What doctors wish patients knew about skin cancer risk and prevention

Skin cancer can take many forms, but the most common are basal cell carcinoma, squamous cell carcinoma and melanoma. The common culprit behind these skin cancers is often too much exposure to ultraviolet rays either from the sun or from artificial sources like tanning beds. But they can occur for other reasons too. That is why it is important to understand your risk and know what steps to take to prevent skin cancer.

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There are three main types of skin cancer:

• Basal cell carcinoma, which is the most common type of skin cancer and often looks like a flesh-colored or pink bump on sun exposed areas.
• Squamous cell carcinoma, which tends to be more aggressive and often looks like a firm, red nodule or a flat lesion with a scaly, crusty surface.
• Melanoma, which is the deadliest, most severe skin cancer and may present as a mole that has changed in size, color, or texture and may bleed. It can also have an abnormal border and sections that appear red, white, blue or bluish black. Dark lesions can also develop on your palms, soles, fingertips or toes, or in the nose, mouth or genitals.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines, especially throughout the COVID-19 pandemic.

In this installment, two AMA members took time to discuss what patients should know about skin cancer prevention. They are:

• Evelyn Jones, MD, a dermatologist and owner of WellSprings Dermatology and WellSprings SkinCare in Paducah, Kentucky.
• Klint Peebles, MD, a dermatologist in Washington and suburban Maryland at Mid-Atlantic Permanente Medical Group, a member of the AMA Health System Program.

“Rates of all skin cancers are rising, and melanoma rates have been rising rapidly in the United States in the last 30 years,” said Dr. Peebles. “Melanoma is the second most common form of cancer in women age 15 to 29 years old.

“And women younger than 30 years old are six times more likely to develop melanoma if they tan indoors versus those who do not,” Dr. Peebles added.

“One of the interesting things to me about skin cancer is that we are not saying a whole lot of different things to decrease the risk and protect the skin,” said Dr. Jones. “Yet compliance and follow through is obviously not being heard, in some ways, because the incidence of skin cancer continues to rise.”

One myth about skin cancer is that it is a disease that afflicts only people with light-colored skin.

“It can happen to anyone, regardless of skin color,” said Dr. Peebles. While white people “have higher rates of melanoma compared to other races or ethnicities, for instance, the annual incidence rate of melanoma is still five per 100,000 in Hispanics, and one per 100,000” among Black people.

“Skin cancer in skin of color is often diagnosed in later stages when it’s more difficult to treat,” Dr. Peebles added, noting that “individuals of color are less likely than their white counterparts to survive melanoma and are also more prone to skin cancer in areas not commonly exposed to the sun, including the palms, soles, groin area, inside the mouth and under the nails.”

“Also, when we’re thinking of some different health disparities, there have been several studies showing that there may be an increased risk of skin cancer in some sexual minority men,” said Dr. Peebles. “We think that has a lot to do with disproportionate indoor tanning behaviors in that population, but there’s still much more to learn on that topic.”

Read about how, in dermatology, health disparities can be skin deep.

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“Just because it's not summer and you're not playing volleyball on a beach doesn't mean that you're not at risk of sun damage, which can result in a heightened risk of not only skin cancer but also cosmetic concerns such as fine lines, wrinkles, and discoloration, among others,” said Dr. Peebles. “Whenever the sun is shining, that risk is there.”

“Also, don’t forget that water, sand and snow reflect the sun really well onto your skin,” Dr. Peebles said. “Even in the peak of winter after a big snowstorm, it’s still possible to get a sunburn and it’s still possible to get those UVA-based aging issues over time.”

“Sunscreen is something that should be applied to all skin not covered by clothing, including the ears, neck, hands, feet and lips,” said Dr. Peebles. “All of those are areas that are commonly forgotten—as well as the scalp, for those who may have thinning hair.”

“Wearing sunscreen every day is important, but one of the big challenges that happens is twofold,” said Dr. Jones. “First, we forget to reapply sunscreen, so we have to remind people that if you’re going to be out for an extended period of time, make sure you reapply sunscreen every couple of hours everywhere the sun can see.”

“Then the second challenge is not using enough, especially when using a spray sunscreen,” she said. “If we’re doing a full body application of sunscreen, you would need a golf-ball size amount of sunscreen.”

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“To decrease risk, it is also important to wear sun-protective clothing,” said Dr. Jones, noting that “these used to be available in very few places, but now most of the activewear companies will have sun-protective clothing.”

