Q&A: Skin Cancer and Melanoma

Cancer.Net Q&A Forum
Skin Cancer and Melanoma with Charles M. Balch, MD, and Lynn Schuchter, MD

Questions posted June 1 and June 13, 2005
Questions posted June 20, 2005

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Charles M. Balch, MD, is Executive Vice President and CEO of the American Society of Clinical Oncology. As a member of ASCO since 1981, Dr. Balch has served on eight ASCO committees and as a member of the Board of Directors from 1991 to 1994. In addition to his work for ASCO, Dr. Balch is a part-time clinical and academic oncologist at JohnsHopkinsMedicalCenter as a Professor in the Department of Surgery and the OncologyCenter. He is also Adjunct Professor in the Division of Surgery, Department of Surgical Oncology at the University of Texas M.D. Anderson Cancer Center and Chair of the Scientific Advisory Committee of the U.S. Military Cancer Institute.

Lynn Schuchter, MD is an oncologist at the University of Pennsylvania Cancer Center, and an Associate Professor at the School of Medicine. Her clinical research interests include skin and breast cancers, including new, targeted therapies and vaccine trials. Dr. Schuchter is a board member of Living Beyond Breast Cancer, a Philadelphia-based education and support organization for women affected by breast cancer. She is currently a member of the ASCO Cancer Research Committee and is a past chair of the ASCO Cancer Communications Committee. Dr. Schuchter is the recipient of numerous awards and honors and has edited and published more than 60 peer-reviewed textbooks and articles.

Questions posted June 1 and 13, 2005

Question 1: At 31 years old, I had a wide local excision (WLE) to remove a stage I tumor on my arm. What are the odds this tumor will show up as having spread years in the future? Do many people with melanoma that are "cured" from WLE never have another incidence of the disease? I am now convinced all my moles are "bad." I am looking for information on stage I melanoma and patient follow up. Are most patients cured and melanoma free decades later?

Dr. Schuchter: Your melanoma was detected very early, and the vast majority of patients with stage I melanoma are cured of their melanoma with the WLE surgery. So, that is terrific. It is important to follow up with a dermatologist on a regular basis, which is often every six months or once a year, depending upon the types of moles you have, and whether you have a family history of melanoma. This way, a dermatologist can keep an eye on your moles. Sometimes photography can be done to help track your moles. Many patients with stage I melanoma are followed by their surgeons and dermatologist, and never see a medical oncologist. A chest x-ray and blood work is often done every six months or annually. You should perform a regular skin examination every month, and practice safe sun strategies.

Question 2: I am a melanoma survivor. What lifestyle practices help most in boosting the immune system, so the chances of a cancer recurrence are reduced?

Dr. Schuchter: This is good question, but a tough question. It is not entirely clear how to boost the immune system through lifestyle practices. There are some good books written on the subject. Other than healthy diet and regular exercise, I don't have other specific recommendations.

Question 3: I am 66 years old, and I had a growth removed from my nose and neck. My doctor is taking a "wait and see" approach. I have fair skin and have always been a runner; now I run in the evenings, so I can stay out of the sun as much as possible. I also use sunscreen with SPF (sun protection factor) of 35 every day. I am working on weight reduction and getting my blood pressure down. Do you have any other suggestions to minimize my risks?

Dr. Schuchter: You are already making good decisions for your health. Protective clothing, hats, and shirts are also important. Remember to wear a hat that covers your ears as well. Continue with regular dermatology visits as well. Keep running!

Question 4: Are there any vaccines available for melanoma? I have stage IV melanoma, and I have recently heard about Melacine available in Canada. Can you please tell me more?

Dr. Schuchter: There are no FDA-approved melanoma vaccines in the United States, but there many vaccine clinical trials available. You can look at clinical trial section or ask your doctor to look into a clinical trial for you. Many of the clinical trials are national, so you may be able to enroll in a study near your home.

