Laura Ferris, MD, PhD discusses ways to stay safe in the summer sun and some of the early signs of skin cancer.
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– This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgments when advising their patients. Patients in need of medical care should consult their personal care provider.
– Summer’s here, and it’s time for fun in the sun. But how much time is too much time, and what are the early signs of skin cancer? Hi, I’m Tonia Caruso. Welcome to this UPMC HealthBeat podcast, and joining us right now is Dr. Laura Ferris. She’s a dermatologist with UPMC. Thank you so much for spending time with us today.
– Thanks for having me.
– Such an important topic. Lots of families heading on vacation, lots of us heading to the pool or to the beach. What are the things that we should be thinking about as we head to the pool and as we head to the beach?
– Well, I think the most important thing is have fun, enjoy the outdoors, but just keep your skin safe. So, what does that mean? To me, that means you don’t come back from vacation certainly not with a sunburn and really not even with a tan. So, there are lots of ways to be outside, enjoy the outdoors without exposing your skin to that excess radiation from the sun.
– OK, so everybody at this point is gasping and saying, “That’s the whole reason I go to the pool or I go to the beach because the sun makes us look so good.” What, in essence, is the sun really doing to our skin?
– So what the sun is doing is it’s actually damaging the DNA and the cells of your skin, unfortunately, and we know that cancer starts with DNA damage, and that that damage, maybe it gets repaired and you’re lucky, or maybe it doesn’t get repaired and that damage gets passed on to the next cell or gets amplified and that’s how you get cancer. So, the tan, while we think it looks good, it’s actually our body’s way of trying to give us one last protection. You can see when you look at tanned skin under the microscope, you can see a little cap of pigment, the melanin pigment sitting over the nucleus, which is the center part of the cell that contains all the DNA, and it’s basically trying to make a little shield or umbrella to protect your DNA because your cells or your body can tell that that is damaging radiation that’s coming in. So, while we think a tan looks good, it’s actually our body saying, “Whoa, I need to do everything I can to protect myself.”
– Self-tanners — what are your thoughts on self-tanners?
– Yeah, self-tanners really are by and large safe. So, while I would like to propagate the idea that tan is not beautiful, that’s probably going to be a losing battle. And so if somebody really wants to look tan, I’m OK with self-tanners, particularly the ones that you’re applying at home. It will give you the appearance of a tan, but you’re not getting it from the damage. Now, it’s important to say that tan, or the little bit of color that you get on your skin, does not provide any protection from the sun. So, it doesn’t mean, “Great, I don’t need to use sunscreen or I don’t need to use as much,” but I’m OK with self-tanners. If you’re getting them sprayed on, the one thing I would say is make sure that you’re in a ventilated area, that you’re not breathing in the fine aerosol mist, but particularly if you’re doing it at home, it’s OK.
– Are there any chemicals that we should watch out for in those?
– Not in the ones that are currently available in the U.S. Those are all generally pretty safe. If it must be tan, I’d rather it come from self-tanners.
– All right, so you mentioned they’re not sunscreen. So when someone has to be outside, or, let’s face it, there’s still going to be people going to the pool, going to the beach. What are the rules when it comes to SPF? How often should you apply sunscreen, and do those numbers really mean things?
– So the numbers definitely really do mean things. So, a higher SPF is going to give you more protection. So the SPF is really measuring the protection from burning, but you really want the broad spectrum. So you want a sunscreen that says that it’s broad spectrum against UVA and UVB, the two major ultraviolet wavelengths that we get from the sun. When you look at those numbers, you do get some protection, really, with any of them. Some people will recommend 15 is enough. I really think, and the American Academy of Dermatology would say, 30 is a better number to go for. And, frankly, if you’re going to be outside, you’re going to be at the beach, you’re going to be hiking outside, sitting at the pool, I really recommend doing 50 or even higher. There’s not really harm in going higher. The reason why higher may be better is that that number is based on perfect use. So that is you use enough of it, you reapply it every 90 minutes, you spread it very evenly over every single surface of your body, and that’s really not what happens with most people. So if you’re using an SPF 50, but you’re really using a thinner coat and it’s maybe half of what you should be using, you may only be getting SPF 25. So I think that going to the higher number kind of helps us correct for our own errors.
– And what about headgear or hats? Are hats good for the sun?
– Hats are great. So, that’s a really important point is I think sometimes we first think SPF, let me put on sunscreen, that’s it, that’s all I got. That’s only one sort of tool that we have for protection. So, hats are great. So, hats, one, most of us aren’t going to put sunscreen on our hair. So that protects our scalp because we do see skin cancers develop on the scalp. And sometimes those are some of the worst ones that we will see in practice. So, one, a hat is good, one with a brim is good, ’cause it’ll help protect your face and shoulders. The other things you can do are lightweight clothing. So, a lightweight, long-sleeve T-shirt is going to also give you extra protection. And then, of course, just not being out in the direct sun. So, you can sit by the beach or by the pool under an umbrella, have that same enjoyable experience, but not have the sun damaging your skin. So those are all really important factors.
