What You Need To Know About Skin Cancer National Institutes of Health National Cancer Institute Revised April 1993 [Graphic Omitted] This booklet is about skin cancer. You may have questions about this disease. Call the Cancer Information Service to talk with someone about skin cancer. The staff can talk with you in English or Spanish. The number is 1-800-422-6237 (1-800-4-CANCER). The call is free. Each year, more than 600,000 people in the United States learn that they have skin cancer. This National Cancer Institute (NCI) booklet will give you some important information about this disease. It explains how skin cancer is diagnosed and treated and has information about preventing this disease. Other NCI booklets are listed on page 22. Our materials cannot answer every question you may have about skin cancer. They cannot take the place of talks with doctors, nurses, and other members of the health care team. We hope our information will help with those talks. Research has led to better methods of diagnosing and treating this disease. It is encouraging to know that skin cancer is now almost 100 percent curable if found early and treated promptly. Our knowledge about skin cancer and other types of cancer is increasing rapidly. For up-to-date information, call the NCI-supported Cancer Information Service (CIS) toll free at 1-800-4-CANCER (1-800-422-6237). The Skin The skin is the body's outer covering. It protects us against heat and light, injury, and infection. It regulates body temperature and stores water, fat, and vitamin D. Weighing about 6 pounds, the skin is the body's largest organ. It is made up of two main layers: the outer epidermis and the inner dermis. The epidermis (outer layer of the skin) is mostly made up of flat, scale-like cells called squamous cells. Under the squamous cells are round cells called basal cells. The deepest part of the epidermis also contains melanocytes. These cells produce melanin, which gives the skin its color. The dermis (inner layer of skin) contains blood and lymph vessels, hair follicles, and glands. These glands produce sweat, which helps regulate body temperature, and sebum, an oily substance that helps keep the skin from drying out. Sweat and sebum reach the skin's surface through tiny openings called pores. [Graphic Omitted] What Is Cancer? Cancer is a group of more than 100 diseases. Although each type of cancer differs from the others in many ways, every cancer is a disease of some of the body's cells. Healthy cells that make up the body's tissues grow, divide, and replace themselves in an orderly way. This process keeps the body in good repair. Sometimes, however, normal cells lose their ability to limit and direct their growth. They divide too rapidly and grow without any order. Too much tissue is produced, and tumors begin to form. Tumors can be benign or malignant * Benign tumors are not cancer. They do not spread to other parts of the body and are seldom a threat to life. Often, benign tumors can be removed by surgery, and they are not likely to return. * Malignant tumors are cancer. They can invade and destroy nearby healthy tissues and organs. Cancer cells also can spread, or metastasize, to other parts of the body and form new tumors. Types of Skin Cancer The two most common kinds of skin cancer are basal cell carcinoma and squamous cell carcinoma. (Carcinoma is cancer that begins in the cells that cover or line an organ.) Basal cell carcinoma accounts for more than 90 percent of all skin cancers in the United States. It is a slow-growing cancer that seldom spreads to other parts of the body. Squamous cell cancinoma also rarely spreads, but it does so more often than basal cell carcinoma. However, it is important that skin cancers are found and treated early because they can invade and destroy nearby tissue. Basal cell carcinoma and squamous cell carcinoma are sometimes called non-melanoma skin cancer. Another type of cancer that occurs in the skin is melanoma, which begins in the melanocytes. More information about this disease can be found in the booklet What You Need To Know About Melanoma. Cause and Prevention Skin cancer is the most common type of cancer in the United States. According to current estimates, 40 to 50 percent of Americans who live to age 65 will have skin cancer at least once. Several risk factors increase the chance of getting skin cancer. Ultraviolet (UV) radiation from the sun is the main cause of skin cancer. Artificial sources of UV radiation, such as sunlamps and tanning booths, can also cause skin cancer. Although anyone can get skin cancer, the risk is greatest for people who have fair skin that freckles