Skin Cancer (Non-Melanoma)Last Updated: May 28, 2009 This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/09 Overview
Skin cancer is the most common of all cancers, with doctors finding skin cancer in about one million Americans each year. Reducing exposure to ultraviolet (UV) radiation from sunlight can prevent most skin cancers. If skin cancer is found early, it can usually be cured by relatively simple surgery. Skin cancer is responsible for less than 1% of all cancer deaths. The skin, the body's largest organ, protects against infection and injury and helps regulate body temperature. The skin also stores water and fat and produces vitamin D. Skin is made up of two main layers: the epidermis (outer layer of skin) and the dermis (inner layer of skin). Types of skin cancer Cancer begins when normal cells begin to change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body). There are three main types of skin cancer: Squamous cell carcinoma. Most of the epidermis is made up of flat, scale-like cells called squamous cells. Approximately 10% to 30% of skin cancer resembles these cells and is called squamous cell carcinoma. This type of cancer is mainly caused by sun exposure, but it can appear on skin that has been burned, damaged by chemicals, or exposed to x-rays. Basal cell carcinoma. Cells in the lower epidermis are round cells known as basal cells. About 80% of skin cancer develops from this type of cell that has been exposed to the sun and is called basal cell carcinoma. Basal cell carcinoma most often forms on the head and neck. Melanoma. Where the epidermis meets the dermis, there are scattered cells called melanocytes, which produce the melanin that gives skin color. Melanoma starts in melanocytes, and it is the most aggressive of the three types of skin cancer. This section describes basal cell and squamous cell skin cancers. Learn more about melanoma. Squamous cell carcinoma and basal cell carcinoma are known as non-melanoma skin cancers, to distinguish them from melanoma, which arises from very different cells and is treated differently. Typically, non-melanoma skin cancer can be treated with relatively simple surgery. If the cancer is very small, cryosurgery (freezing) or laser surgery may be used. Basal cell carcinoma grows slowly and rarely metastasizes (spreads) to other parts of the body. Squamous cell carcinoma also rarely spreads, but it is more likely to spread than basal cell carcinoma. Statistics In 2009, more than 1 million cases of non-melanoma skin cancer are expected to be diagnosed in the United States. Basal cell carcinoma and squamous cell carcinoma are highly curable and are not traditionally included in overall cancer statistics. An estimated, 2,940 deaths from non-melanoma skin cancer will occur this year. Basal cell carcinoma. This is the most common type of skin cancer, accounting for about 80% of all skin cancers. Basal cell carcinoma grows slowly and does not usually spread. Nearly half of people with one basal cell carcinoma develop another one within five years. Squamous cell carcinoma. This skin cancer makes up 20% of all skin cancers and may grow faster than a basal cell carcinoma. Cancer statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with non-melanoma skin cancer. Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2009. Find out more about basic cancer terms used in this section. Medical Illustrations
Risk Factors and Prevention
A risk factor is anything that increases a person’s chance of developing cancer. Some risk factors can be controlled, such as sunbathing, and some cannot be controlled, such as age and family history. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor may help you make more informed lifestyle and health-care choices. The following factors may raise a person’s risk of developing skin cancer: Exposure to sunlight/UV radiation. Ultraviolet B (UVB) radiation causes sunburn and plays a role in the development of basal and squamous cell cancers. Ultraviolet A (UVA) penetrates the skin more deeply and contributes to photoaging (premature aging of the skin) or wrinkling. The role of UVA in the development of non-melanoma skin cancer is suspected, but not yet certain. People who live in areas with year-round, bright sunlight (which includes both UVA and UVB) or at high altitudes have a higher risk of developing skin cancer, as do those who spend significant time outside or on a tanning bed (which emits mostly UVA). Fair skin. Less pigment (melanin) in skin offers poorer protection against UV radiation. People with light hair and light-colored eyes who have skin that tans poorly or freckles, or those who burn easily, are more likely to develop skin cancer. Gender. Rates of skin cancer in older white men and younger women have increased in recent years. Age. Most basal cell and squamous cell cancers appear after age 50, but cancers may appear earlier in individuals with sun-damaged skin. A history of sunburns or fragile skin. Skin that has been burned, sunburned, or injured from disease has a higher risk of skin cancer. Squamous cell