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Scott Webb (Host): There are many mental and physical benefits to being outdoors, especially on a nice sunny day, but we do need to be mindful of the damaging effects that UV rays can have on our skin, especially when it comes to melanomas and skin cancer. And joining me today to discuss skin cancer, including treatment options and how we can protect ourselves, is Dr. Amy Paik. She's a Dermatologist who practices at the SVMH Specialty Clinic in Salinas. This is Ask the Experts a podcast from Salinas Valley Memorial Healthcare System. I'm Scott Webb. So, Dr. Paik, it's a pleasure to be on with you today. We're talking about skin cancer, which is something, especially folks in the region definitely have to deal with and need to be educated about. So, let's start here. What is a melanoma?

Aimee Paik, MD (Guest): Melanoma is a type of skin cancer that is derived from melanocytes, which are the cells that make moles.

Host: Yes. I've heard that melanoma is an aggressive type of cancer. So, why is that? And why is it so dangerous?

Dr. Paik: So, melanoma can be very aggressive because it easily metastasizes, meaning that some cells can break off and spread to lymph nodes or organs. In the beginning stages when melanoma is growing and when it's very thin, the risk of it metastasizing is very low. So, we use something called Breslow's Depths to determine or to predict how patients will do. So, thin melanomas, the less than one millimeter patients actually do very well, but any melanomas that are thicker, especially greater than four millimeters patients do poorly. And that's because their risk of it spreading is much higher as it invades deeper into the skin.

Host: Yeah, so it seems that if a melanoma is caught early, that it is survivable.

Dr. Paik: Absolutely. Yep. If a melanoma is considered thin, so thin melanomas are typically determined to be less than one millimeter, then the prognosis is really good. Patients do really well. Five-year survival is 97% or greater. But the danger is when they're caught late and then the prognosis can be really poor, meaning that patients tend to not do well if it's caught late. And if it's spread to other organs.

Host: Definitely and we will talk about the spread coming up here in a bit, but if a patient has a son or an aunt or any family member with a melanoma, are they at increased risk?

Dr. Paik: Yeah. So, this is a question I commonly get. So, family history is important for melanoma. So, if you have a family history of melanoma, your risk is increased a bit, but that's only for first degree relatives. Meaning if you have a sibling, a full sibling or a parent who's had melanoma, then your risk is also higher. But that said, the risk of melanoma is very low. So, this takes a low risk and makes it a little bit bigger, but it's still generally a low risk.

Host: And I know there are stages, right? So, let's go through the stages of melanomas zero to four, et cetera. Can you take us through those stages?

Dr. Paik: So, stage zero is a melanoma that has not invaded enter the skin at all. So, this would be something like a melanoma in situ. And in situ means in its place, meaning it has not invaded below the level of the epidermis. It's still confined within that level. So, any melanoma in situ's are considered a stage zero melanoma, meaning there's really no risk to your life at that point.

Stage one is for thin melanomas. Stage two melanomas are where the tumor has gotten a little bit thicker, greater than two millimeters in thickness or if there is any ulceration. And an ulcerated melanoma means that it is more aggressive. So, if there's any ulceration that kind of bumps you up to the stage two category for melanoma, if it's over one millimeter.

So it's kind of a technical, very technical determination of stages. Stage three is when the cancer has spread to lymph nodes and then stage four, if it has spread to other sites of the skin or if it has spread to different organs such as the brain or the lungs.

Host: Yeah, so let's talk about the spread. You mentioned that earlier as well. How does skin cancer metastasize, how does it spread to organs? You know, how does that happen from a spot on your hand or somewhere on your body, how does it spread from there to your organs?

Dr. Paik: As the tumor gets bigger, certain cells can break off and go free. And so, cancer is defined as uncontrolled growth of cells. So, cancers just grow and grow, or tumors just grow and grow and grow. And then they have the ability to break off and live at other sites. Then that is what makes it a malignant tumor. So, cells can get picked up by the lymphatic system, so they can go and travel to lymph nodes, or they can travel via the bloodstream and they can travel to various organs, including liver, sometimes the kidney, sometimes the brain. So, they just get picked up by the bloodstream and then they kind of enter at different sites and then they start growing at this new location.

Host: Always wondered, you know, how that happens exactly. How does it go from here to there and how does it spread, you know, and are there people with certain skin types that are more prone to developing melanomas? And if so, who and what are the risk factors?