easily-often those with red or blond hair and blue or light-colored eyes. The risk of developing skin cancer is also affected by where a person lives. People who live in areas that get high levels of UV radiation from the sun are more likely to get skin cancer. In the United States, for example, skin cancer is more common in Texas than it is in Minnesota, where the sun is not as strong. Worldwide, the highest rates of skin cancer are found in South Africa and Australia, areas that receive high amounts of UV radiation. In addition, skin cancer is related to lifetime exposure to UV radiation. Most skin cancers appear after age 50, but the sun's damaging effects begin at an early age. Therefore, protection should start in childhood to prevent skin cancer later in life. Whenever possible, people should avoid exposure to the midday sun (from 10 a.m. to 2 p.m. standard time, or from 11 a.m. to 3 p.m. daylight saving time). Keep in mind that protective clothing, such as sun hats and long sleeves, can block out the sun's harmful rays. Also, lotions that contain sunscreens can protect the skin. Sunscreens are rated in strength according to a sun protection factor (SPF), which ranges from 2 to 30 or higher. Those rated 15 to 30 block most of the sun's harmful rays. The NCI is supporting research to try to find new ways to prevent skin cancer. This research involves people who have a high risk of developing skin cancer-those who have already had the disease and those who have certain other rare skin diseases that increase their risk of skin cancer. Symptoms The most common warning sign of skin cancer is a change on the skin, especially a new growth or a sore that doesn't heal. Skin cancers don't all look the same. For example, the cancer may start as a small, smooth, shiny, pale, or waxy lump. Or it can appear as a firm red lump. Sometimes, the lump bleeds or develops a crust. Skin cancer can also start as a flat, red spot that is rough, dry, or scaly. Both basal and squamous cell cancers are found mainly on areas of the skin that are exposed to the sun-the head, face, neck, hands, and arms. However, skin cancer can occur anywhere. Actinic keratosis, which appears as rough, red or brown, scaly patches on the skin, is known as a precancerous condition because it sometimes develops into squamous cell cancer. Like skin cancer, it usually appears on sun-exposed areas but can be found elsewhere. Changes in the skin are not sure signs of cancer; however, it is important to see a doctor if any symptom lasts longer than 2 weeks. Don't wait for the area to hurt-skin cancers seldom cause pain. [Graphic Omitted] Detection and Diagnosis Detection The cure rate for skin cancer could be 100 percent if all skin cancers were brought to a doctor's attention before they had a chance to spread. Therefore, people should check themselves regularly for new growths or other changes in the skin. Any new, colored growths or any changes in growths that are already present should be reported to the doctor without delay. Doctors should also look at the skin during routine physical exams. People who have already had skin cancer should be sure to have regular exams so that the doctor can check the skin-both the treated areas and other places where cancer may develop. Diagnosis Basal cell carcinoma and squamous cell carcinoma are generally diagnosed and treated in the same way. When an area of skin does not look normal, the doctor may remove all or part of the growth. This is called a biopsy. To check for cancer cells, the tissue is examined under a microscope by a pathologist or a dermatologist. A biopsy is the only sure way to tell if the problem is cancer. Doctors generally divide skin cancer into two stages: local (affecting only the skin) or metastatic (spreading beyond the skin). Because skin cancer rarely spreads, a biopsy often is the only test needed to determine the stage. In cases where the growth is very large or has been present for a long time, the doctor will carefully check the lymph nodes in the area. In addition, the patient may need to have additional tests, such as special x-rays, to find out whether the cancer has spread to other parts of the body. Knowing the stage of a skin cancer helps the doctor plan the best treatment. Treatment Planning In treating skin cancer, the doctor's main goal is to remove or destroy the cancer completely with as small a scar as possible. To plan the best treatment for each patient, the doctor considers the location and size of the cancer, the risk of scarring, and the person's age, general health, and medical history. It is sometimes helpful to have the advice of more than one doctor