Cheryl Martin (Host): Skin cancer is the most common cancer here in the United States. One in five Americans will develop it by age 70. Melanoma is the deadliest form of skin cancer. Up next, what you need to know about melanoma with surgical oncologist Dr. Sonia Orcutt. This is UAMS Health Talk, a podcast from the University of Arkansas for Medical Sciences. I'm Cheryl Martin. Dr. Orcutt, so glad to have you on.

Sonia T. Orcutt, MD: Thanks for having me. So glad to be here.

Host: First, talk about melanoma, what it is, and the extent of the problem here in the U.S.

Sonia T. Orcutt, MD: Sure. So as you mentioned, melanoma is a type of skin cancer. It represents about 10 percent of skin cancer, but as you mentioned, it can be quite deadly. So it arises from the melanocytes, which are cells within the skin that form pigment. Melanoma itself, we find in the United States about 100,000 new cases per year, so it's quite a lot.

However, it is not one of the deadliest cancers within the United States, even though it is one of the deadliest skin cancers. And a lot of that is because, you know, we see our skin a lot. And so, a lot of these cancers luckily will present early, but it can certainly be a problem. It is estimated actually that the rates of melanoma, will continue to rise.

They have been rising in the last few decades. And it's estimated that by 2040, it may actually overtake several other cancers and become the second most common cancer that we see. So it, certainly will continue to be a problem.

Host: What accounts for it rising so dramatically?

Sonia T. Orcutt, MD: Some of it is just better knowledge, that we are more aware of melanoma. We're more aware of the risk factors and what to look for. And so a lot of the new diagnoses are at very early stages. But some of it is also that one of the big risk factors for melanoma is UV. And I'm speaking for skin melanomas, and I make that distinction because there are some melanomas that can occur in parts of the body that don't really see much sun, like the anus as an example, and those are less, likely related to UV exposure, but most skin melanomas or cutaneous melanoma as we refer to it, are from UV exposure. And back, a few decades ago, we didn't know the benefits of sunscreen to protect against UV. We didn't know that tanning beds were bad for you. We know that now, and it can take a long time for melanomas to develop. So part of it is that we're seeing melanomas now in elderly people who didn't know about how to protect themselves and part of it is just because we know more about it and we're finding it more.

Host: So those at risk the most are those exposed to UV?

Sonia T. Orcutt, MD: Correct. So it's partly a lot of UV exposure and it's partly some of your own genetics that you can't change. So people who have fair skin, who have red hair, a lot of freckles, have a much higher sensitivity to UV exposure. So even if they have the same level of exposure as someone with darker skin, the person with fairer skin is at higher risk of developing skin cancers.

Host: So how is melanoma diagnosed?

Sonia T. Orcutt, MD: Most of the time it's diagnosed via a skin biopsy because usually somebody will come in and say, Hey, you know, I have this mole on me and it's changing. It's getting itchy. It's getting darker. It's growing in size, something to that effect. They might present to their primary care doctor or dermatologist, and then get a biopsy and that would show melanoma.

It's uncommon, although it can happen, that people will present with metastatic disease, meaning spread to some other part of the body. So they might, you know, come in with some symptom they can't explain and then imaging identifies a problem and then we identify that it's metastatic melanoma. But most of the time, people will present or will find a skin lesion that looks worrisome to them and that's how we find out.

Host: So, if you have a family history of melanoma, how often should you get checked?

Sonia T. Orcutt, MD: So, that's a good question. Having a family history often means that you as an individual have been exposed to similar environmental factors like UV exposure or amount of sunscreen use, those sorts of things as your family members. So while there are some genetic conditions that can predispose you to melanoma, most of the time it's actually environmental factors. But if you do have a family history, particularly if you are someone who, again, is fair skinned, has red hair, a lot of freckles, that sort of thing, it is a good idea to get established with a dermatologist early, in your teens, twenties, like early, for skin checks.

A lot of times they'll start with just yearly skin checks, but if they start seeing abnormalities or things that they need to biopsy frequently or things along those lines, they might see you more frequently. Usually, after a person has a history of melanoma or a history of abnormal moles that might lead to melanoma, those patients are often seen every three months or so.

Host: You mentioned the moles or any other lesions that look suspicious. Any other signs a person should watch out for?

Sonia T. Orcutt, MD: So if you do have a history of abnormal moles or what we call dysplastic moles, that can increase your risk of melanoma, but melanomas can also arise even without moles, so they can just appear on a part of your skin that didn't have a mole before. Again, the main things that you're looking for though or something changing. There are a few factors that we teach, that patients or physicians, should be watching out for.

So we call them the ABCDEs of melanoma. So A is for asymmetry. So if you have a dark lesion on you somewhere and one side looks different from the other side, that should raise your suspicion. If the border is irregular, that also should raise your suspicion. If the color is varied, so half of the lesion is a light brown, the other half is a dark brown, again, that's suspicious.

