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The Sun and Us—Skin Cancer and What You Should Know

By Joann Mazzio

I was lying on a gurney wide-eyed and nervous. In an outpatient clinic, the heads of five gurneys were pushed together so the plastic surgeon standing in the middle could perform an operation on each of five faces. Called a multiplex operation, this was an assembly line for dealing with skin cancers. The four men and one woman (me) all had skin cancers on the left sides of their faces. The plastic surgeon, Dr. Daniel Allan of Las Cruces, said this most likely resulted from our driving habits.

Who would have thought you should wear a hat and sunblock while driving or sitting in a car? Apparently, we assume tinted glass in the vehicles keeps the UVA/UBA radiation from the sun. It doesn't. We make a lot of assumptions about the sun and its effects on us. The American Academy of Dermatology (AAD) says: "More than 3.5 million non-skin cancers are diagnosed in more than 2 million people in the United States annually. Estimates today are that one in five Americans will develop skin cancer in their lifetime." Yet, many fair-skinned Caucasians and darker-skinned Hispanics and African-Americans assume they will not be the losers in the skin cancer casino.

Since melanoma is the deadliest of skin cancers, the statistics on its effects are more routinely reported than that of other skin cancers. The rate of new melanoma diagnoses in New Mexico more than doubled between 1975-2007. In 2009, it was estimated that about 52 New Mexicans die every year from melanoma. In the years 2003-2007, the annual rate of new melanoma diagnoses in Grant County was 15.1-29.2. This is far from being the worst in the state. The melanoma rate in Sandoval County (north of Albuquerque) is about 40% higher than the national and statewide average. Los Alamos County has the highest rate of new melanoma diagnoses in the state, higher than 95% of counties nationwide. Most alarming is the rising rate of melanoma in young people. It is the second most common form of cancer for the 15-29-year age group. (All statistical references can be found at www.epa.gov/sunwise/statefacts.html )



Risk factors

•     Fair-skinned people have more risk of developing skin cancer than do darker skinned folks. This could partly explain the high rate of melanoma in Los Alamos County since the population is more than 88% white. In fact, Caucasians have a risk five times higher than Hispanics and 23 times higher than Africa–Americans in developing melanoma. Melanoma (more later) is the Darth Vader—the black star—of skin cancer. It's a killer if not detected in time and it can occur in any of us.
•    Sunburns rank high in cancer risk. The more, the worse. Radiation damage from the sun accumulates from babyhood all the way through life. (http://www.skincancer.org/skin-cancer-information/skin-cancer-facts)
•    Another factor is exposure to ultraviolet light, which humans get too much of when the ozone layer thins, as it is doing now. The high-altitude at which many New Mexicans reside raises the risk factor. White New Mexicans have a death rate from melanoma 24 percent higher than the national average for this group.
•    Having more than 50 moles, atypical moles, freckles, history of sunburn, or family members with melanoma—all are factors that add to your risk.
•    Tanning beds or tanning of any sort raises the risk factors so high that they should be ranked as hazardous.

Screening

Screening should include communication with your relatives. Ask about their experiences with skin cancer, moles, raised scaly bumps, or burn scars from treatment. If there is skin cancer in the family, this raises your risk factors. Then, visit a dermatologist. This is easy to say, harder to do. Our area of the Southwest is seriously underserved by skin specialists. But, a visit is important to know where you, your spouse, and your children stand in this race against cancer. A responsible dermatologist will point out the moles and other strange spots, and explain what you need to look for in your at-home screenings. This you should do monthly with the help of a partner. What you look for is a change in size, borders, and color of these bumps. This is a real "show me yours and I'll show you mine" situation. That means behind ears, on butts, under fingernails, in various crevices. A website hosted by Glamour Magazine shows a wide array of photographs of the various kinds and phases of skin cancer. Go to: http://glamour.com/magazine/2009/04/the-two-minute-cancer-test . Comparing your moles with the photos will help you identify the healthy ones, and the ones where cancer is taking over. Casey Gallagher, MD, a dermatologist in Boulder, Colorado, says, "The earlier you can catch skin cancer, the easier it is to cure."

Types of skin cancer

Skin cancers are named for the type of cells that become malignant. The three most common types are basal cell and squamous cell cancers and melanoma. The epidermis or top layer of skin is mostly composed of flat cells called squamous cells. Below these are round cells called basal cells.  The cells that make the pigment found in skin are called melanocytes and they are scattered among the basal cells.

Basal cell skin cancer usually occurs in places that have been exposed to the sun. Unless one wears a burka or ski mask, the face is almost always bare, so it's no surprise that many skin cancers form there. It is the curse of the fair-skinned.