before starting treatment. It may take a week or two to arrange for a second opinion, but this short delay will not reduce the chance that treatment will be successful. There are a number of ways to find a doctor for a second opinion: * The patient's doctor may be able to suggest a doctor, such as a dermatologist or a plastic surgeon, who has a special interest in skin cancer. * The American Academy of Dermatology and the American Society of Plastic and Reconstructive Surgeons can provide the names of specialists in local areas. * The Cancer Information Service, at 1-800-4-CANCER, can tell callers about treatment facilities, including cancer centers and other programs that are supported by the National Cancer Institute. * Patients can get the names of doctors from their local medical society, a nearby hospital, or a medical school. * The Directory of Medical Specialists lists doctors' names and gives their background. It is in most public libraries. Treating Skin Cancer Treatment for skin cancer usually involves some type of surgery. In some cases, doctors suggest radiation therapy or chemotherapy. Sometimes a combination of these methods is used. Surgery Many skin cancers can be cut from the skin quickly and easily. In fact, the cancer is sometimes completely removed at the time of the biopsy, and no further treatment is needed. Curettage and Electrodesiccation Doctors commonly use a type of surgery called curettage. After a local anesthetic numbs the area, the cancer is scooped out with a curette, an instrument with a sharp, spoon-shaped end. The area is also treated by electrodesiccation. An electric current from a special machine is used to control bleeding and kill any cancer cells remaining around the edge of the wound. Most patients develop a flat, white scar. Mohs' Surgery Mohs' technique is a special type of surgery used for skin cancer. Its purpose is to remove all of the cancerous tissue and as little of the healthy tissue as possible. It is especially helpful when the doctor is not sure of the shape and depth of the tumor. In addition, this method is used to remove large tumors, those in hard-to-treat places, and cancers that have recurred. The patient is given a local anesthetic, and the cancer is shaved off one thin layer at a time. Each layer is checked under a microscope until the entire tumor is removed. The degree of scarring depends on the location and size of the treated area. This method should be used only by doctors who are specially trained in this type of surgery. Cryosurgery Extreme cold may be used to treat precancerous skin conditions, such as actinic keratosis, as well as certain small skin cancers. In cryosurgery, liquid nitrogen is applied to the growth to freeze and kill the abnormal cells. After the area thaws, the dead tissue falls off. More than one freezing may be needed to remove the growth completely. Cryosurgery ususally does not hurt, but patients may have pain and swelling after the area thaws. A white scar may form in the treated area. Laser Therapy Laser therapy uses a narrow beam of light to remove or destroy cancer cells. This approach is sometimes used for cancers that involve only the outer layer of skin. Grafting Sometimes, especially when a large cancer is removed, a skin graft is needed to close the wound and reduce the amount of scarring. For this procedure, the doctor takes a piece of healthy skin from another part of the body to replace the skin that was removed. Radiation Skin cancer responds well to radiation therapy (also called radiotherapy), which uses high-energy rays to damage cancer cells and stop them from growing. Doctors often use this treatment for cancers that occur in areas that are hard to treat with surgery. For example, radiation therapy might be used for cancers of the eyelid, the tip of the nose, or the ear. Several treatments may be needed to destroy all of the cancer cells. Radiation therapy may cause a rash or make the skin in the area dry or red. Changes in skin color and/or texture may develop after the treatment is over and may become more noticeable many years later. Topical Chemotherapy Topical chemotherapy is the use of anticancer drugs in a cream or lotion applied to the skin. Actinic keratosis can be treated effectively with the anticancer drug fluorouracil (also called 5-FU). This treatment is also useful for cancers limited to the top layer of skin. The 5-FU is applied daily for several weeks. Intense inflammation is common during treatment, but scars usually do not occur. Clinical Trials In clinical trials (research studies with patients), doctors are studying new treatments for skin cancer. For example, they