Detection and Treatment of Non- residents to daily use vs - PDF document

• Sunscreens- Australian study randomized Detection and Treatment of Non- residents to daily use vs discretionary us between 1992 and 1996 Melanoma Skin Cancers • Risk for developing any melanoma reduced by 50% and invasive melanoma risk reduced by 73% Toby Maurer, MD • Same trial also showed reduction of risk of University of California, San Francisco developing squamous cell cancer Green et al. J Clin Oncol 2011 Jan 20; 29:257 Basics of Skin Cancer • Large majority caused by sun exposure • Often sun exposure before age 20 • Sunscreens- Australian study randomized residents to daily use vs discretionary us between • Persons who burn easily and tan poorly are at 1992 and 1996 greatest risk • Risk for developing any melanoma reduced by 50% and invasive melanoma risk reduced by 73% • Same trial also showed reduction of risk of developing squamous cell cancer Green et al. J Clin Oncol 2011 Jan 20; 29:257 1

Vitamin D controversy Bottom Line Recommendations • Intermittant weekly UVB exposure is most • Sun exposure causes cancer convenient source of vit D. • Supplement Vit D with food/vitamins until • Vit D-plays vital role in muscle and bone more is known health • Decreased Vit D levels being implicated in more cancers/solid tumors • Right level of Vit D debated and oral doses and forms of vit D being worked out Tanning Beds “I’m Here for a Skin Check” • Screening for skin cancer: an update from US • International Agency for Research on Cancer preventive services task force: Annals of • Comprehensive metaanlaysis found that risk of Internal Med 2009 Feb-Wolff T, et al. melanoma (skin and eye) increases by 75% when • Can screening by Primary MD reduce tanning begins before age 30. morbidity/mortality from skin cancer? • Cite this to your young patients • Hard to do study-need to follow 800,000 El Ghissassi et al. Lancet Oncol 2009 Aug 10:751 persons over long period of time to determine this-studies not done 2

Non-Melanoma Skin Cancers Bottom line: • Not enough evidence for or against to advise • Basal cell carcinoma (BCC) that patients have routine full body exams • Actinic keratosis (AK) BUT • Squamous cell carcinoma (SCC) • Know risk factors and incorporate exam into full physical and teach patients what to look for Diagnosis of BCC: Shave or Punch Basal Cell Carcinoma (BCC) Biopsy • Who is at Risk? – Age 20+ – Fair-skinned persons – Sun-exposed sites • over 50% on face 3

Recommended Treatment of BCC Differential Diagnosis of BCC • Surgical excision (head and neck) • Intradermal Nevus • Curettage and desiccation (trunk) • Sebaceous hypersplasia • Radiation therapy (debilitated patient) • Fibrous Papule (angiofibroma) • Microscopically controlled surgery (Mohs) • Eczema – Recurrent/sclerotic BCC’s • Melanoma – BCC’s on eyelid and nasal tip Aldara (Imiquimod) Treatments NOT Recommended • Topical therapy designed for wart treatment • Cryotherapy • Upregulates interferon/ down regulates tumor • Topical chemotherapy necrosis factor/works on toll like receptors - 5 Fleurourical (Efudex) • Seems to have efficacy in superficial BCC’s • Radiation therapy (good surgical candidate) • Do Not use in BCC’s that are nodular or invasive • Biopsy to confirm diagnosis BEFORE treatment 4

When to Refer Actinic Keratosis (AK) • It depends on your surgical skills • Who is at risk? • > 1 cm – Over age 35-40 – Fair-skinned persons • Sclerotic BCC – Sun-exposed sites • Recurrent BCC • Face, forearms, hands, upper trunk • Eyelid BCC – History of chronic sun exposure Clinical Features of AK Diagnosis of AK • Red, adherent, scaly lesions, usually < 5mm • Diagnosis • Sandpapery, rough texture – Clinical features – Shave or punch biopsy • Tender when touched or shaved • Differential Diagnosis • Thick, warty character (cutaneous horn) – BCC/SCC – Seborrheic keratosis – Wart 5

Treatment of AK Photodynamic therapy • Place photosensitizer on skin and then use light • Cryotherapy-goal is 2x15 sec thaws therapy-increases absorbency of light • Topical chemotherapy/chemical peel • Evidence that it changes histologic features of – Efudex (5FU crème) 2x’s/day x 6 wks or Imiquimod- photodamage and changes expression of oncogenes 3X’s /wk and 3 mos. Uses in: • Actinic keratoses • Basal cell cancers • Superiority studies being evaluated • Bagazgoitia et al BJD 2011 July Squamous Cell Carcinoma (SCC) Clinical Features of SCC • Who is at risk? • Papule, nodule or tumor – Age 50+ • Non-healing erosion or ulcer – Chronic sun exposure • Cutaneous horn (wart-like lesion) • Head, neck, lower lip, ears, dorsal hands, trunk • Fixed, red, scaling patch/plaque (Bowen’s- – Special circumstances SCC-in-situ) • Immunosuppression (organ transplant) • Radiation therapy 6

Differential Diagnosis of SCC How to Diagnose • Actinic keratosis • Punch or excisional/incisional biopsy • Wart • Shave biopsy for flat, non-elevated lesion • Seborrheic keratosis • BCC • Eczema or psoriasis Treatment of SCC When to Refer • Recommended treatment • SCC’s may metastasize – Excision • Low threshold for biopsy and referral – Radiation therapy ( in debilitated patient) • Regularly check draining lymph nodes • Treatments NOT recommended • High risk SCC’s – Curettage and desiccation – Topical chemotherapy 7

High-risk SCC’s Keratoacanthomas • Lip • What are they?-self-healing SCC’s • Look like SCC’s but history is that they come up • Temple quickly • Immunocompromised host (i.e. organ transplant) • Biopsy to rule out SCC • Area of previous radiation therapy • Sometimes pathologist cannot tell the difference • Treat by injecting methotrexate, 5 FU-but close follow-up to make sure that tumor regression is evident-if not, excise like SCC 8