Transcription:
Skin Cancer and Melanoma

Host: Welcome to Weill Cornell Medicine Cancer Cast, conversations about new developments in medicine, cancer care and research. I'm your host, Dr. John Leonard. And today, we will be talking about skin cancer and in particular melanoma.

Today's guest is Dr. Anna Pavlick. She's a medical oncologist at Weill Cornell Medicine and New York Presbyterian Hospital with over 20 years of expertise, treating patients with skin cancer, including melanoma, basal cell carcinoma, squamous cell cancer and Merkel cell carcinoma. And we'll talk in a minute about what some of those are. Dr. Pavlick is the director of the Weill Cornell Cutaneous Oncology program where she also cares for patients with ocular melanoma, eyelid tumors, and other rare solid tumor malignancies. So this is large panel of types of patients and diagnoses Dr. Pavlick deals with, but we're going to focus on skin cancer primarily here today. So, Anna, thank you for joining us. It's great to have you.

Guest: Thank you, John. My pleasure to be here.

Host: So why don't we get into the details of skin cancer? One stat that I read was that skin cancer is the most common form of cancer. But clearly, there are many types of skin cancer, some of which are I don't want to say mild, but are relatively manageable and local and others are much higher risk and, in some cases, life-threatening. So maybe you could give us a quick overview of the key types of skin cancer that people might be dealing with.

Guest: So basically, there really are three major types of skin cancers with basal cell carcinoma being the most common where roughly one in two people are going to be diagnosed with a basal cell cancer sometime in their life. Most basal cell cancers grow exceedingly slowly. And so they are really managed by a dermatologist who will just take it off and you'll be done with it. However, there are some basal cell carcinomas that are neglected and they can become very aggressive. And those are the times that basal cell cancer patients get to see an oncologist.

Squamous cell carcinomas are the second most common type of skin cancers. these are all caused by sun damage or UV exposure and squamous cells like basal cells happen in the course of a person's lifetime. As you get older, you can get more squamous cells. If patients are immunocompromised, because they have had a transplant or on immunosuppressive drugs, for some reason, they are more prone to developing squamous cell carcinomas. And in general, they are also managed by the dermatologist because they're found early and they're removed. If however, squamous cell carcinoma is left untreated, or they can evolve into some aggressive types of squamous cell carcinoma, that would then be a reason for patients to see an oncologist because they need systemic therapy.

And then finally, there's melanoma. Roughly one in five people in the United States by the age of 70 is going to get diagnosed with melanoma. This is why it's so important for people to get skin checks, know what to look for when it comes to melanoma, because melanoma is the deadliest type of skin cancer that's out there. Melanoma likes to grow deep into the layers of the skin. It can get into what we call our lymphatics or our lymph channels that lead to lymph nodes, or it can get into blood vessels. And once cancer cells get into either lymphatics or blood vessels, they essentially can spread to other parts of the body. And that's why melanoma is the most deadly of all of the skin cancers, and really the most important for us to really screen for.

Host: So you mentioned sun exposure and I think almost everybody knows that sun exposure is a risk factor for certain, if not all, forms of skin cancer. And I should note that we're recording this in May, which is skin cancer awareness month, so that's all the more reason to talk about screening and risk factors. What other risk factors are there that are out there? And I think the obvious thing that everyone would say is, "Well, I should stay out of the sun, but I like to go to the beach or I like to do this or that." And I'll ask you as a follow up question, what do you tell people in that regard to protect themselves even if they have the need or the desire, which I think many of us do to at least spend some time in the sun?

Guest: I guess we can talk about risk factors and the people most at risk for developing melanoma and the other skin cancers are people who are fair-skinned, blonde hair, blue eyes, freckles. Redheads predominantly are at the highest risk, even more so than blondes. People who have a family history of melanoma. There is a rare genetic type of hereditary melanoma that is associated with family history of pancreas cancer. So we also make sure that we do a very good family history when we talk to patients. People who are immunocompromised are more risk of squamous cell carcinoma. We talked a little bit about that before. And it's important to know that patients who have had one type of skin cancer are at an increased risk of developing a second type of skin cancer or another one of the same. So they really need to be followed closely.