“Keep in mind that no sunscreen can block 100% of the sun's rays, which is why protective clothing in addition to all other sun-protective measures are so important,” said Dr. Peebles. “Look for lightweight long-sleeve shirts, pants and sunglasses with ultraviolet protection.”

Additionally, “wearing hats protect your facial skin a little bit more,” said Dr. Jones. But “we have to still wear sunscreen because of reflection off of the water, pavement or ground.”

“How we eat dramatically impacts our health and the foods that we eat either drive unhealthy inflammation or can boost our good immune response,” said Dr. Jones. “If we eat a rainbow color of fruits and vegetables then we are increasing our protection from skin cancer dramatically, as well as other cancers and even other chronic diseases—autoimmune diseases, heart disease, stroke, type 2 diabetes and obesity.” “A lot of people want to hold on to the idea that if they take vitamin C, E and D, and selenium and zinc that it’s going to help, but studies have shown vitamin and mineral supplementation is not the answer,” she said. “Even if we have a genetic tendency and are higher risk for skin cancer, other cancers or chronic disease, we can turn on and off those genes to a degree by the foods that we eat.”

“There’s a myth that we need ultraviolet light for vitamin D,” said Dr. Jones. “The best way to get vitamin D is from natural sources of food or supplementation. .

“Most tanning beds are a UVA light, and it is damaging to the skin—it definitely increases the risk of skin cancer,” she added.

Additionally, women under 30 “are six times more likely to develop melanoma if they tan indoors,” said Dr. Peebles. “Even just one tanning bed exposure is enough to increase someone’s general lifetime risk of many of these skin cancers.”

In fact, “if you’ve ever used a tanning bed, you increase your risk of squamous cell cancer by 83% and basal cell cancer by 29%,” Dr. Jones said.

“It’s important to go to your dermatologist and have an annual exam,” said Dr. Jones. “But I also like to tell people—the first of every month, get in the habit of looking at their skin and becoming familiar with it.”

“The American Academy of Dermatology encourages individuals to perform these self-skin exams on occasion to be in touch with how your skin looks because almost half of melanomas are self-detected,” said Dr. Peebles. “The self-skin exams actually become even more important for those at higher risk of skin cancer such as people with a personal or family history of skin cancer.”

“Sometimes I will recommend, at the very least, making it a habit on your birthday of doing a full self-exam. If it’s your birthday, get yourself in your birthday suit and get familiar with what’s on your skin,” Dr. Peebles said. “Also, keep in mind that skin cancer can happen anywhere where there’s skin—not just sun exposed areas.”

“We can see skin cancer on any area of the body, including the palms, soles, buttocks and genitalia. But we can also see these cancers beyond the skin, including in the eye and inside the mouth, among other sites,” Dr. Peebles said.

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“A is for asymmetry,” said Dr. Jones. “That means, if you draw a line down the middle of the mole, one side’s different than the other.”

“B stands for border, so thinking about how smooth and even the borders are,” said Dr. Peebles. “If you have a nice round circular mole that's often a good sign as opposed to a really jagged and curved mole that could be more concerning.”

“C stands for color. Normally we like to see moles that have a fairly even color to them—basically a smooth, even, consistent shade of brown or maybe a couple different shades,” Dr. Peebles said. “But when we start seeing a variety of different colors in the same lesion—shades of red, black and yellow—that’s definitely something that we’re going to be worried about.”

“D stands for diameter of six millimeters or about the size of a pencil eraser, but there are melanomas smaller than that and there are benign moles much larger than that,” said Dr. Jones. “And then E is evolving or changing. If you’re doing monthly exams, people will begin to start noticing differences in appearance.”

“Especially with squamous cell cancers and melanomas, early detection changes your survival risk,” said Dr. Jones, noting that “those are the two skin cancers that can cause death.

“If detected early, the five-year survival rate for melanoma is 99%,” she added. “But if it progresses beyond the very top layer of the skin, depending on the depth you have a much higher risk of it becoming metastatic and leading to death.”

“Ultimately, the frequency of skin cancer screenings really depends on the specific person who we're talking about and their specific circumstances,” said Dr. Peebles. “It matters what their family history of skin cancer is, what their personal history of skin cancer is, how much sun damage they've had, the general appearance of their moles, how many moles they have, among other factors.

“All of those factors go into determining the recommendations that we make for how often screening should happen and what that screening is going to look like,” Dr. Peebles added. “As of now, it is a very personalized thing that comes down to really discussing that in detail with a board-certified dermatologist.”