Skin cancer refers to a low-grade malignant outgrowth on the skin. It begins as normal cells on the skin and transforms to have a cancerous potential. In contrast to other cancers, most of the skin cancers are not highly metastatic and, therefore, not life threatening if treated at early stages. The incidences of skin cancers appear to be on the rise as it results in about eighty thousand deaths per year as of 2014 (Hallberg & Johansson, 2013). In the United States alone, over three million cases are diagnosed yearly, making it the most common type of cancer in the country (Simmons, 2012). It is divided into melanoma skin cancer and non-melanoma skin cancer (NMSC) that consists of squamous cell skin cancer (SCC) and basal cell skin cancer (BCC). Of the three categories melanoma is the most aggressive in spreading to other sites while BCC is unlikely to affect other tissues. According to Coelho & Hearing (2009), more than ninety percent of these cases are as a result of exposure to UV radiation from the sun. It is more likely to affect light-skinned people or those with low immunity due to drugs or diseases such as HIV/AIDS. The increased number of individuals acquiring this disease has been attributed to the thinning of the ozone layer due to environmental pollution.
Signs and Symptoms
The skin cancers have few if any systemic symptoms. However, some patients may experience constitutional symptoms such as weight loss, fever, and night sweats (Coelho & Hearing, 2009). In some instances, Basal Cell Skin Cancer is painful. Each of the three categories appears differently on the skin. However, all forms start as a bleeding, oozing, and crusting sore that is persistent. Usually, they are bumps that are raised on the edges with an ulceration at the center.
The Basal-Cell Skin Cancer manifests as a smooth raised bump described as pearly on the areas of the skin exposed to the sun such as the neck, shoulders, and head. Within these outgrowths, small blood vessels also known as telangiectasia may be seen (Marks, 2005). In most cases, according to Coelho & Hearing (2009), bleeding and crusting occurs at the center of the bump and may be confused with a persistent sore. These tumors may appear as dark, red, or shiny pink patches that are translucent and slightly scaly. The condition may also start as a hard and waxy growth on the skin that is not painful. The symptoms usually appear following long-term exposure to the sun rays.
The Squamous-Cell Skin Cancer usually presents as a red, thickened, scaling patch in the areas of the skin exposed to sunlight such as the scalp, face, and hands (Simmons, 2012). However, it can manifest on any part of the body including the genitals and the palate. It may appear as a new sore or on an old scar culminating into a nodule. It may also appear as growth resembling a wart. If not treated early, it may form a large mass in which bleeding or ulceration may occur.
Melanoma is the most aggressive of the three and affects the melanocytes responsible for making melanin. It can also rarely occur in the eyes or internal organs such as the intestines. In most cases, it starts as new pigmented moles on the skin. Normal moles have a uniform color such as black or brown, which is distinctive from the rest of the skin. They are usually round and about six millimeters in diameter. (Hallberg & Johansson, 2013) However, in some cases, unusual moles may occur. These unusual ones may have an asymmetrical shape, larger than 6mm, uneven color distribution, irregular borders, and keep on changing with time. (Marks, 2005) Hidden melanomas may also occur in unexposed skin areas such as under the nails, urinary and vaginal tract, or in the eyes (Simmons, 2012). Therefore, any abnormal outgrowth on the skin warrants a doctors visit to evaluate the cause.
In other instances, actinic keratosis, crusty and scaly lesions often found on the face or hands may appear due to excessive exposure to ultraviolent radiation. According to Simmons (2012), they are usually precancerous, and if not treated early, they may develop to SCC or rarely BCC. Also, moles only develop into melanomas if they are not treated early enough.
Causes of the Disease
The primary environmental cause of skin cancers is the exposure to the ultraviolet radiation from the sun. Additionally, tobacco smoking, infections with Human Papilloma Virus, and chronic wounds have also been associated with Squamous-Cell Skin Cancer. Some genetic disorders such as Congenital Melanocytic Nevi Syndrome have also been linked to the development of melanoma. Other causes include environmental carcinogens, artificial ultraviolet radiation from tanning beds, aging, and immunosuppressive drugs such as cyclosporine and azathioprine. (Simmons, 2012)
Course and Outcome of the Disease
The cancers are made of epithelial tumors whose origin is the epidermis, or squamous mucosa. In the course of the disease, the tumor may become elevated, ulcerative and start bleeding. It destroys the basement membrane and initiates an invasion to the adjacent connective tissues of the epidermis (Marks, 2005). Tumor cells are transformed into keratinized squamous cells that form concentric nodules. There is a reduction in the surrounding stroma and presence of inflammatory cells, mainly lymphocytes. While the BCC rarely spreads to other organs, SCC and melanoma may spread to other parts of the body through the hematopoietic or lymphatic pathways (Hallberg & Johansson, 2013). If not treated early, at stage four, it might spread to organs such as the lungs, liver, brain, and bones.