But really within the last 10 years, something that has really taken the forefront in skin cancer is the use of tanning beds. So many young people while their cells are still actively dividing are going into these tanning beds and exposing these young, healthy cells to intensive UV radiation that then have to pay the price later down the line with these really awful melanomas. We know that even one exposure in a tanning bed is going to increase your chance of developing melanoma by 20-fold. So that's a really scary number. We really do encourage young people not to use tanning beds or tanning booths. You know, they're just as bad if not worse than cigarettes, in my opinion. And so these are the things that really increase people's risk.

Host: And what guidance do you give people about-- you know, obviously people hear of sunscreen. Are there any tips that you pass along as far as things to look for? I think that's a very good practical thing for our audience. What about some of the clothes that have UV protection? Any kind of guidelines?

Guest: try Yeah I try to counsel my patients on the fact that you can't hide every day and not go outside. I mean, life is meant to be lived. We just have to live it safely. And so I routinely tell them that they need to apply sunscreen every day, whether it's cloudy, overcast, or snowing 365 days a year. The most convenient way to do that is to have the bottle of sunscreen in the bathroom. So when you get out of the shower and you're all dried, rather than putting on some type of body lotion, apply your sunscreen top to bottom.

And when we talk about applying sunscreen, it's also important to know that a squirt in your hand should never be all that you need to cover your body. The rule of thumb is that it should take a shot glass full of sunscreen to be able to coat your body adequately. And if it's going to be a warm day where you're going to sweat or you're going to exercise, you've got to remember to reapply that sunscreen again after either being in the pool or being outside and sweating or exercising.

Sun protective clothing is another great way to protect yourself from the sun. It is not a reason to not use sunscreen. So sunscreen should be your base, no matter what. You should then think about using sun protective clothing, a wide-brimmed hat. It's really important for men because most men will put on a golf hat or put on a baseball hat and men have a high tendency to get skin cancers on the apex of their ears. Why? Because they forget to put sunscreen on their ears and those ears are not covered by a baseball cap. So again, you have to think about the type of hat that you're going to wear. There are hats that also have sun protective fabric, so those are obviously the best.

We also tell people that it's important to wear UVA/UVB protection sunscreen, because we know that UVA and UVB rays can cause skin damage. What SPF? Again, we tell people somewhere around 50 or higher. You don't want to use any type of tanning oil. That's only going to generate skin damage. And also, UVA and UVB protective eyewear. A lot of people don't think about that, but we're not really sure why people can develop ocular melanoma. And we sure don't want to take the chance, so we tell everybody over the summer good UVA/UVB protective eyewear as well.

And if you can possibly stay out of the direct sun between 10:00 and 4:00, that's ideal. You know, if you really feel like you want to be outside and you don't want to wear a hat or you don't want to wear sun protective clothing in the summer, wait until the sun goes down, it's still light out, then you can safely go outside or go outside before 10:00 AM in the morning. But again, you should still always have sunscreen on.

Host: That's great advice. And I think very practical particularly, if I have it right, the UVA/UVB sunscreen with 50 plus SPF seems to be the key recommendation. Correct?

Guest: Correct. And even look at the ingredients because if your sunscreen has titanium dioxide, I mean, you remember way back,, probably even before we were born, the lifeguards used to put the zinc oxide on their nose. And it was that thick, white, cakey, sticky goo, but it blocked 100% of the UVA/UVB rays. Titanium dioxide is a cousin of this and it's clear and it really does give you some amazing protection.

Host: So I want to move to screening and early detection. And like with many cancers, everything around skin cancer seems to also focus on early detection and screening. It's the basic guideline that pretty much everybody should get screened by a dermatologist or someone with experience in this area once a year. Is there any kind of exception to that? Anybody that needs more or less than that generally speaking?

Guest: There are no firm guidelines for skin cancer prevention screening. We know that if you have had a skin cancer and particularly melanoma, we do recommend that you see a dermatologist three to four times a year. If you have fair skin, Blonde hair, blue eyes, fit that high-risk category, many of us do recommend people see a dermatologist at least once or twice a year. Depending upon the number of moles someone has and if they have dysplastic or funny-looking moles, then those are people who are also going to be recommended to see the dermatologist more than once a year.