are exploring the value of injecting interferon directly into the tumor. They are also testing photodynamic therapy, the use of laser light and drugs that make the cancer cells sensitive to light so the laser can destroy them. Followup Care Even though most skin cancers are cured, people who have been treated for skin cancer have a higher-than-average risk of developing a new cancer of the skin. That's why it's so important for them to continue to examine themselves regularly, to visit their doctor for regular checkups, and to follow their doctor's instructions on how to reduce their risk of developing skin cancer again. Questions To Ask the Doctor Skin cancer has a better prognosis, or outcome, than most other types of cancer; it is curable in over 95 percent of cases. But any diagnosis of cancer can be frightening, and it's natural to have concerns about medical tests, treatments, and doctors' bills. Patients have many important questions to ask about cancer, and their doctor is the best person to provide answers. Most people want to know exactly what kind of cancer they have, how it can be treated, and how successful the treatment is likely to be. The following are some other questions that patients might want to ask their doctor: * What types of treatment are available? * Are their any risks or side effects of treatment? * Will there be a scar? * Will I have to change my normal activities? * How can I protect myself from getting skin cancer again? * How often are checkups needed? Some patients become concerned that treatment may change their appearance, especially if the skin cancer is on their face. Patients should discuss this important concern with their doctor. And they may want to have a second opinion before treatment. Skin Cancer Research Scientists at hospitals and research centers are studying the causes of skin cancer and looking for new ways to prevent the disease. They are also exploring ways to improve treatment. When laboratory research shows that a new prevention or treatment method has promise, doctors use it with people in clinical trials. These trials are designed to answer scientific questions and to find out whether the new approach is both safe and effective. People who take part in clinical trials make an important contribution to medical science and may have the first chance to benefit from improved methods. People interested in taking part in a trial should discuss this option with their doctor. What Are Clinical Trials All About? is an NCI booklet that explains some of the possible benefits and risks of such studies. One way to learn about clinical trials is through PDQ, a computerized resource developed by NCI. PDQ contains information about cancer treatment and an up-to-date list of trials all over the country. The Cancer Information Service can provide PDQ information to doctors, patients, and the public. Medical Terms Actinic keratosis (ak-TIN-ik ker-a-TO-sis): A precancerous condition of thick and scaly patches of skin; also called solar or senile keratosis. Anesthetic (an-es-THET-ik): A drug that causes loss of sensation or feeling in a part (local) or all (general) of the body. Basal cell carcinoma (BAY-sal sel kar-si-NO-ma): A type of skin cancer in which the cancer cells resemble the basal cells of the epidermis. Basal cells: Small, round cells found in the lower part, or base, of the epidermis. Benign (be-NINE): Not cancerous; does not invade nearby tissue or spread to other parts of the body. Biopsy (BY-op-see): The removal of a sample of tissue that is then examined under a microscope to check for cancer cells. Cancer: A general term for the more than 100 diseases in which cells grow and divide abnormally. Cancer cells can spread through the blood or lymphatic system to other parts of the body. Carcinogen (kar-SIN-o-jin): Any agent that is known to cause cancer. Carcinoma (kar-si-NO-ma): A type of cancer that begins in the lining or covering tissues of an organ. Clinical trials: Studies conducted with people. Each study is designed to answer scientific questions and to find better ways to prevent or treat cancer. Cryosurgery (kry-o-SIR-je-ree): Destruction of tissue by applying extreme cold. Curettage (kyoo-re-TAHZH): Removal of tissue with a curette. Curette (kyoo-RET): A spoon-shaped instrument with a sharp edge. Dermatologist (der-ma-TOL-o-jist): A doctor who specializes in the diagnosis and treatment of skin problems. Dermis (DER-mis): The lower layer of skin. Electrodesiccation (e-LEK-tro-des-i-KAY-shun): Use of an electric current to destroy cancerous tissue and control bleeding. Epidermis (ep-i-DER-mis): The surface layer of skin. Fluorouracil (floo-ro-YOOR-a-sil): An anticancer drug. Its chemical name is 5-fluorouracil, commonly called 5-U. Follicles (FAHL-i-kuls): Shafts through which hair grows. Interferon (in-ter-FEER-on): A substance that can improve the body's natural response to the presence of cancer. It slows the rate of growth and division of cancer cells causing them to become sluggish and die. Kaposi's sarcoma (KAP-o-seez sar-KO-ma): A relatively rare type of cancer that develops on the skin of some elderly persons or those with a weak immune system, including those with acquired immune deficiency syndrome (AIDS). Lymph (limf): The almost colorless fluid that travels through the lymphatic system and carries cells that help fight infection and disease. Lymph nodes: Small, bean-shaped structures in the lymphatic system. The lymph nodes store special cells that can trap cancer cells or bacteria traveling through the body in lymph. Lymphatic system (lim-FAT-ik): The tissues and organs that produce, carry, and store cells that fight infection and disease. This system includes the bone marrow, spleen, thymus, lymph vessels, and lymph nodes. Malignant (ma-LIG-nant): Cancerous (see Cancer). Melanin (MEL-a-nin): The pigment of the skin. The amount of this substance accounts for variations in skin color in different people and different races. Melanocytes (me-LAN-o-sites): Cells that form and contain a pigment called melanin. Melanoma (mel-a-NO-ma): Cancer that begins in the melanocytes. Melanoma usually starts in the skin, often in a dark mole. Unlike the more common skin cancers, melanoma tends to spread to internal organs. Metastasize (me-TAS-ta-size): To spread from one part of the body to another. When cancer cells metastasize and form secondary tumors, the cells in the metastatic tumor are like those in the original (primary) tumor. Mycosis fungoides (my-KO-sis fun-GOY-deez): A cancer of the body's immune, or defense, system. This cancer, also called T-cell lymphoma, first appears on the skin. Nonmelanoma skin cancer: Skin cancer that does not involve melanocytes. Basal cell cancer and squamous cell cancer are nonmelanoma skin cancers. Pathologist (pa-THOL-o-jist): A doctor who studies cells and tissues removed from the body, then makes a diagnosis based on changes that diseases cause in these cells. Photodynamic therapy (FO-to-die-NAM-ik): Treatment that destroys cancer cells with lasers and drugs that become active when exposed to light. Plastic surgeon: A surgeon who specializes in minimizing scarring or disfigurement that may occur as a result of disease (such as skin cancer), accidents, or birth defects. Precancerous (pre-KAN-ser-us): A term used to describe a condition that may or is likely to become cancer. Prognosis (prog-NO-sis): The probable outcome of a disease; the prospect of recovery. Radiation therapy (ray-dee-AY-shun): The use of high-energy rays to treat disease. Sources of radiation include x-ray, cobalt, and radium. Risk factor: A substance or condition that increases an individual's chance of getting a particular type of cancer. Sebum (SEE-bum): An oily substance produced by the skin. Skin graft: Skin that is moved from one part of the body to another. Squamous cell carcinoma (SKWAY-mus sel kar-si-NO-ma): A type of skin cancer in which the cancer cells resemble the squamous cells of the epidermis. Squamous cells: Flat cells that look like fish scales and make up most of the epidermis. Stage: The extent of disease. Sun protection factor (SPF): A number on a scale (from 2 upwards) for rating sunscreens. Sunscreens with an SPF of 15 to 30 protect the skin from most of the sun's harmful rays. Sunscreen: A substance that blocks the effect of the sun's harmful rays. Using lotions that contain sunscreens can reduce the risk of skin cancer. Surgery: An operation. T-cell lymphoma (lim-FO-ma): A cancer of the immune system that appears in the skin; also called mycosis fungoides. Topical chemotherapy (kee-mo-THER-a-pee): Treatment with anticancer drugs in a lotion or cream. Tumor: An abnormal mass of tissue that results from excess cell division. Tumors perform no useful body function. They may be either benign or malignant. Ultraviolet (UV) radiation (ul-tra-VI-o-let ray-dee-AY-shun): Invisible rays that are part of the energy that comes from the sun. UV radiation can burn the skin and can cause skin cancer. UV radiation that reaches the earth's surface is made up of two types of rays called UVA and UVB rays. UVB rays are more likely than UVA rays to cause sunburn, but UVA rays pass further into the skin. Scientists have long thought that UVB radiation can cause skin cancer. They now think that UVA