Diagnosis and Staging
In most cases, a dermatologist can come up with diagnosis by observation of the outgrowths on the skin. However, for confirmation, a skin biopsy is obtained under local anesthesia and sent to a pathologist for confirmation. Lymph node biopsy and fine needle aspiration may also be used. The Basal Cell Skin Cancer does not have a particular system of staging, and its seriousness can only be determined by the size and location. The Squamous Cell Skin Cancer is staged from 0- V by its thickness, invasion into the inner layer of the skin, into the skins tiny nerves or its location on the ear (Simmons, 2012). On the other hand, melanoma is staged from 0- IV according to the thickness and depth of the tumor, and the extent of metastasis to the lymph nodes and other distant sites (Hallberg & Johansson, 2013).
Treatment and Prevention
People at risk are usually encouraged to use sunscreen to prevent melanoma and SCC. Additionally, they should wear protective clothing and sunglasses to avoid sun burning, and avoid exposure to the sun at peak hours. Also, the risk can be reduced by avoidance of using tobacco products and decreasing indoor tanning. Proper nutrition is also encouraged as some foods and antioxidants have been found to mitigate the risk of sunburns. (Simmons, 2012)
Treatment of the skin cancers, on the other hand, depends on the type, body part affected, the age of the patient, and whether it is a recurrence or not. For instance, surgery for excision may be indicated to a young person but not to a geriatric patient. Also, topical chemotherapy is usually used for superficial BCC for aesthetic purposes but is ineffective in more invasive BCC or SCC. Both chemotherapy and radiotherapy are inadequate for the treatment of melanoma. (Coelho & Hearing, 2009) Low-risk skin cancers are treated adequately with external beam radiotherapy, cryotherapy, and topical chemotherapy. Other treatment modalities include photodynamic therapy curettage and electrodessication, mainly for BCC and SCC. One of the invasive procedure is the Mohs micrographic surgery that removes the tumor minimally to ensure the results are aesthetically favorable (Marks, 2005). In cases where there is metastasis to other organs, more surgical procedures in the affected regions and systemic chemotherapy may be required. Medications for metastatic melanoma include biological compounds such as pembrolizumab and BRAF inhibitors such as vemurafenib. (Simmons, 2012)
The most common form of treatment for the skin cancers currently is reconstructive surgery aimed at restoring the normal functioning and appearance. Small skin defects are repaired simply by closing with sutures and leaving a linear scar which may not be clearly visible. Larger defects are corrected using a local skin flap, a skin graft, a microvascular free flap, or a pedicle skin flap (Marks, 2005). Skin grafting may be done using full or split thickness. Split thickness is used in smaller defects, in which a shaver obtains a layer of the skin from the thigh or abdomen. Full thickness grafting is done by extracting a segment of skin entirely and is used in large defects and with a desirable cosmetic outcome. However, it is more challenging in surgery and reconstruction of cancers affecting the face due to numerous functional and visible anatomic structures.
According to Simmons (2012), the mortality rate of BCC and SCC is around 0.3 percent causing about two thousand deaths in the US annually. Melanomas mortality rate, on the other hand, is about twenty percent, with about sixty thousand deaths annually in the US. The prognosis is dependent on when patients start treatment. It is favorable if detected and excised early but bad if there is already metastasis. As of 2008, according to Simmons (2012), the overall rate of cure with Mohs surgery was about ninety-five percent for recurrent BCC. Therefore, there is a need for early screening of unknown skin lesions to establish and manage the underlying cause.
Coelho, S. & Hearing, V. (2009). UVA Tanning is Involved in the Increased Incidence of Skin Cancers in Fair-Skinned Young Women. Pigment Cell & Melanoma Research, 23(1), 57-63.
Hallberg, O. & Johansson, O. (2013). Increasing Melanoma-Too many Skin Cell Damages or Too Few Repairs? Cancers, 5(1), 184-204.
Marks, R. (2005). An Overview of Skin Cancers. Cancer 75 (S2), 607-612.
Simmons, S. (2012). Non-melanoma Skin Cancers. Nursing, 42(6), 39.
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