Host: And in between visits or otherwise, what are some of the things that people should take special note of? And we're not expecting a lay person or a nonspecialist to have all the expertise, but what are some of the key things that you would say, "Gee, if you have something this nature, you really should call somebody sooner rather than wait?"

Guest: It's very important for people to learn how to do self-skin exams and also to get to know the moles that they have on their body. Most people will be the ones to recognize that something is wrong or something is abnormal and then present themselves either to their doctor or primary care doctor or go to the dermatologist.

But the rule of thumb is that there are ABCDEs of melanoma detection. So the A is that you have a mole that's asymmetric, so it's not even all the way around. B is borders. Your borders on your moles should be perfectly sharp and crisp. They should not be cauliflower-like or ruffled. So that would be something that you should go and report to your dermatologist. C is color. Moles should be uniformly one color, not multiple colors like pink, brown, black, white. Very abnormal-looking because of these multiple colors needs to be evaluated. D is diameter. We tell patients that if your mole is larger than the size of an eraser on the end of a pencil, which is actually six millimeters, you need to go have that looked at. And then, E is evolution. So if you are born with a mole that you've had forever and ever and you start to notice that it gets bigger, it gets itchy or it starts to bleed where it evolves and it changes, that is absolutely a sign that you need to have that mole assessed to make sure it is not melanoma.

Host: And what are some of the kind of special areas that people should keep in mind that they may not notice something but where melanomas could evolve or could appear in kind of a hidden area?

Guest: The most common places are ears and head and neck on men. On women, it can be the back of their legs again because in the summer women are not wearing pantyhose or pants, so these are sun-exposed areas. But we also need to think about the atypical or the strange melanomas that can occur. So we're talking about the ocular melanomas. If you notice any visual changes it's important to go see your eye doctor. It doesn't mean that visual impairment or seeing floaters in front of your eyes means that you have melanoma, but don't wait. Have it evaluated.

There are very rare melanomas that can occur in the mouth and the sinuses. And so those are usually assessed by people's dentists. And, you know, you also have vulvar and vaginal melanomas, anorectal melanoma. Anorectal melanoma can sometimes be confused with large hemorrhoids. And anytime you find something that just doesn't belong or doesn't feel right or you've not noticed before, just get it checked out because it's always better to be safe than sorry. It's easier to cure cancer when it's early than when it's late.

Host: And what about people of diverse ethnic backgrounds? Do you see melanomas in African-Americans and Asians? Do they have any particular other characteristics that are important to note?

Guest: You know, that is such an important question because I think melanoma is commonly thought as the cancer that you can only get if you're a Caucasian or have fair skin, and that is not a true statement. All people can develop melanoma, it's just where you develop melanoma. We know that African-American patients commonly can develop melanoma on the palms and soles of their feet. Why? Because that's the area of their body that they don't have as much pigment compared to all the other parts of their body. We see that there are a large number of Asian patients as well who may develop a melanoma also on the bottom of their feet or underneath their fingers or toenails. So there are places that we look specifically based on a person's ethnicity to make sure that we're really checking that that doesn't occur and go unnoticed.

Host: So I want to get into treatment of skin cancers and first talk briefly about surgery and then we'll talk about in particular some of the newer systemic treatments for people who have more advanced or widespread disease. But in general, could you just kind of mention the key points of some of the surgical advances that many patients can avail themselves of? And in many cases if not most, trying to maintain a cosmetic good result is obviously important as long as it deals with the cancer and the risk from the cancer.

Guest: Yeah. Again, if you've got melanoma that occurs on your head and neck, many surgeons who perform head and neck surgery are really experts and are plastic surgeons or work with plastic surgeons to make sure that the cosmetic result is very good while the cancer is being adequately addressed.

When we do a surgical resection on a melanoma, it's a little bit different than a squamous cell or basal cell. On squamous cell and basal cell, we want to make sure that we take out the cancer as well as some additional good tissue surrounding it so that we don't leave any microscopic cancer behind. But when it comes to melanoma, we have some rules that we follow. So depending upon the depth and how big that melanoma is will depend upon what our surgical margins are.