A diameter over six millimeters, that's about the size of an eraser on the back of a pencil. If it's at least that size, although some can be smaller than that size. And then the last one, which sometimes is often the most important, is evolution. So if someone has a mole that is changing or has a spot that is changing, most of the time it's going to be getting bigger or darker, that is a really, strong, suspicious feature of melanoma.

Host: Okay, now you mentioned earlier that there are some instances where melanoma can develop in areas of the body that have little or no exposure to the sun. Should a person be checking their entire body, or how common is this?

Sonia T. Orcutt, MD: These other types of melanomas that appear in other areas, we refer to them as mucosal melanomas, those are very rare. And no, not necessarily. Yeah, those are extremely rare. The cutaneous or the skin melanomas, like I mentioned, those are pretty common, 100,000 per year in the U.S.

Host: Okay, so what precautions can be taken to lower your risk for melanoma?

Sonia T. Orcutt, MD: So sun avoidance for better or worse.

And avoiding tanning beds. Those are the best things you can do. So try to limit going out in the sun at times of day, particularly when the sun is the strongest. So between 10 a. m. and 2 p. m. try to avoid the sun. Wear sunscreen and wear it every day, because even when you're outside just for a few minutes, that's a few minutes of UV exposure you don't want.

So wear sunscreen every day, at least an SPF of 30, ideally. People ask a lot about what's the best kind of sunscreen to wear and really it's whatever you're going to wear that you will wear every day. So if you don't like the mineral stuff that, you know, gives you a white caste and that's going to make you not wear it, then just wear a different one.

There's a lot of chemical and mineral. Those are the two main categories of sunscreen. So mineral ones are the ones that tend to have that white caste. Children, especially babies should only wear the mineral ones. But the other side of them is chemical ones. So those are ones that, can leave a residue, but don't tend to leave that white caste. Those are the ones you tend to get in spray bottles. But the most important thing about sunscreen is that you reapply it every two hours and or every time you get wet. So if you're going swimming and you get out of the water, you got to make sure you reapply it.

A lot of people forget that part, which is the reapplying part. So those are some of the big things. Nowadays, we also have a lot of clothing that has UPF in it. That's like, the SPF of sunscreen, but it's for your clothing. So there's a lot of wide brimmed hats. There's a lot of long sleeves, shorts, pants, short sleeves, all sorts of good clothing that's available now that can also protect you.

Host: Great. So, when should you see a doctor? We talked about if a person has a family history of melanoma, but let's say, you know, you're looking at your moles and lesions, at what point should you contact your doctor?

Sonia T. Orcutt, MD: If you're concerned about any one of them, if you notice any changes, those are the big things that really would prompt visit. But yes, if you have a lot of moles or if you have a strong family history, you should get established regardless, but when you need to contact the doctor with a concern is if you're seeing something changing.

Host: Okay. And what are the treatment options?

Sonia T. Orcutt, MD: About 90 percent or so of patients will present with melanoma that is not spread, so localized melanoma, and this is the bulk of patients, and for all of these patients, surgery is the primary option. When things get more advanced, when they start spreading to lymph nodes and or other parts of the body, then we really need the help of our medical oncologists.

Immunotherapy is the class of drugs that is now available for melanoma, has been available for about a decade or so. And this class of drugs, you know, it revs up your immune system to make your body fight the melanoma. But it really works on revving up your immune system.

And so it's not the same kind of side effects you get with chemotherapy and other kinds of drugs, where you might lose your hair, or get really sick. A lot of people can tolerate immunotherapy really well, but that's what we use when patients have either melanomas that are at high risk for spreading or have already spread.

Host: So, chemo or radiation. They are not options.

Sonia T. Orcutt, MD: Chemotherapy, we don't use. No. Radiation, we will use sometimes, but not frequently.

Host: Anything else you'd like to add, Doctor, just on the topic of melanoma and preventative measures or even just the takeaways that you want us to walk away with?

Sonia T. Orcutt, MD: Yeah, I think the big takeaways, just to reiterate. So one, if you have a lesion, particularly one that is dark and that is changing in any way, make sure you see a doctor to get it biopsied and get it checked out. That's one. And then two, to try to do your best to minimize the risk of developing anything. Stay out of the sun as much as you can, but if you go in the sun, wear sunscreen at least an SPF of 30, wear big hats, wear long sleeves, and just be safe in the sun.

Host: Dr. Sonia Orcutt, thank you so much for educating us on melanoma. Great information. Thank you.

Sonia T. Orcutt, MD: You're welcome. Thank you for having me.

Host: To make an appointment at UAMS, call 501-296-1200. That's 501-296-1200. If you found this podcast helpful, please share it on your social channels and check out the entire podcast library for other topics of interest to you. This is UAMS Health Talk, a podcast from the University of Arkansas for Medical Sciences. Thanks for listening.