

This is St. Joseph's Health MedCast, the podcast from St. Joseph's Health. My name is Prakash Chandran. So Dr. Albert, really great to have you here. Thank you so much for your time. Let's get started with the basics. What exactly is melanoma?

Dr Scott Albert: Hi, thanks for inviting me. So yeah, so melanoma is a skin cancer that develops in melanocytes or the cells that create pigmentation in the skin. This is a potentially aggressive type of skin cancer that many patients or people can get.

Prakash Chandran: And from a medical perspective, one of the things I mentioned at the top was there's like rising cases. Why exactly do you think that cases are rising at such a rapid rate?

Dr Scott Albert: Like many increases, that's not always clear. It's probably a variety of factors. For some melanomas, there's probably a lag time between sun exposure and development of the cancer. So, the previous generation where sun exposure was intense and more frequent and maybe less thought was put into sun protection, those people are now developing melanoma as they age. I also think that most likely there's a component of detection. And I think that we are becoming more aware of the disease and we are more aggressive about biopsying, you know, abnormalities on the scan and therefore, there's also probably a certain percentage of melanomas that are just being detected earlier.

Prakash Chandran: Yeah. And so I want to ask some more broad questions here. Is it safe to assume that the majority of melanoma is caused by sun exposure?

Dr Scott Albert: Yes and no. I mean, we see melanomas in all parts of the body. So melanomas can develop even in parts of the skin that have never seen the sun. So clearly, UV radiation is a strong component to melanoma, but it's not the only part of the equation, I would say, because there's a strong link, but clearly there's other factors, most likely genetics that we don't completely understand that predisposes people to melanoma.

The sun exposure link is very strong with other types of skin cancers, like basal cell and squamous cell. And no doubt, either strong, intense, intermittent exposure or exposure to the sun over many years without protection increases your risk of melanoma, but it also increases your risk even higher for other types of less aggressive skin cancers. So I always tell patients that have developed a melanoma, not to really beat themselves up too much when they have the diagnosis, because they really are hard on themselves saying that they really could have prevented it. And I tell them yes and no in the sense that clearly there is a link, but not always. And it's not always as strong as people think. So I try to kind of give them that type of reassurance.

Prakash Chandran: Yeah. So let's dig into that. I think you kind of raised an important point. There are different types of skin cancer, right? I think you mentioned the squamous cell. There's the melanoma. Can you just talk at a very high level between the different types and the ones that are most prevalent?

Dr Scott Albert: Yeah. So far and away, basal cell carcinoma is the most common skin cancer. This is the most common skin cancer, period, and that really does not pose a metastatic risk. So it can be locally destructive and needs to be treated and can be treated in a variety of ways but not necessarily the risks that melanoma poses.

Squamous cell is similar. Most squamous cell carcinomas behave in the sense that they are a local problem. Melanoma is different in the sense that it can spread to other parts of the body. It can spread to lymph nodes. And that's really what obviously concerns me as a surgical oncologist and what, you know, concerns patients, obviously, is the metastatic potential of melanoma. The majority of melanomas do not spread. I usually tell patients that as well. And the spread risk, the chance of a melanoma metastasizing is really based on the local biology and how aggressive or how deep that melanoma is. And so, that initial biopsy really gives us a lot of insight.

Prakash Chandran: Yeah. Hence, what you were saying earlier about the importance of that early detection. Let's talk broadly about that. So can these skin cancers or melanoma specifically be detected with screening and when should people start?

Dr Scott Albert: So, yeah, absolutely. Screening can be done by lots of medical professionals. It can also be done by individuals that are just aware of their skin changes. I think starting can be any time, really. I think once people are developing lesions on their skin, they just need to be basically aware of them. And if there is a sudden change in a skin lesion, not to ignore it. And that by far and away, a change in a lesion on the skin, a sudden change especially, is sort of a tip off that it needs to be investigated further from biopsy or evaluation by a skin professional, whether it's, you know, a surgeon, a plastic surgeon, but a dermatologist obviously has a lot of expertise in managing skin diseases. And I think once you get to the point of either having risk factors for skin cancer, whether it's sun exposure, family history, or fair skinned or whatnot, and aging, those might be the times where you really want a professional, like a dermatologist screening you on a regular basis. But I don't want to discredit patients themselves, because many of them can find things that are a problem early on by just being aware of any changes.

Prakash Chandran: Yes, definitely. So if someone gets a screening and a biopsy is taken and something's found, talk to us about what the treatment options look like and what people can expect.

