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Q&A on melanoma - Answers from Dr. Richard Arenas, chief of Surgical Oncology

July 30, 2015

Published in the July issue of Healthcare News of Western Mass.

Questions answered by:

Dr. Richard Arenas

Chief of Surgical Oncology

Baystate Regional Cancer Program

Baystate Health

Q. My twin sister, who is 45, lives in Florida and was just diagnosed with melanoma skin cancer. How does melanoma differ from other skin cancers and why do they call it deadly?

A. Melanoma is considered a deadly form of skin cancer because of its ability to spread to other parts of the body. I don’t know how long your sister has had her melanoma, but if not diagnosed and treated early, melanoma can spread to the lymph nodes or other organs in our body.

Q. Can it be cured?

A. Yes, if diagnosed early, melanoma is very treatable and potentially curable. In fact, most melanomas that are diagnosed in this country are effectively treated and cured because they were detected early enough, before they spread into other areas of the body. Although melanoma can be treated, once it has spread to other parts of the body, treatments become much more complicated, and the results are not always successful in achieving a cure. Therefore, early detection is the mainstay to effectively treating melanoma.

Q. The doctor told my sister that her constant sun worshipping likely resulted in her cancer. I was a sun worshipper, too. Does that mean my chances are greater of developing melanoma at some point in my life and what would my survival rate be?

A. Overexposure to the sun substantially increases your risk of developing skin cancer. Although melanoma is one possible cancer that can develop in skin that has been subjected to the harmful ultraviolet rays of the sun, there are other skin cancers that are more likely to develop, such as basal cell or even squamous cell cancers. It is important to realize that exposure to the sun increases the risk of most types of skin cancer, not just melanoma.

The survival rate of patients who develop melanoma is based on the stage of the cancer at the time of diagnosis, and whether treatment is effective enough in eliminating the disease. The stage of melanoma is determined by the depth of invasion of the tumor within the skin and whether the melanoma has spread to either the lymph nodes or other organs of the body.

Q. Are there other skins cancers to worry about, and does melanoma begin as a less severe skin cancer?

There are different types of cancer that can develop within the skin. Some, like basal cell cancer, are more common than melanoma. There are also precancerous conditions that can develop within the skin such as actinic keratosis, which left untreated can develop into another type of skin cancer called squamous cell carcinoma. Melanoma does not necessarily arise from a precancerous skin lesion, although many melanomas can develop from a mole or birth mark.

Q. Are there other risk factors associated with melanoma?

Exposure to sun and other forms of ultraviolet radiation (such as tanning salons) is a major risk factor for developing melanoma. Age is also an important risk factor, since our skin accumulates changes over time from constant exposure to our environment. Those with fair skin complexions – often found in people with red or blonde hair and those with blue eyes – lack the pigmentation that protects the skin from sunlight, therefore increasing one’s risk for melanoma. Since many melanomas can develop from a mole, individuals with many moles or birth marks may be of greater risk for developing melanoma.

Q. At my age, is it too late, or are there ways to decrease my risk of getting melanoma?

Although the harmful effects of the sun are thought to be cumulative, which means you cannot reverse the changes that your skin may have already developed, it is still important to practice reasonable protection from overexposure to the sun, which includes seeking shade, especially during the hours when the sun is at its greatest intensity, using an effective sunscreen with a Sun Protection Factor (SPF) of at least 30 or greater, and wearing protective clothing.

Q. What are the symptoms of melanoma cancer?

Melanoma usually develops as a pigmented skin lesion, not necessarily within areas of the skin that have been repeatedly exposed to the sun. There are certain criteria or parameters such as remembering ABCDE, which can help you to determine if a skin lesion may be a melanoma.

A – Asymmetry (is the skin lesion irregular in shape?)

B – Border (is the border difficult to define, is it not smooth or rounded?)

C – Color (are there different shades of black or brown pigments in the lesion?)

D – Diameter (is it greater than 6 millimeters in size, larger than an eraser head on a pencil?)

E – Evolution (is it changing?)

Not all melanomas follow the ABDCE rule. Some melanomas, for example, are not pigmented or black in color. What should be emphasized is that if you have a skin lesion that is changing, bring it to the attention of your primary care provider immediately. He or she may decide to biopsy the skin lesion or refer you to a dermatologist for further evaluation.

Q. What is the best screening method for melanoma?

Besides risk reduction, which means minimizing any overexposure to the sun or ultraviolet rays, the best screening for melanoma involves a skin self-examination. It is important from time to time to inspect our entire skin, to become accustomed with the markings such as moles or birthmarks on our skin, and to especially detect concerning lesions that have either developed or changed. A mirror can help to inspect the skin in particularly difficult areas to visualize, or consider having someone whom you are comfortable with help in your skin self-exam. We all need to be advocates of our own health care. So, don’t be afraid to ask your primary care provider to perform a thorough skin exam as part of your routine physical examination.

Q. We have a teenage daughter who has visited a tanning salon several times. Is she at risk? I have visited them, too, once or twice before vacationing in Hawaii during the winter months.

There are two types of ultraviolet rays, UVA (long wave) and UVB (short wave). UVB rays cause our skin to become reddened or sunburned. These rays are at their highest intensity during the late morning and early evening hours (10 a.m. to 4 p.m.) and especially during months (April to October) of the year in the United States when the sun’s greatest exposure is directed above the equator.

We are exposed to UVA rays primarily from the sun, which over our lifetime causes our skin to age and develop wrinkles and age spots. UVA rays deeply penetrate into the skin and cause changes to the cells within the deepest (basal) layers. It is believed that some of these changes, which include damage to the DNA of our cells, are harmful and can contribute to or even cause the development of skin cancers including melanoma.

Tanning salons use lamps that emit both UVA and UVB rays, but with greater intensity than the sun. That is why the Food and Drug Administration (FDA) has publicized findings from the World Health Organization’s International Agency for Research on Cancer which note that both UVA and UVB rays cause changes capable of causing skin cancer. Especially concerning are findings that demonstrate the risk of melanoma may be increased by as much as 75%, especially in individuals who start using tanning salons before the age of 35.

Government agencies, such as the FDA, are especially concerned about the use of tanning salons by children and teenagers, which has led to legislation in some states requiring parental consent. Again, it is important to realize that many of the harmful effects from ultraviolet radiation are cumulative over time and may not necessarily be reversible.

Q. What does the future hold for treatment and increased survival rates?

Surgery, used mainly to excise the melanoma from the skin, is the mainstay for treatment. When melanoma is diagnosed early, surgery alone can effectively achieve excellent chances for a cure. What has been challenging is the fact that when melanoma has begun to spread, either to the lymph nodes or other organs, survival rates have decreased significantly. Recently, there have been great advances in developing new treatment strategies that target the body's own immune system against melanoma. In the past, this therapy – referred to as immunotherapy – was only available at certain cancer centers and carried a great risk of adverse side effects including death. But, with the advent of new drugs, such as Ipilimumab and Nivolumab, which both target certain aspects of the body's immune system to effectively treat melanoma, the promise of cure can be extended to those patients with advanced stages of melanoma.

Most importantly, however, is the greater need for public awareness. The incidence of melanoma is rising close to 1 in 50. It remains the #1 cause of cancer-related deaths in individuals in their 20 and 30 years of age. Melanoma can be prevented if all of us just use sound judgment in protecting ourselves from sun overexposure and avoiding other harmful forms of ultraviolet radiation such as tanning salons.