– So, let’s talk now about the early signs of skin cancer. Can you lay out the levels of skin cancer for people?
– Sure, so there’s many different types of skin cancer, but we think about the three most common ones as being basal cell carcinoma, squamous cell carcinoma, and melanoma. And those are going from most to least common. So melanoma is probably the one that we worry about the most or that people hear about the most. So, that is probably responsible for the most number of skin cancer deaths, even though it’s not quite as common as the others. So, melanoma is one that we know is related to sun exposure, and it has the potential to be found early and removed with a pretty minimal surgery that could be done in your dermatologist’s office. However, it can also spread and be devastating, go to the brain, or the liver, or the lungs, and require kind of these more advanced therapies.
– And, really, how long of a process can that be? Is that something that can happen quickly, or does that just happen over a long period of time, because most of the time it’s not detected?
– So, that’s a great question, and it probably varies. So there are some forms of melanoma that are slower-growing, and they may sit there and grow very slowly and not spread for months or years. And then there’s other forms of melanoma that can pop up very quickly. So, nodular melanoma is one, the more serious forms of melanoma. That generally develops very quickly. You may not have seen it, and all of a sudden there’s a little bump, brown or black, or maybe even pink or red bump on the skin that’s just popped up, and it starts growing rapidly. That can grow and spread really over a period of months.
– You just led me directly to my next question. How do you know? What should you be looking for? Especially when it comes to melanoma, and then we’ll get to the lesser forms.
– Sure. So melanoma, we try to come up with these easy things to remember. So we like to say the A, B, C, D, Es. And so, “A” is asymmetry. So, if you looked at that spot on the skin, if you drew a line down the middle of the two halves, wouldn’t look identical. “B” is borders that are irregular. So, it’s not a nice round circle or oval, it’s maybe kind of jagged at the edges. Color can be more than one color. So it’s not just one uniform light brown lesion, it’s maybe brown, and black, and a little bit pink, or a little bit red. I also think about a color that’s sort of remarkable, like a black color. So, most of your moles may be brown, but if you’ve got one that’s black, that’s concerning. And then, “D” is diameter, or how wide it is across. So I say if it’s 6 millimeters, which is about the size of a pencil eraser. So if it’s wider across than a pencil eraser, that would be more concerning for melanoma. And then finally we have “E,” which is evolving or changing. So if you know that that mole on your arm was just a little brown circle last year, and you look at it this summer, and it looks like it’s two halves, and it’s also half-black now, and it’s really different-looking, that’s something that needs to be looked at.
– Right. Is it only caused by sun? Can melanoma be hereditary, or are there people more at risk for it?
– Yes. So, while sun is an important driver, because it is what’s helping to cause the additional DNA damage, genetics are also very important. So, we know that if you have a family history, which we consider a parent or a sibling who has had melanoma, you’re at higher risk. And so, that is something you should talk to your doctor about. And if you have multiple family members who have had melanoma, then your risk is probably even higher still. So, what should you do if that’s the case? Mention it to your physician, make sure that they’re aware of that. They’re likely to recommend that at some point you start going to see a dermatologist to be screened or to be looked at. So, genetics are important, too.
– If it’s hereditary, even if I’m not someone who’s out in the sun, there’s a potential that I could get it?
– There is, yes. So there is some potential. Your risk will go up the more sun exposure you have. But I think it’s important to really acknowledge that because sometimes people think, “Well, I don’t go in the sun, I won’t get melanoma, I’ll be fine,” or they think, “Well, that spot is where my bathing suit would cover it,” or, “It’s on the bottom of my foot. So I’m certainly not sunbathing with my feet up in the air, so that can’t be skin cancer, I won’t worry about it.” And those are actually places where we do see melanoma, and we really think that that’s probably driven more so by the genetic aspects.
– Are people with fairer skin more susceptible, or if someone has olive skin, or Mediterranean, they’re less likely to have skin cancer?