Dr. Paik: Caucasians are definitely at higher risk for melanoma. People who have fair skin that easily burns are at higher risk for melanoma. But that being said all skin types can develop melanoma. It's not always related to sun exposure. Individuals with darker skin, such as Blacks or Hispanics, darker skin Hispanics, or Asians can develop melanoma on the palms and soles at equal rates to whites. Or if you've had a lot of sun exposure, you can also develop melanoma as well. But the lighter skin types that easily burn are at a higher risk in general for melanoma.

Host: Yeah. And you mentioned sun. So, let's talk about that. You can't get away from the sun right? In Salinas and Monterey County, yeah, so the sun is pretty prevalent, right? And that's really one of the reasons to live there because it's so sunny and beautiful, but, the sun can be bad as can tanning beds. So, let's talk specifically about those beds. Cause I remember doing that a lot when I was in college. It was, seemed to so important to me to be tan when I was, you know, in my twenties, why are tanning beds so damaging to the skin?

Dr. Paik: Tanning beds use UVA rays. So, there's two types of UV rays that, that reach the earth. UVB rays which are higher energy. These penetrate more superficially into the skin and UVA rays, penetrate deeper into the skin where kind of the melanocytes lie. So, that's one reason why tanning beds are specifically linked to an increased risk of melanoma is because of the UVA rays that they use. Tanning beds use, these UVA rays also really contribute to skin aging. So, responsible for a lot of wrinkling of the skin, you know, discoloration, spots. So, lots of good reasons not to use tanning beds. An increased risk of melanoma is definitely one of them.

Host: Definitely. And in California, minors need parental permission, right?

Dr. Paik: Yeah. It has the same protection for minors as cigarette smoking. So, it's considered in the same class in terms of the protection that we place for our youth because of its carcinogenic potential.

Host: Yeah, that's good to know. And good for parents to know. And is it possible for us to tell the difference between a normal mole or freckle and skin cancer? Can we just look at our skin and say, oh yeah, that doesn't look right?

Dr. Paik: I think so. I have a lot of patients who come in, who've noticed that their, that mole is different or who have had a loved one, who's told them, hey, this one looks different than your other moles, and really prompted them to come in. Self-skin checks, where you take a look at your own skin is really important.

So, a typical mole will be one even color. If it's soft and fleshy, that's actually a really good sign. I always say, if you have a little hair coming out from it, that's also a very good sign because hair is a complicated skin structure. Cancer doesn't know how to make complex things. All it knows is how to grow. So, anything like hair is actually a pretty good sign for a mole. And a melanoma would look different. A melanoma would be multiple colors and unusual shape, rapidly growing. So anything that looks different, is acting different than anything else that you have, I like to call it the ugly duckling lesion. And then that's the one that we want to be concerned about.

Host: Besides the let's say ugly duckling syndrome or symptom, are there any other symptoms and do we feel anything, you know, how do we know, basically, other than something doesn't look right, or somebody tells us, and then we come to see an expert like yourself, right?

Dr. Paik: This is a really good question because melanoma does not have any symptoms in it's early stages, or typically doesn't. Some people, you know, are not concerned about a mole per se, because it doesn't hurt, it doesn't itch. And generally they don't. Once in a while, a mole that is cancerous like a melanoma will have symptoms, but I would say the vast majority are not symptomatic.

So, how do you know again, it's that if it's rapidly changing, that's a really important sign, something to be aware of and one that just looks different from the rest. So, asymmetry where one half doesn't match the other, multiple colors, funny shapes. Those are all really important signs, to tell you, hey, this mole is not acting the way it should be.

Host: Yeah. And it definitely sounds like we are sort of the first level in diagnosis. Like we know our bodies, we know how things used to look and how they look maybe now, and maybe then that's a sign to come in and see someone see the primary, see you. But let's just say, unfortunately, that someone has been diagnosed with a melanoma. What are the treatment options? Are we talking surgery? And if so, what are the most common types of surgeries that you perform related to melanomas?

Dr. Paik: So, one of the most important treatments for melanoma is surgery. So, we call it wide local excision. So, once a melanoma has been diagnosed, then the first step is to take out that skin cancer and a rim of normal skin around it mean because there can be some microscopic spread. So, just a few errant melanocytes or individual cells that want to travel out from that location and spread to other sites.