Squamous cell skin cancer also occurs in fair-skinned people in places exposed to the sun. It is the most common type of skin cancer found in the dark-skinned. In them, it occurs in places not in the sun, such as legs or feet.

Melanoma, the most dangerous of skin cancers, begins in the pigment cells and can occur on any skin surface. My daughter, who certainly knew better, got a deep tan on her neck from wearing a baseball cap when she was exposed to the sun. She developed melanoma on her neck. In women, it's most common on the lower legs or between the shoulders and hips. In men, it may be found on the head, the neck or between the shoulders and hips. Melanoma is not common on dark skin. When it does develop, it is found in unlikely places such as the soles of feet, under the fingernails or toenails, or on the palms of the hands. (Most of this information came from the National Cancer Institute at http://www.cancer.gov/cancertopics  .

Skin cancers of all types are liable to invade normal tissue bordering the malignant areas. This may be the lips or eyes. It can spread throughout the body if not treated. Melanoma is more likely to move to other parts of the body.

Treatment of pre-cancerous conditions

Now for some good news. It is possible to prevent some cases of squamous skin cancer. These cancers do not appear out of the blue sky—well, yes, they do. As precursor to skin cancer, there is a stage of sun-damaged skin known as actinic (or solar) keratosis. Scaly or crusty, nasty-looking growths appear on sun-exposed skin such as the backs of hands, faces, and bald scalps. It may also appear on the shoulders and necks of older generations of people who thought long sleeves and farmer-style hats would protect them as they gardened or played golf. I have many scars on my neck and torso where actinic keratoses developed and were cut out.

Fortunately, there are options other than burning or cutting today. In the treatment known as cryosurgery, which is widely used, liquid nitrogen applied as a spray or touch applicator, freezes the red, tan, and/or flesh-colored spots. This burn is like any other burn in which blisters appear. This usually stops the development of squamous cell cancers. So do the other options listed below.

These are prescription drugs to be applied to the skin lesions at home by the patient. Some dermatologists are reluctant to prescribe them, apparently afraid, as dentists were once afraid of fluoride treatment, that it will ruin the profit side of their business. Considering the large number of people with precancerous and cancerous skin conditions, there seems little likelihood of this happening.

•    5-fluoruoracil (5-FU) ointment or liquid, FDA-approved, has cure rates up to 93%.
•    Imiquimod 5% cream, FDA-approved, stimulates the body's immune system to produce interferon. This chemical destroys cancerous and precancerous cells. Healthy cells are not affected. Redness and crusty ulcerations may develop in some people.
•    For persons overly sensitive to the other medications, diclofenac is a non-steroidal anti-inflammatory drug used in combination with hyaluronic acid, a chemical found in the body. It must be applied to the skin for two to three months. While this seems a long time for treatment, the lack of inflammation keeps the patient from having to answer the question, "What have you done to your face?"
•    Ingenol mebutate is a topical gel recently approved by the FDA that effectively treats actinic keratosis in just two or three days. However, the patient may have to answer a question like the above.
•    Some of the above treatment options can be combined to be more effective.
Other options are:
•    Chemical peeling, which is known from cosmetic treatments.
•    Laser surgery is widely advertised.
•    Photodynamic therapy is used for lesions on the skin or scalp. A photosensitizing agent is applied to the lesions, then the area is exposed to strong light that activates the agent.

Further details can be found at http://www.skincancer.org/skin-cancer-information/actinic-keratosis .

 Prevention

Authorities at the Centers for Disease Control and Prevention recommend the following for the prevention and/or reduction of the risks of getting sin cancer:

•    As all of Grant County knows, we have an abundance of sunlight all year long. However, even on cloudy and overcast days, we are not only receiving radiation from the sun, but sunny or cloudy, we also get reflections from water, snow, sand, and pavements. To cut back on our exposure, remember the hours from 10 a.m. to 4 p.m. are most dangerous. If possible, stay in the shade during these midday hours.
•    Wear clothing to protect exposed skin. I'm a non-paid promoter of sun-proof clothing, and bought one of the first shirts on the market. It felt like a burlap sack and cost a lot, but pro-rated over the years, it was not so expensive. Now, the clothing looks and feels a bit better. The cost is still high, but beats going to a dermatologist or plastic surgeon. I like protective clothing in place of high SPF sunscreen, because the sunscreens are waterproof, both from the outside and the inside. I perspire a lot in the sun, on hikes, or working outdoors, and the sun-proof clothing allows my body to perspire and to breathe. If you don't care for the sun-proofed clothing, do wear long sleeved shirts and pants with long legs all made from tightly woven fabric. A T-shirt is not enough.
•     Wear a hat with a wide brim to shade face, ears, and neck. Again, a tightly woven hat is better than a straw hat with holes, which allow the sunlight through. If you must wear a baseball cap, say, while you are driving, wear clothing that covers your ears, face, neck, etc., or slather on sunscreen with an SPF of 15 or higher. I strongly recommend higher.
•    Wear sunglasses to protect your eyes against both UVA and UVB rays. They also protect the tender skin around the eyes. Glasses reduce the risk of cataracts and keep you from squinting, thus also reducing the development of crow's-feet.
•    Avoid efforts to tan, whether outdoors or indoors. Tanning beds are especially dangerous, yet the FDA until recently has not made efforts to label and regulate them to keep teenagers and children as young as ten years from using them. According to the American Academy of Dermatology, exposure to tanning beds increases the risks of melanoma, especially in women 45 years or younger. The Centers for Disease Control and Prevention reports that indoor tanning has been linked with skin cancers including melanoma, squamous cell carcinoma, and cancers of the eye, called ocular melanoma.

Good news

There is more good news about detection, prevention, and treatment of skin cancer than this red-haired, blue-eyed, fair-skinned writer has known in several decades.

•    More research and education have alerted victims in how to recognize and report changes on the skin that can lead to early detection of cancer.
•    My daughter discovered her melanoma herself and went immediately to her dermatologist. He told her more and more people are scanning and discovering melanoma in time for successful treatment. Her removal surgery was successful and she is free of melanoma today.
•    Prevention of sunburn is much easier with clothes designed to protect the skin.
•    In 2010, research proved that daily sunscreen use halves the occurrence of melanoma.
•    New FDA rules prompted the development of inexpensive creamy sunscreens that replace the pricier sunscreens of the past, which looked, felt, and flaked off like house paint. Also, higher SPF numbers allow more time in the sun before re-applying.
•    Pressure is building on the FDA to change the rating of tanning beds from Class 1 medical devices (includes elastic bandages and tongue depressors) to the same class as plutonium and cigarettes, and to restrict the use of indoor tanning to those 18 years and older.
•    Everyone and her/his grandmother have known for some time that the sun ages skin. The really good news is that sunscreen not only blocks the skin from burning, it helps prevent the aging caused by the sun. In Australia, 900 men and women participated in a study in which people who used sunscreen (SPF 15) daily over a period of 4.5 years were less likely to have wrinkles and dark spots. Most of us have become skeptical by before and after photos showing impossible changes. In this scientific study, silicon masks were made of the 900 faces with every wrinkle and damaged spot measured before and after. Half the participants received bottles of sunscreen from the researchers. The contents of the bottles were measured regularly (yes, some of the folks cheated) to determine daily use. Sunscreen users had skin that was visibly less aged. The measurements showed 24 percent fewer signs of aging. Middle-aged people showed the same benefits as those who began the study with fewer signs of aging. What a bonus—gaining younger-looking skin while protecting your skin from further skin problems in the future. (Annals of Internal Medicine, American
College of Physicians, 2013)
•    Actinic keratosis and some cancers can be stopped in their tracks.
•    Prescription drugs applied at home can prevent some of the pain and disfiguring caused by cutting and burning of pre cancerous growths and cancers in a doctor's office.
•    Survival from melanoma increased from 49 percent (1950) to 92 percent (1996-2003)
•    For those who have suffered scars and reddening from burning, cutting, and some prescription medications, there are now effective ways to remove or substantially reduce the disfiguration, especially from the face. Vitamin E in capsule form is very effective, but excessively oily. (Opened bottles of Vitamin E oxidize and lose their effectiveness.) Aloe vera in liquid form is equally effective, but, in my experience, takes longer to treat scars. Mederma is a brand-name cream that combines both aloe vera and Vitamin E and works well even on sites other than the face. It also reduces old scar tissue. Any of these products must be rubbed firmly onto the affected areas after the prior treatment has healed.

Lying on a gurney in Las Cruces three years ago getting a large mass of skin cancer removed from my face was my last experience with the scalpel. Since then, I've kept outbreaks of actinic keratosis under control with one of the prescription medications described above.
 
Remember that the sun is like some people. You can't live without it, and it's sometimes hard to live with it.


—Joann Mazzio lives at 7000 feet altitude, where the atmosphere is thin, and writes books, articles and stories for both print and online media. Her book, LEAVING ELDORADO, a historical novel, is used as a resource in the materials suggested by the Common Core State Standards, an educational reform effort now sweeping the country.

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