Melacine is available in Canada. You must have a certain tissue type or HLA type, which is a blood test that your doctor can order, in order to be a candidate for the Melacine treatment. This treatment has very few side effects, though it is not clear how effective this treatment is yet for patients with melanoma.

Question 5: What does Rituximab (Rituxan) do for painful skin lesions? What side effects can be expected?

Dr. Schuchter: Rituximab is a monoclonal antibody for patients with lymphoma. It is sometimes used for cutaneous lymphoma as well. It is not used for melanoma. Side effects can be infusion reaction when the treatment is being administered such as fever, chills, and a drop in blood pressure. Overall, it has very few side effects.

Question 6: Is there any connection between the chemical dioxin (agent orange) and any form of skin cancer?

Dr. Schuchter: The chemical dioxin is considered a carcinogen. The data have been somewhat controversial regarding the risk of cancer and exposure to dioxin. There is one report that did indicate an increase of melanoma in Vietnam veterans exposed to dioxin, though other studies in which individuals had higher exposure to dioxin have not reported an increase in melanoma. There is possibly an increased risk of cutaneous T-cell lymphoma related to exposure to dioxin.

Question 7: If you develop basal cell carcinoma more than once, what are your chances of developing a more serious form of skin cancer? Also, if you let basal cell carcinoma go untreated for two years, what are the chances of it spreading elsewhere?

Dr. Schuchter: It is common for a person to develop multiple basal and squamous cell skin cancers, particularly in sun-exposed areas of the body. This is not alarming, but does mean you should continue to undergo regular skin exams by a dermatologist. Basal skin cancer is a very slow growing cancer; and it is not uncommon for it to be present for a long time before treatment begins. It is extremely rare for basal cell skin to metastasize (spread) throughout the body, even if the basal cell skin cancer has been present on the skin for years. It can become a local problem, especially if it is on the nose or near the eyes, so it definitely needs to be treated. Having basal cell skin cancer does increase the risk of developing a more serious form of skin cancer known as melanoma. This is because people who develop basal cell skin cancer generally have fair complexion, blonde hair and blue eyes, and prior sun exposure, all risk factors for melanoma. Again, regular skin examinations by a dermatologist can also detect melanoma early, which is highly curable when detected early.

Question 8: Does nutrition have a role in the prevention of melanoma recurrence?

Dr. Schuchter: There is no definite dataon whether any particular diet can prevent recurrence of melanoma. There are some books (Dr. Andrew Weil), which describe diets that enhance immune function. However, whether this will result in preventing recurrence of melanoma is not known.

Question 9: I have seen information suggesting that local recurrence spindle cell melanoma is less likely to spread to nodes than other types regardless of size. Do you have any information on this?

Dr. Schuchter: Spindle cell melanoma is an uncommon form of melanoma, characterized by the melanoma cells under the microscope appearing spindle like. There are some data that local recurrence is more common with this type of melanoma, so it is important to have very clear margins (normal skin around the melanoma) at the time of removal (wide excision). Some studies have suggested a lower rate of cancer spread to regional lymph nodes, though this is not totally clear. I would recommend monitoring lymph nodes the same way we do for the more common types of melanoma.

Please check back next week for more answered questions. In addition, feel free to post a question.

Questions posted June 20, 2005

Question 1: In Central Oregon, we are seeing a dramatic increase in melanoma before age 40. Since it takes years, presumably many years, for the ultraviolet (UV) rays of the sun to result in clinically detectable malignant lesions, what is the youngest age, in general, at which melanoma should be attributed to this etiology? The teenage years? 20-30? 30-40?

Dr. Schuchter: I don't know the answer to this excellent question. No matter what the age, etiology of melanoma is likely due to a combination of factors, genetic predisposition, precursor lesions (nevi, congenital, dysplastic, etc.) and UV exposure. I agree with the writer; we are seeing a lot more melanoma in younger individuals, including children. The melanoma in children is real melanoma and potentially lethal. I am seeing about five to 10 children with melanoma each year, the youngest was eight years old.