– So it is true that having fairer skin makes you more at risk of having melanoma, as well as the other forms of skin cancer. So, the lighter your skin and eye color and hair color, the higher your risk of developing melanoma. That does go down with darker skin types. But, it’s also important to say melanoma can occur in all skin types. In fact, one of the challenges that we have is that our patients who have darker skin types are less likely overall to get melanoma. So, it may not be sort of at the top of their mind. And even for maybe their health care practitioner, they might not be thinking, “Boy, I’ve got to really think about melanoma in this patient population.” So, unfortunately, some of our patients with skin of color will actually be, while they’re less likely to get melanoma, if they do get it, they’re more likely to have a bad outcome. And we’re not sure why that is. So, part of it might be the genetic nature, they may have more aggressive tumors, and part of it may just be that they get caught later because that’s not the first thing that somebody thinks of when they see the lesion. Our patients with skin of color are more likely to get melanoma on areas like the palms, their soles, sometimes in the mucosa, so inside the mouth or nose. Those can be hard to find, but it’s important to think that melanoma may look different in different skin types.
– Right. From melanoma to the two lesser forms, and let’s quickly explain the difference between the two lesser forms.
– So, basal cell and squamous cell, they derive from the actual skin cells. So, not the pigment-producing cells like melanoma does, but from the different parts of the keratinocytes, or skin cells, and different parts of the skin. They are both also very related to sun exposure. So, there’s some genetic predisposition, but for most patients, you really see these more in patients with fair skin. So, lighter skin colors, eye colors, hair colors. So, for all these skin cancers, for example, redheads tend to have the highest risk. People who have that really creamy white skin, they only freckle, they’ve got red hair, blue eyes, those are the patients who I worry most about developing all forms of skin cancer. So, these drive from those skin cells. They are very sun-related. The other risk factor that’s important to know, particularly for squamous cell carcinoma, is that patients who are immunosuppressed are at higher risk. So, we know our immune system protects us from infection, but it also helps protect us from cancer, and particularly cancer like squamous cell carcinoma. So if a patient has had a transplant, for example, something we do lots of here at UPMC, we put patients on medicine so they will not reject their organ. Unfortunately, those medicines will also put them at risk of skin cancer.
– So, are there any identifying factors to either of those cancers that we should be looking for in moles and on our bodies?
– So, these don’t tend to arise in moles. So, melanoma, about 50% will arise in a preexisting mole or kind of brown spot that’s on the skin. About 50% will arise kind of out of normal-looking skin. We really don’t see squamous cell and basal cell carcinomas coming up in moles. They tend to arise on their own. They tend to be in sun-exposed skin, most commonly on the face, the scalp, the neck. We can see them on the hands and on the arms. They’re a little less likely to be in these sort of hidden, covered areas. But, again, skin cancer can show up anywhere. And what you’re looking for are pink or red, particularly for basal cell carcinomas, they tend to be pink to red bumps that will arise. They can also just be flat, scaly pink or red spots. Squamous cell carcinomas tend to have a little more crustiness or scaliness to them, also to be in a pink or red color. It’s hard to tell the difference sometimes between them until we biopsy them. Things that I tell patients to look for are sores that don’t heal. So, if you have, you think, “Oh, I don’t know. Maybe I just, you know, scraped my hand or scraped my arm,” but that sore doesn’t heal and it’s been weeks or months, that’s something that needs attention. Or maybe there’s a spot on your face. You wash your face and you just notice that every time you dry your face off, it bleeds a little bit, it never seems to go away, that also needs attention.
– Are there any other symptoms besides we might see something on our skin? Are there any headaches, or fatigue, or anything like that that could go along with that?
– We don’t tend to see that at the stage where we would diagnose something early. So, if you’re symptomatic, it’s probably a pretty advanced later-stage cancer. So, sometimes people will say, “Gosh, I felt fine. I thought, how could this be anything? I feel fine.” So most people who walk into us with any of these skin cancers, they feel fine. They don’t feel tired, they haven’t had headaches, they’re not losing weight, there’s just one spot on their skin that looks a little different.
– Wow. OK, so we’ve talked all through this that obviously catching something early, the earlier you catch it, the better. Do you recommend, even if you’re not someone who spends a lot of time in the sun to come and get a yearly check? What does that look like?
– So, it’s interesting. We don’t have great guidelines. So if you’re talking about breast cancer or colon cancer, your physician would be citing guidelines like, “We recommend you start screening at this way, at this time, and do it this often.” We don’t have that for skin cancer. Patient awareness is really important. So, unlike, for example, colon cancer or breast cancer, you can find your own skin cancer at its most early curable stage. So, get to know your own skin, make sure that if you see something that doesn’t look right, that you bring it to the attention of your primary care provider or a board-certified dermatologist and get that evaluated. So, that’s one thing. Should everybody come in for a skin check? We don’t really have guidelines that say every person needs to see a dermatologist every year. Things you can do are the more you know, the better advocate you are for yourself. If you’re seeing your primary care doctor for a physical every year, you can ask them, “Hey, could you take a look at my skin while you’re doing my exam? Tell me if you see anything you’re concerned about.” And then talk to them about if you have risk factors like a family member who’s had a melanoma or a lot of sun exposure, or you’ve had maybe a skin cancer — maybe five years ago, you were diagnosed with basal cell carcinoma. You might be somebody who should see a dermatologist regularly. You can ask your primary care doctor about it. If you have an established dermatologist for a skin cancer, they’ll probably tell you how often you should be coming in for a check.