radiation also may add to skin damage that can lead to cancer. For this reason, skin specialists recommend that people use sunscreens that block both kinds of UV radiation. Resources Information about skin cancer is available from the sources listed below. You may wish to check for additional information at your local library or bookstore and from support groups in your community. Cancer Information Service (CIS) The Cancer Information Service, a program of the National Cancer Institute, is a nationwide telephone service for cancer patients and their families and friends, the public, and health care professionals. The staff can answer questions (in English or Spanish) and can send free National Cancer Institute booklets about cancer. They also know about local resources and services. One toll-free number, 1-800-4-CANCER (1-800-422-6237), connects callers all over the country with the office that serves their area. American Cancer Society (ACS) The American Cancer Society is a voluntary organization with a national office (at the above address) and local units all over the country. It supports research, conducts educational programs, and offers many services to patients and their families. To obtain information about services and activities in local areas, call the Society's toll-free number, 1-800-ACS-2345 (1-800-227-2345), or the number listed under "American Cancer Society" in the white pages of the telephone book. Skin Cancer Foundation Suite 2402 245 Fifth Avenue New York, NY 10016 212-725-5176 This nonprofit organization provides publications and audiovisual materials on the prevention, early detection, and treatment of skin cancer. The Foundation also publishes Sun and Skin News and The Skin Cancer Foundation Journal, which have nontechnical articles on skin cancer. Send a stamped, self-addressed envelope to receive free printed information. American Academy of Dermatology Post Office Box 4014 Schaumburg, IL 60168-4014 708-330-0230 The American Academy of Dermatology is an organization of doctors who specialize in diagnosing and treating skin problems. It provides free booklets on skin cancer and can refer people to dermatologists in their local area. American Society of Plastic and Reconstructive Surgeons 444 East Algonquin Road Arlington Heights, IL 60005 1-800-635-0635 This Society sends free information about various surgical procedures. It can also provide the names of board-certified plastic surgeons in a patient's area. For Further Information The National Cancer Institute booklets listed below are available free of charge by calling 1-800-4-CANCER. * Facing Forward: A Guide For Cancer Survivors * Radiation Therapy and You: A Guide to Self-Help During Treatment * Taking Time: Support for People With Cancer and the People Who Care About Them * What Are Clinical Trials All About? * What You Need To Know About Melanoma * What You Need To Know About Moles and Dysplastic Nevi * When Cancer Recurs: Meeting the Challenge Again How To Do a Skin Self-Exam You can improve your chances of finding skin cancer promptly by performing a simple skin self-exam regularly. The best time to do this self-exam is after a shower or bath. You should check your skin in a well-lighted room using a full-length mirror and a hand-held mirror. It's best to begin by learning where your birthmarks, moles, and blemishes are and what they usually look like. Check for anything new-a change in the size, texture, or color of a mole, or a sore that does not heal. Check all areas, including the back, the scalp, between the buttocks, and the genital area. 1. Look at the front and back of your body in the mirror, then raise your arms and look at the left and right sides. 2. Bend your elbows and look carefully at the palms, the forearms, including the undersides, and the upper arms. 3. Examine the back and front of the legs. Also look between the buttocks and around the genital area. 4. Sit and closely examine the feet, including the soles and the spaces between the toes. 5. Look at your face, neck, and scalp. You may want to use a comb or a blow dryer to move hair so that you can see better. [Graphic Omitted] By checking your skin regularly, you will become familiar with what is normal. If you find anything unusual, see your doctor right away. Remember, the earlier skin cancer is found, the better the chance for cure. This booklet was written and published by the National Cancer Institute (NCI), 9000 Rockville Pike, Bethesda, MD 20892. The NCI is the U.S. Government's main agency for cancer research and information about cancer. The NCI's publications are free. They may be copied or reproduced without written permission.