Routinely, we take anywhere from one to two centimeters depending upon the size and depth of the melanoma. If a melanoma is greater than one millimeter in depth, we would then offer the patient what's called a sentinel lymph node biopsy. Sentinel lymph node biopsy is essentially mapping out and finding the area of drainage that the first potential cancer cell or first potential melanoma cell, which is the lymph node that that cancer cell can go to first. That's why it's called sentinel because it's the first lymph node. And then we take that out while the patient is undergoing their surgical excision of their primary melanoma. And we look at that lymph node and slice it into multiple sections looking to see if there are any cancer cells in that lymph node.

If there are a few microscopic cancer cells, we have now done studies to say that you don't need to go and complete what's called a lymph node dissection or take out more lymph nodes. However, if you have a large focus of cancer in the sentinel lymph node, we would then go and tell patients, "Yes, you do need to have surgery." So that's really predominantly how we surgically manage our patients.

Host: So in our last couple of minutes, I really want to ask your take and hear your opinion on some of the highlights of the new systemic therapies. I know that's been a big area where you've made major contributions and it seems to me like harnessing the immune system is a big theme in cancer. And it seems like in melanoma, that's had a great impact particularly in recent years. So maybe just give us a sense of how systemic treatment has changed. Now, you have a lot more to work with. It's a lot more rewarding and, obviously, most important, benefits patients in a number of different ways.

Guest: Yeah. We've really moved the field forward very significantly in the last really 10 years. You know, the survival rate of metastatic melanoma in the year 2000 was less than 5%. Whereas now, survival with metastatic melanoma is at almost 60%. And that is just so amazing for me to be able to sit here and say that. And it comes through clinical trials and this is why research is so very important. We have been able to identify what we call checkpoint inhibitors or medicines that will look at immune cells and turn them on so that the body will then go and attack the cancer especially melanoma.

We have other types of therapies called targeted therapies because we identified a genetic mutation called the BRAF mutation, which is an abnormality or genetic abnormality that's found within the melanoma cell. It's not a genetic abnormality that you can transmit to your family members or your children, but it's a target that some melanoma cells have where we've been able to develop medicines that target that mutation and subsequently shut down the melanoma from growing any further and cause the tumors to regress.

So we've taken all of this exciting information that we've done with patients who have distant disease or metastatic disease and have now moved those therapies up into the preventative setting, so we are now looking at giving patients who have positive lymph nodes that have been fully removed and essentially have been rendered surgically free of disease either BRAF medicines if they have a BRAF gene or immunotherapy as prevention, which really has reduced the risk of patients recurrences by about 50%. So we've really made an impact not only in the metastatic setting but in the preventative setting as well in what we call the adjuvant setting and have really reduced patient's risk of recurrence and ultimately improve their long-term survival.

So people will say, "Well, what else do you have to do since you've made so many advances?" And my rebuttal is always that, "Yes, we've been able to help over 50% of our patients, probably closer to 60% of our patients. But 60% does not equal 100." And so there's still a large fraction of our patients who will either get targeted therapies or get immunotherapies and still have progression of their disease.

And so research is now focusing on how do we overcome either BRAF resistance because patients responded initially two targeted therapies and now their cancer is growing and we need to get it under control or how do we get people to respond to immunotherapy if either they didn't at all or they did for a short while and now have recurred. So there's so much research going on in the melanoma field.

There's also lots of interest and clinical research that's going on in the squamous cell as well as the basal cell field. So there's still so much work to be done, so much research, that we can push that needle even further and take it from 50% to 60% to hopefully, by the time I'm ready to retire, to maybe 80% to 90%, and that's my goal.

Host: Well, on that note, this has really been a great discussion. And I think we've covered I think the waterfront of oncology from prevention to detection to surgical treatment and even exciting systemic treatment. And I know a lot of what you've highlighted is also available to patients through clinical trials, the new drugs that are out there, the new settings to try these checkpoint inhibitors that you mentioned.

And so it's been great to have you here and to give us an overview on this really important topic and again reminding everybody, given that summer is almost here and we're going to be outdoors more for lots of reasons, to do what you can to be careful and still enjoy the sun safely. So, thank you, Anna.

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That's it for Cancer Cast, conversations about new developments in medicine, cancer care and research. I'm Dr. John Leonard. Thanks for tuning in.