So, you really want to take out the skin cancer, a rim of normal skin around it, anywhere from one to two centimeters around it, and then go down deep into the fat, to the level of the fascia. So, that's the first treatment. Then it depends on how thick the melanoma was when it was first diagnosed. If it tends to be thicker what's really thick then we know that, oh, patients have a pretty poor prognosis may not do very well, then we're more aggressive with scans and imaging and make sure they haven't had distant spread already. But sometimes there's this intermediate zone where it's kind of this, not fully thin but not really thick melanoma. In those cases, we can do some additional tests to try to figure out if the melanoma has spread or not. Something called a Sentinel lymph node biopsy, or some testing of the actual tissue itself. We can do something called gene expression profiling, which will tell us whether this is a melanoma that is at high risk for spreading or one that is at very low risk or spreading. Treatments for more advanced stage melanoma. There's other various treatments for advanced stage melanoma.

Host: Yeah. And when we talk about advanced, especially stage four, are we talking chemotherapy, radiation, that sort of thing.

Dr. Paik: So, advanced stage melanoma, we used to not have very many good options at all. Traditional chemotherapy and radiation don't work great for melanoma. So, even 10 years ago if you had a stage four melanoma, the really recommendation was a clinical trial to try to get onto one of these new drugs that potentially may be effective. But since then, we've had this remarkable wave of new medications that came actually quite effective for metastatic melanoma. They are generally either immunotherapy medications, medications that stimulate your own immune system to attack and fight off the skin cancer, or targeted therapy. So, it's targeting the genes or the proteins of the cancer to prevent it from growing so easily.

Host: So, let's talk about outcomes and the type of followup that you do with patients.

Dr. Paik: Within the last 10 years, there have been incredible and advancements in the treatment of advanced stages of melanoma or metastatic melanoma. And some patients do incredibly well, which is really amazing. It's just a complete 180 from when I trained 10 years ago. That being said, so if you've ever had melanoma, no matter what the stage, you want to keep an eye on that site because you always want to monitor for a risk of recurrence.

So, if it were to come back. It can that come back at the original site. So, you always kind of want to take a look at it and make sure there's no moles, color coming back around the area of the scar. You can feel it, make sure you don't feel any lumps or bumps underneath that scar where you've had that melanoma removed. Cause it can come back, underneath the skin. But if you have more advanced melanoma, you're under very close watch by your physician. Care at that point, it really gets transferred to an oncologist who can discuss all the different options in terms of immunotherapy or targeted therapies for advanced stages of melanoma.

And you're monitored very carefully in conjunction with the dermatologist. So, every three months, three to four months for the first couple of years. And then depending on how you do, this followup can be kind of stretched out a bit longer. But for anyone who's had melanoma other than stage zero melanoma, but if you've had a melanoma that is even a little bit invasive or very invasive, we do recommend frequent skin checks. Because we want to make sure you don't have a recurrence of the melanoma at that site, but also because your risk of developing a second melanoma is higher. So, that means skin checks every three to four months for the first two years, then every six months for the next three years, and then yearly for the rest of your life, you get a full total body skin exam.

And in terms of patients who have advanced stage melanoma, but who do really well, then it's just a matter of getting followed and checked up by your doctor, you know, and also based on symptoms and making sure that if you had any concerning symptoms, concerning abdominal pain or pain at certain sites, jaundice would be a really bad sign that then you wouldn't let your doctor know.

Host: When we talk about an examination, this is kind of interesting. Take us through and describe the A, B, C, D, E examination process.

Dr. Paik: So, this is a mnemonics that is used to kind of teach people what about a mole is unusual? What do I need to be concerned about? So, A stands for asymmetry. If you cut a mole down the middle, you want the two halves to generally match up, to basically look the same as one another. B is border. We want a nice, smooth border. If it's rough or jagged or scalloped, then that's more concerning. No mole is going to be perfectly round or perfectly oval, but we want it to be generally a nice, smooth shape. And again, it's kind of scallops at borders that would be more concerning. C is for color. And that's a really important one. If there's multiple colors within a mole that is very concerning. So, if it's you know, not just brown and dark Brown, but if it's black, if there is a little bit of white area, if it's reddish, anything that has a kind of a slight pinky tone to it means that there's some inflammation going on. It's very concerning.

So we say, three or more colors within one mole. Now that's not true for all melanomas. Sometimes melanomas are just one color. IT can be black. Sometimes they can even be pink. So, that doesn't catch all melanomas, but it does catch a lot of them. D is diameter. If it's bigger, we tend to worry about it more. So, that's bigger than six millimeters, which is the size of an eraser on your pencil. Now this does not apply to congenital moles, meaning molds that you're born with can be big and they can be okay. But if it's kind of a newer mole and it's big, then that would be concerning. And E which is the most important, is evolution or change. So, when a mole is rapidly evolving. One side is growing and not the other. One side is changing color, then that would be very concerning and that's what a good reason to come on in right away.