– And for these less serious forms, what does treatment look like?
– So, in general, treatment is an excision in your dermatologist’s office, or maybe a plastic surgeon’s office. If you have something on the face, so certain higher-risk tumors, or squamous cell or basal cell carcinomas that are on the face, on the scalp, on the neck, maybe on like the finger and area that’s a little bit harder to excise, we’ll do something called Mohs surgery. And so this is a process where a specially trained dermatologist will go in and remove all of the visible tumor, freeze that tissue, and section it, and stain it, and look at it under the microscope while you’re sitting right there bandaged up and look and see if they got it all. So they can look at every single margin or edge of that tissue and either say, “Great, we know it’s all gone. We’ll close you back up and send you home the same day,” or say, “Turns out there’s a little bit left, but I know right where it is. It’s at this part at 3:00 on your tissue. I’ll go back and take a little bit more, and we’ll do that until you’re clear.” That has several advantages. One, they can know right then and there with pretty good certainty that everything’s gone, and then they can do the closure. You know, two, they can see more of the edges of the tissue than you would if you just send it out in a bottle to the lab. So, we learn more from that, it does take more time. And that really isn’t something that we need to do for every skin cancer, but for certain ones in certain areas, it makes sense.
– Right. Tell me a little bit about your research work when it comes to skin cancer.
– Sure. So I’m interested in thinking about how we can best find skin cancer, and particularly melanoma, early. So, one thing that we’ve looked at is trying to answer this question around screening. We don’t have guidelines. So, we try to look at the practices that we have and say, “Is there one thing that seems to work better?” So, one initiative that we’ve had here at UPMC is we worked with our colleagues in primary care. We did a training on how to recognize skin cancer with a focus on melanoma and then suggested that patients who are 35 and older, because skin cancer, definitely your risk goes up with age, and we’re probably going to even move this starting age a little bit later based on what we’ve learned, but for our first initiative, 35 and older, to say look at the skin, and then just mark in the chart through our electronic record either that their skin cancer screening was done, or if you couldn’t do it because they had other issues, just leave it blank. So then we followed our patients and said, “Here’s our group who got screened, and here’s our group who didn’t.” And then we looked into the skin cancers that they developed, and we looked at their melanomas. And what we found was that the patients who were screened were more likely to have early melanomas as measured by how thick they are, how deep they go into the skin. So, thin melanoma is most curable just with the basic surgery in the office. And we found that that was really correlated with having had a skin exam. And then we’re trying to look and say, even more importantly, “Are we preventing sort of the late, more deadly, or the melanomas that need more surgery, maybe need things like chemotherapy. We don’t quite have all of that information, but our early readout does suggest that you’re much more likely to be diagnosed with a thin, early, more curable melanoma if you were in that group that got screened. And we think this is mostly important for particularly older patients. So we’re probably going to be moving that age, starting actually up to 65. These are our patients who really tend to have the highest risk of getting melanoma and the highest risk of dying from melanoma.
– So, bottom line, what do you want to say to people about what they should be thinking about as summer approaches and all these fun summer activities are taking place?
– You know, go out, enjoy yourselves, enjoy the outdoors. It’s so important, we’ve all been cooped up for years. Go out there and be healthy, but be careful while you do it. So, avoid the peak sun. So, don’t sit outside, 10 to 4 are our peak hours of sun. Avoid being in direct sunlight. But you can do that with an umbrella, with a hat, with just sitting in the shade when that’s an option. Wear your sunscreen, SPF 30 or higher. And if you’re really going to be at the beach or the pool, I’d say 50. And reapply it about every 90 minutes, and every time you swim or sweat a lot. So, just be careful, enjoy it. Know what skin cancer is, have it on your radar. If something doesn’t look right on your skin, don’t ignore it. It may be nothing, but then that’s going to be a quick trip to your dermatologist. They’ll reassure you, and you can go on with the rest of your summer or the rest of your day. If there’s a question, make sure you get it looked at, though. Educate yourself about melanoma. There’s lots of good pictures and information online because an educated patient is always a patient who’s going to do better. And when in doubt, ask for professional advice, see a board-certified dermatologist.
– Well, Dr. Laura Ferris, thank you so much for coming in and spending some time with us today, some really great information. Thanks for your time.
– Thank you.
– I’m Tonia Caruso. Thank you for joining us. This is UPMC HealthBeat.
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