and basal cell cancers occur more often in people with higher lifetime exposure to the sun or other sources of UV radiation. Individual history. People with weakened immune systems or those who use certain medications (such as immunosuppressive drugs, certain steroids, and drugs that make the skin sensitive to light) have a higher risk of developing skin cancer, particularly squamous cell cancer. People with some rare genetic conditions, such as xeroderma pigmentosum, nevoid basal cell carcinoma syndrome, or albinism have a much higher risk of developing skin cancer. Previous skin cancer. People who have had any form of skin cancer have a higher risk of developing another skin cancer. Thirty-five percent (35%) to 50% of people diagnosed with one basal cell cancer will develop a new skin cancer within five years. Therefore, people who have had one skin cancer need ongoing, follow-up care to watch for additional cancers. Precancerous skin conditions. Lesions called actinic keratoses (rough, red or brown scaly patches on the skin) or Bowen's disease are usually more common in areas exposed to the sun. Such areas can change into squamous cell cancers in some people. Bowen's disease in non-sun-exposed areas may be related to arsenic exposure. Use of sunscreens may decrease the risk of actinic keratoses. Human papillomavirus (HPV). Research indicates that infection with this virus is a risk factor for squamous cell carcinoma, particularly if the person’s immune system becomes suppressed. HPV is most commonly passed from person to person during sexual activity. There are different types, or strains, of HPV, and some strains are more strongly associated with certain types of cancers. Learn more about HPV and cancer. Prevention Reducing exposure to sunlight and other sources of UV radiation lowers the risk of skin cancer. This is important for all age groups, but is especially important for people who have risk factors for skin cancer. Sun damage is cumulative, meaning it builds up over time. Steps to reduce exposure and help prevent skin cancer include:
For more information, learn about protecting your skin from the sun. Symptoms
People with basal cell or squamous cell carcinoma may experience the following symptoms. Sometimes, people with basal cell or squamous cell carcinoma do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. The skin features that people with basal cell or squamous cell carcinoma frequently develop are listed below. If you are concerned about a symptom or skin feature on this list, please talk with your doctor. Changes in the skin are the main warning sign for skin cancer. Each type of skin cancer can appear differently, and an accurate diagnosis by a doctor or other health-care professional is essential. For basal cell cancer, two or more of the following features may be present:
Squamous cell cancer can often crust and bleed and appears as:
Early detection: Finding skin cancer early Regular self-examinations of the skin may help find skin cancer early. Examinations should be performed in front of a full-length mirror in a brightly lit room. It helps to have another person check the scalp and back of the neck. Non-melanoma skin cancer most often begins on skin that has frequently been exposed to the sun. Include the following steps in a skin self-examination:
A doctor should be consulted if you find:
Diagnosis
Doctors use many tests to diagnose cancer and determine if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
Because basal cell and squamous cell cancers rarely spread, a biopsy is often the only test needed to determine the stage (extent) of cancer. A biopsy is the removal of all or part of the growth for examination under a microscope. The tissue sample removed is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). No further treatment beyond the biopsy may be necessary if the entire cancer is removed. If the cancer is present at the edges of the tissue (called the margin) taken during the biopsy, additional surgery will usually be necessary. Learn more about what to expect when having a biopsy. Find out more about common terms used during a diagnosis of cancer. Staging
Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). Basal cell and squamous cell rarely spread. On rare occasions, the patient’s lymph nodes (tiny, bean-shaped organs that help fight infection) may be removed to determine if the cancer has metastasized. The doctor may perform other tests, including blood tests, chest x-rays, and diagnostic scans of the liver, bones, and brain, but this is uncommon.Treatment