Dr Scott Albert: Yeah. So like many cancers, it's a team approach to managing melanoma. Many times I see patients that have been evaluated by a dermatologist and they're part of the team that treats melanoma. Sometimes melanomas can be easily be treated by a dermatologist with further excision and followup. The other melanomas can get more complicated in the sense that, as melanomas become more aggressive, they tend to be deeper into the thin, you know, top layers of the skin, the epidermis and dermis. And those are really the melanomas that need to be treated with a bigger team.

And so, the first part of management is the biopsy. The second part is deciding what needs to be done based on those biopsies. And the next treatment usually is a wider excision of that site. And those are incisions that are based on huge international clinical trials that have been done throughout the world, so we know based on evidence what type of margin we need for melanoma. We have that luxury of having evidence on what to do. And the second part, depending on how deep that melanoma is in the scan, is checking lymph nodes. And the potential for spread, like I said, is based on how deep that melanoma is. And so that's the first part of treatment and based on the surgical pathology really dictates the next steps, whether it's surveillance with a dermatologist on more frequent timeframe, or do we need a medical oncologist or do we need a radiation doctor or do we need more surgery? These are all sort of parts of the team that sometimes are needed. So, it all starts with the biopsy and then moves from there.

Prakash Chandran: So I want to talk about potentially more advanced treatments. One of the things that I was reading about was molecular diagnostics. Can you talk to us broadly about what that is and what's being developed for melanoma treatment?

Dr Scott Albert: Yeah. So like lots of cancers, the biology is really the driver or king of the treatment. And biology is basically the molecular phenotype of that tumor. So what are the genes or aspects of that individual melanoma that are predisposing that cancer to being more aggressive or not? And so molecular diagnostics are a tool to help decide on which tumors might be more aggressive. And that's being developed for melanoma as well as other cancers. We're sort of on the cusp of really that explosion of molecular testing of melanoma. We're trying to incorporate it into this management algorithm. We're not quite there yet, but it can be used at times. So, I think we need to be aware of how we use that test and how it's going to change our management.

I am all for molecular testing, it's just how do we best utilize it? Because right now, we base our treatment decisions on histopathology, what does the tumor look like, how deep is it, what's the sentinel node, meaning the lymph node status of that melanoma. And I think in the future, we will also need molecular diagnostics on a regular basis. We use that in other diseases like breast cancer, for example. It's evolving, it's available now, but it is the future.

Prakash Chandran: Yeah, it definitely sounds like it. We talked some about early detection, going to your dermatologist. Certainly if you notice a change, you should get screened. But another part of it is just general preventive. Now, obviously, that is applying sunscreen if you're going to have sun exposure. Even though there might not necessarily be a direct link, it's always good to do that. Is there anything else that we can proactively do to prevent getting skin cancer?

Dr Scott Albert: I think you made the biggest point is really just avoiding excess sun exposure. Obviously, tanning beds are discouraged. There is definitely a causal link between tanning bed usage and sun exposure. So I think just being thoughtful about sun damage and how to minimize it, whether it's sunscreen, covering your skin, avoiding tanning bed use. Those are all things that are pretty easy to do. And I think those are some of the main aspects of prevention.

Prakash Chandran: The last question that I always like to ask is, given all of your experience as a surgical oncologist, what's one thing that you just know to be true that you wish more patients knew?

Dr Scott Albert: Melanomas can be a scary disease. I usually tell people that people come in with a diagnosis and they're rightfully concerned, but the vast majority of melanomas are early-stage melanomas. So they survive the cancer. I tell people it's a chronic disease. They need more frequent followups with dermatologists. You may need some other treatments. But for the most part, people do just fine.

In addition, I would also tell people that the treatment for melanoma has been revolutionalize with, therapies. Those are treatments that did not exist five to ten years ago and have transformed the landscape for melanoma. So even if you are unfortunate to have a bad disease, we have so many different tools now that we can manage the disease successfully in many cases. So there's hope even if you have a more aggressive type of melanoma at this point. We have lots of options.

Prakash Chandran: Well, Dr. Albert, I think that's the perfect place to end. Thank you so much for your time.

Dr Scott Albert: Thank you very much.

Prakash Chandran: For more information, you can visit skincancer.org. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. This has been St Joseph's Health MedCast from St. Joseph's Health. My name is Prakash Chandran. Thanks again for listening.