Host: Yeah. And it sounds like that's why it's particularly important that we do self-checkups, that we look ourselves over. Even if you have to sort of look backwards in the mirror and look at our backs or have a family member or a friend, take a look and say hey what's going on over here. Right. So, really looking out for those things that are evolving.

Dr. Paik: Yeah, absolutely. I mean, not everyone needs a skin check every year. There are some people who do benefit from regular skin checks. Other risk factors that we didn't talk about for melanoma include, if you've ever had melanoma before, so a personal history of melanoma, then you are someone who is at greater risk for a second melanoma. Anyone who is immunosuppressed or on certain medications that increase your risk for melanoma. Those are some individuals who may benefit from more frequent skin checks, a history of frequent sunburn. So, having a history of blistering sunburns, or more than five sunburns in your life, that increases your risk of melanoma. It doesn't mean that you absolutely need skin checks every year, but you're someone who needs to be at heightened awareness to kind of keep an eye on your skin more closely.

Host: Yeah, that's a good way to put it, just that heightened awareness of your risk factors. How best can we protect ourselves against skin cancer? Is it just bathing in sunscreen or is there more that we can do?

Dr. Paik: There was nothing that dermatologists are more passionate about than sunscreen. We love sunscreens because it absolutely has been shown to prevent skin cancers not just melanoma, but other non-melanoma types of skin cancers, including basal cell cancers and squamous cell cancers. So, one of the big things again, is to avoid sunburns. And the statistic I've heard is for every five sunburns, your risk of melanoma doubles, which can sound like a very alarming number. Again, the risk is overall very low, but it just serves to show you how much sunburns really affect the melanocytes. And then one of the big reasons why is because melanocytes don't easily die, they don't easily undergo something called apoptosis or programmed cell death, where if they accumulate enough damages to their DNA, they'll go ahead and just kind of self-destruct. Melanocytes don't really do that.

So, they accumulate all that damage over your years from childhood all the way on. So, every sunburn that you get will increase your risk of melanoma just by a little. You really want to be mindful of really protecting your skin. Sunscreen's a great option. A great tool to use to protect your skin from sunburn. Other important things are to try to avoid the midday sun when the UV rays are the strongest. One of my favorite features of my Apple watch is that there's a setting on the weather portion of it, where you can go down, you can scroll down and it tells you the UV index for that particular time.

And that I find that it's a really helpful tool. There's also various apps that you can download. There's one by the EPA, which is free that shows you for every location in the United States, what that specific UV index is at that particular time of the day. So, that's also a very useful tool. But generally UV rays are strongest between the hours of say 10 to 11 or 3, so try to avoid that mid day sun. The UV index is actually not much related to temperature. It can be hot at 5:00 or 6:00 PM and sunny, and the UV rays can be pretty low or it can be cool and cloudy and foggy, in the middle of the day, but UV index can be quite high.

So, I think there's this false sense of security when it's sometimes on the peninsula, we have kind of these cold days in the middle of the summer where we think we don't need to wear screen, but that's actually a time where people can get sunburned very easily. Hats are really important, wide brimmed hats. I'm never outside without a wide brim hat. And the protective clothing, try to cover up when you can. So, I have my kids wear rash guards. I wear rash guards at the pool, just to kind of protect our skin from the sun, from the damaging rays of the sun.

Host: Yeah and a lot of clothing now actually has UV protection built in right?

Dr. Paik: Yeah. So, there are some clothes that are marketed for UV protection, but really all clothes will provide some sort of UV protection. The tighter the weave, the more that the light will be stopped by the clothing. Kind of a good rule of thumb is if you pick up your shirt or you pick up your hat and you put it underneath the light. If you can see that the sun or the light poking through, if you see little holes, little dots of, you know, the sun on your skin, then that hat, or that clothing is not doing a good job of protecting your skin. So, you kind of want a tighter weave where you're really able to block the sun's ray.

Host: Yeah. And you're so right about the UV, you know, I think we all sort of associate temperature, right? So, if it's hot out, then we like, oh, well we better use sunscreen today, but it's, oh, it's kind of cool today. But even in my family my wife and my son can burn on an overcast day. And my daughter and I, we just immediately tan. So, interesting that you mentioned that, that the temperature really shouldn't be the deciding point or the marker for whether or not to use sunscreen. Basically, if we're outside, we should probably always use it. Right?