The treatment of skin cancer depends on the size and location of the tumor, whether the cancer has spread, and the patient’s overall health. In many cases, a team of doctors, including a dermatologist (a doctor who specializes in diseases and conditions of the skin), surgeon, radiation oncologist (a doctor who specializes in giving radiation therapy to treat cancer), and medical oncologist (a doctor who specializes in treating cancer with medication), will work with the patient to determine the best treatment plan. This section outlines treatments that are the standard of care (best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, visit the Clinical Trials section. Descriptions of the most common treatment options for skin cancer are listed below. Surgery Many skin cancers can be removed from the skin quickly and easily, and often no further treatment is needed. Most of these treatments use a local anesthetic to numb the skin and can be done outside of a hospital, either by a dermatologist, general surgeon, or plastic surgeon. Different types of surgical procedures are used depending on the size of the cancer and where it is located. Curettage and electrodessication. In this common procedure, the cancer is removed with a curette, which is a sharp, spoon-shaped instrument. The area can then be treated with electrodessication, which uses an electric current to control bleeding and kill any remaining cancer cells. Many people have a flat, pale scar after this procedure. Mohs surgery. This technique involves removing the visible tumor, in addition to small fragments of the edge around where the tumor existed. Each small fragment is examined under a microscope until all cancer is removed. This is typically used for larger tumors, those in hard to reach places, and for cancers that have come back in the same place. Freezing. Used most often on precancerous skin conditions, this procedure (called cryosurgery) uses liquid nitrogen to freeze and kill cells. The skin will later blister and shed off. This procedure will sometimes leave a pale scar. More than one freezing may be needed. Laser therapy. A narrow beam of high-intensity light can destroy precancer confined to the outer layer of the skin. Grafting. When a large tumor is removed, surgeons may use a skin graft from another area of the body to both close the wound and reduce scarring. Learn more about cancer surgery. Radiation therapy Radiation therapy is the use of high-energy rays or other particles to kill cancer cells. Radiation therapy may be used for skin cancer that is hard to treat with surgery, such as skin cancer that appears on the eyelid, tip of the nose, and ear; several treatments may be needed. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. The side effects from radiation therapy may include a rash, dry or red skin, or a change in the color of the skin. Most side effects go away soon after treatment is finished. Learn more about radiation therapy. Topical chemotherapy Chemotherapy is the use of drugs to kill cancer cells. For cancers located only on the top layer of the skin or to treat precancerous skin conditions, doctors may prescribe chemotherapy in a cream or lotion. These drugs are usually applied daily for several weeks. They may cause inflammation, which goes away once treatment is finished. In addition to the topical chemotherapy that has been used for many years, some doctors are using imiquimod (Aldara), a topical immune response modifier, to treat early basal cell carcinomas, actinic keratoses (a precancer to squamous cell carcinoma) and very thin squamous cell carcinoma. Imiquimod is applied several times a week. Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases. Advanced skin cancer In rare cases, squamous cell cancer can grow deeper into the skin and can spread to other parts of the body. Sites of a chronic inflammatory skin condition, mucous membranes (skin that lines the mouth, nose, vagina, and anus), and the lips are most susceptible to squamous cell cancer. Surgery alone is not effective to treat skin cancer that has metastasized. To control this distant spread, a person’s health-care team may recommend chemotherapy, radiation therapy, or immunotherapy. Immunotherapy (also called biologic therapy) is designed to boost the body’s natural defenses to fight the cancer. It uses materials either made by the body or in a laboratory to bolster, target, or restore immune system function. Find out more about common terms used during cancer treatment. Clinical Trials Resources
Doctors and scientists are always looking for better ways to treat patients with skin cancer. A clinical trial is a way to test a new treatment to prove that it is safe, effective, and possibly better than a standard treatment. The clinical trial may be evaluating a new drug, a new combination of existing treatments, a new approach to radiation therapy or surgery, or a new method of treatment or prevention. Patients who participate in clinical trials are among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment. Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that finding new drugs and other therapies is the only way to make progress in treating skin cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with skin cancer. Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill”. The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials. To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials. For specific topics being studied for skin cancer, lean more in the Current Research section. Side Effects of Cancer and Cancer Treatment
Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects do occur. Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health-care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatment you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and the person’s overall health. Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health-care team if they do happen. Also, be sure to communicate with the doctor about side effects you experience during and after treatment. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. In addition to physical side effects, there may be psychosocial (emotional and social) effects are well. Learn more about the importance of addressing such needs, including concerns about managing the cost of your cancer care. Learn more about late effects or long-term effects by reading the After Treatment section or talking with your doctor. After Treatment
After treatment for skin cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. Routine screening for new additional skin cancers, including whole body skin examinations by a health-care professional, is necessary as part of follow-up care. This is because many people treated for one skin cancer later develop other skin cancers. Also, people treated for skin cancer are encouraged to talk with their doctors about following a healthy diet that includes foods containing antioxidants such as vitamins E and C, and selenium. Sun protection is essential to help prevent other skin cancers. Many people who are treated for skin cancer lead an active, outdoor lifestyle, but it is very important to take steps to protect themselves from further skin damage. Participating in outdoor activities before 10:00 AM or after 4:00 PM and wearing long sleeves, pants, sunscreen, and a hat will protect against further skin damage. For most skin cancers, the surgery removes only a small part of the skin, so there is little need for rehabilitation. However, in some cases, there may be some need for rehabilitation services if surgery was more extensive. If the person treated for skin cancer is experiencing pain from surgery, he or she should speak with a pain management specialist to find ways to manage pain. Since non-melanoma skin cancer frequently occurs on the face, a plastic surgeon or facial specialist may be consulted in some instances. This specialist should be able to fully discuss the impact of the surgery on a person’s appearance. People who have surgery, particularly multiple surgeries, on their face may have a substantially altered appearance. Rarely, the eyelid may be altered. The eyelid may not close well, and the person may need to use drops to moisten the eye. In those rare cases when extensive facial surgery is necessary, the person will need support and possibly the help of a caregiver during treatment and recovery. Some of these surgeries are multi-stage surgeries and may require prolonged absence from work or other activities. Rarely, when radiation therapy is used, there is the possibility of a second cancer, which may not appear for more than 10 years after treatment. Chemotherapy is used extremely rarely in advanced disease. It is unlikely that the chemotherapy for advanced disease would have common late effects. It is important to note that chemotherapy is not curative for advanced squamous cell carcinoma and is unlikely to cause leukemia. People recovering from skin cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about healthy living after cancer. Find out more about common terms used after cancer treatment is complete. Current Research
Research for skin cancer is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this time. Always discuss all diagnostic and treatment options with your doctor. Photodynamic therapy. Photodynamic therapy is the use of a cream or other medication that may be combined with light or laser therapy to remove identified skin lesions. Topical medications for actinic keratoses. Ongoing clinical trials of topical medications for use on actinic keratoses are being studied to prevent second cancers. Imiquimod for superficial squamous cell cancer and basal cell cancer. Imiquimod is a type of immune response modifier in which the body uses its own immune system as a method of treatment. EGFR Inhibitors for advanced or metastatic squamous cell carcinoma. Many squamous cell carcinomas express epidermal growth factor receptor (EGFR). Several clinical trials are investigating whether drugs that inhibit EGFR are effective against advanced or metastatic disease. Questions to Ask the Doctor
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:
Patient Information Resources
In addition to Cancer.Net, there are other sources of information about this type of cancer available online. Cancer.Net maintains a list of national, not-for-profit organizations that may be helpful in finding additional information, services, and support. As always, be sure to talk with your doctor about questions you may have about information you find about this disease. View organizations that offer information on this specific type of cancer. |