Question 2: Last year I had eight moles removed from my body due to the potential of skin cancer per my dermatologist, who advised me to wear 30 SPF (sun protector factor) sunscreen or higher as a part of my daily lotion. Recently, I heard about an article that stated sunscreen seemed to be the cause for the increase of skin cancer. The article actually stated that short, 30-minute visits in the sun with no sunscreen in the early morning and late evening would be best, since we do require certain amounts of sunlight. The article also said to avoid using sunscreen unless you are going to spend hours out in the direct sunlight. Can you please clarify?

Dr. Schuchter: There is some evidence that vitamin D may prevent melanoma, and our bodies make vitamin D following sun exposure. However, it is clear that UV exposure from the sun increases skin cancer risk, including melanoma. No one should increase sunlight exposure in order to increase vitamin D levels. I refer the questioner to the American Association of Dermatology website. There is a lengthy discussion regarding the "Myths and Realities of Vitamin D and Sun Exposure."

Question 3: Five years ago, my mother (now age 71) and I (now age 46) were both diagnosed with melanoma in situ, which was removed by wide area excision. At the same time, my brother (now age 48) was diagnosed with stage II melanoma, which was also removed by wide area excision, with sentinel node biopsy, which showed no spreading of the melanoma. After five years, my brother has now been diagnosed with metastatic melanoma, which has spread to his brain, lungs, and now lymph nodes. He is having chemotherapy and radiation treatment. Each visit to my dermatologist has just been a visual scan of my body. I noted that one of the responses here referred to chest x-rays and blood work, which my dermatologist has never ordered. When I see my dermatologist in a few months, should I request any additional testing?

Dr. Schuchter: Melanoma in situ has no potential to metastasize (travel to the blood stream), so there is no need to have a chest x-ray. It does sound like your family has familial melanoma, which is associated with a specific gene mutation. While there is no role for genetic testing at this time, regular comprehensive skin examinations are important for you and all blood relatives. Photography of the moles (so-called mole mapping) may also be a good idea for you and your family members as well as regular (monthly) self-skin examinations. For more information, read The Genetics of Melanoma.

Question 4: I recently had a small spot on the bridge of my nose that was scaly. I, of course, picked at it. It bled, and I applied peroxide and Neosporin. It has healed, but if this reappears could it be skin cancer?

Dr. Schuchter: Maybe, but this doesn't sound like melanoma. It could be basal cell or squamous cell skin cancer, or a precursor to skin cancer called actinic keratosis. If the skin really looks normal now, you can hold off on a follow-up examination, but if the skin is not totally normal, you should see your doctor.

Question 5: I have just been diagnosed with basal cell carcinoma. I will be having a full body check next week. I would like to know if it is possible to have two types of cancer at once, such as basal cell and melanoma?

Dr. Schuchter: It is possible, but unlikely. Basal skin cancer is incredibly common, while melanoma is relatively rare. However, the same risk factors for basal skin cancer are also associated with melanoma (fair skin, blue eyes, excessive sun exposure, and burning). It is always a good idea to have a complete skin examination after a diagnosis of skin cancer.

Question 6: For stage III melanoma, can you speak about the trade-offs in opting to participate in an experimental vaccine/trial (to shrink tumors) versus surgical removal of re-occurring tumors in operable areas of the body, such as the lower leg? Is surgery always preferable?

Dr. Schuchter: We always recommend complete surgical resection of stage III melanoma (regional lymph nodes) if feasible. The study may involve vaccine treatment followed by surgery or surgery followed by vaccine, but it is unlikely for the experimental treatment to not include surgery if it is technically feasible.

Please check back next week for more answered questions. In addition, feel free to post a question.

For more information on melanoma, see the WHO 6th World Congress on Melanoma - Public Screening and Forum
with Karen Graham (of the Billy Foundation, Cancer.Net Advisory Panel Member).

Last Updated: June 01, 2005