Dr. Paik: I think so. I mean, if you really go into it, the UV rays are going to be stronger during the summer. and in the winter, it's really hard to burn in certain locations, certain latitudes, you know, just kind of depends on where you're sitting geographically. But in general, you know, especially during the summer, even if it's a cool day, or in the spring time too, I would definitely put on sunscreen.

So, it's kind of the classic time. It's like a cool cloudy day at the ballpark and you're out there all day. You're not wearing sunscreen that's kind of the classic story. People come in with a really bad sunburn. Because again, they do associate how strong the UV rays are with temperature, but kind of to your other point about you and your daughter can tan without burning, versus your wife and your son, right? That really boils down to skin type. So, there are some skin types that can only tan after burning. So, we kind of, categorize them between skin types, one through six. So, skin types one and two have to burn before tanning, but there are other skin types, skin type three, four or five, six, you can tan without burning. That's where I kind of I sit too. I can put on tons of sunscreen. I won't burn, but I will still tan. And that just kind of relates to your underlying skin type.

Host: Absolutely. That's exactly how it is. My wife will not tan until she burns first. So, when we went to Hawaii, there were those first couple of days, she was like, I'm really burned, but it's going to turn into a tan at some point, right?

Dr. Paik: Yeah. I think sometimes people think, oh, I need to have this baseline protective tan. It will help protect my skin. And unfortunately that is not true. Even if you are very tan, I think it provides an SPF of four. There's also this kind of myth out there about vitamin D. So, everyone kind of associates the sun with vitamin D, which is true, but there's this myth out there that says, oh, if I get 20 minutes of sun three times a day, then I'll have enough vitamin D and that's not true. It really depends on what time of year, your location, your altitude, in terms of how much sun is needed to produce vitamin D by your skin.

And the other side of that is vitamin D is always produced at the expense of your skin, meaning that anytime that vitamin D is produced by your skin, it is damaging your skin. Because the same rays that participate them in D also cause skin cancer. So, I always say a supplement is a much better, a much safer way of getting vitamin D than trying to get out there and getting it through sun exposure.

Host: Yeah. So, interesting you say that because I've heard people say that, oh, well, I'm really going to get my vitamin D today.

Dr. Paik: And I think there's so many other benefits to being outside and being active in the sun. There's a lot of mental benefits, physical benefits that I think are very important, but what I tell my patients is just protect your skin, try to be smart about things, you know, try to do things either earlier in the morning or later in the day when the UV rays are not so damaging. Make sure you're wearing sunscreen. If you could do an activity in the shade, that's much better. If you're taking a walk, always try to stay on the shady side. Don’t walk in full sun or do activities in full sun, if you can avoid it.

Host: This has been so informational and educational for me, especially today. Doctor, as we wrap up anything else you want to tell folks about skin cancer, melanomas, et cetera.

Dr. Paik: I'm very glad there's so much awareness of melanoma these days. I think it's amazing and awesome how people are just so much more aware about the need of sunscreen, especially for their children. And there's so many great sunscreen options available now. But on the flip side of that, I think that there's a lot of anxiety and fear that patients or individuals have about developing skin cancer and melanoma that then starts to really affect people's lives. So, I think there's this real balance. I think it's really important to protect your skin. Use sunscreen. Keep an eye on your moles, but not to have this fear about developing melanoma that kind of pervades your life, which sometimes I'm seeing, especially in my younger patients, I'm not sure about the effect of social media contributing to anxiety, but I do see that as well.

Host: Yeah, I think that's so right. That we do need to be mindful, of course. But as you said earlier, there's nothing like being outside. The mental and physical benefits of being outside on a nice day, are innumerable, but we need to protect ourselves, whether that's hats, clothing, sunscreen, we just don't maybe need to be obsessive about it. We still need to live our lives where we can do it safely in the sun, right?

Dr. Paik: Absolutely. And absolutely no tanning beds. I would say a fake tan and it's much safer, so a fake tan like a spray tan. I think that's fantastic, but tanning beds, you should definitely avoid.

Host: That's perfect. Well, doctor, thanks again for your time today. So, knowledgeable and so great and really a lot of great information here today, and we hope listeners agree. So, thank you so much and you stay well. For more information, go to svmh.com. And if you found this podcast helpful, please share it with friends and family and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Memorial Healthcare System. I'm Scott Webb. Stay well, and we'll talk again next time.