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A Dreaded Diagnosis: MELANOMA


By R. David Simon, DO of Simon Family Medicine


“Sir, your biopsy results are back and it’s Melanoma, it’s cancer.”

These are words that no one wants to hear and no doctor wants to say. Melanoma is one of many types of skin cancer and is a leading cause of skin cancer death. The incidence of melanoma has more than doubled in the last 30-40 years. The elderly (especially elderly men) bear the greatest burden of the effects from melanoma and nonmelanoma skin cancer. Basal cell and squamous cell skin cancers are over 10 times more common than melanoma but result in much less death and disability. Squamous cell cancers, however, may account for 20 percent of all deaths from skin cancer. Cancer is the result of damage to the genetic blueprint of cells in the body that are unable to repair or destroy themselves. This occurs due to combining factors including inherited and environmental variables.

Environmental factors such as sun exposure, severe sunburns early in life, large number of x-rays or other radiation exposure, and chemical exposure increase the risk for skin cancer among people with all skin types. The combination of these variables with fair-skin is especially problematic. Those who sunburn readily and tan poorly, particularly those with red or blond hair and fair skin that freckles are at the greatest risk for developing skin cancer. The incidence of melanoma among whites is 20 times higher than it is among blacks; the incidence of melanoma among whites is about 4 times higher than it is among Hispanics.

While what we inherit from our parents is out of our control, we can shape our behavior and adapt to our environment to reduce our risk of melanoma and other skin cancers. Preventive strategies include: reducing sun exposure (e.g., by wearing protective clothing and using sunscreen regularly), avoiding sunlamps and tanning equipment, and practicing skin self-examination.

We can think of skin cancer as the accumulative effect from radiation and other damaging exposure over many years. Based on your genetic background there is an unknown set amount of exposure that will result in skin cancer. We can relate it to the filling of a rain barrel. When the barrel is full, it overflows. When our radiation exposure exceeds our tolerable amount, we get skin cancer. Until we discover how to remove or repair past damage to our skin, we need to cover the barrel or avoid harmful exposure to prevent skin cancer.

Avoidance

Avoiding direct sunlight by staying indoors or in the shade and wearing protective clothing is the most effective measure for reducing exposure to ultraviolet light. Protect your skin from the sun by wearing broad rimed hats, long-sleeved shirts, long skirts, or pants. It is especially important to avoid sun exposure when it is most intense between 10am and 4pm. Avoid surfaces that reflect light, such as water, sand, concrete, and white-painted areas. Remember that skin burns faster at higher altitudes. Avoid sun lamps, tanning beds, and tanning salons. Increased sun exposure in childhood and adolescence is associated with increased risk for non-melanoma skin cancer, which usually occurs in sun-exposed areas such as the face.

Sunscreen

Use high-quality sunscreens, preferably with sun protection factor (SPF) ratings of at least 30 that protect against both UVA and UVB sunlight. Sunscreen should contain the active ingredient of octylcrylene or avobenzone (Parsol 1789) for protection from UVA radiation. Apply the sunscreen at least 30 minutes before going outside and reapply frequently. Use a sunscreen throughout the year, even during the winter. Use a waterproof formula if engaged in water sports or activities which cause profuse sweating. Daily sunscreen use on the hands and face reduced the total incidence of squamous cell cancer in a study in Australia.

While the effect of sunscreen on melanoma incidence is not completely understood, a study showed children at high risk for skin cancers who used sunscreen developed fewer moles than those who did not. There have been conflicting reports about the effects of sunscreen on melanoma. Some studies have found higher risk for melanoma among users of sunscreens than among non-users. Another study found no effect of sunscreen use on risk for melanoma. The conflicting results may reflect the fact that sunscreen use is more common among fair-skinned people, who are at higher risk for melanoma than others. Perhaps sunscreen use gives people a false sense of security encouraging longer stays in the sun without protecting them completely. Sunscreen use is not thought to causes melanoma.

There has been some concern that use of sunscreen (SPF 15) may result in low levels of vitamin D, which requires the body to absorb sunlight for its production. However, a study of people over 40 years old found that sunscreen use over the summer had no effect on vitamin D levels.

Examination

While there has been a study that showed that skin self-examination was associated with lower incidence of melanoma, the greater importance of self-examination and yearly skin survey with your primary care physician is early diagnosis and removal prior to spread or metastasis.
See your primary care physician if you see any concerning or changing spot, sore or growth on the skin. Observe your skin for change in color, size, texture, or appearance. The development of pain, inflammation, bleeding, or itching are also potential warning signs. Your primary care physician is trained to examine and determine if further action is needed. Based on the characteristics of the lesion, a biopsy may be required to arrive at the correct diagnosis. Hopefully the results will come back as benign, meaning noncancerous. That’s good news for all of us.

 

References
U.S. Preventive Services Task Force. Screening for Skin Cancer. Guide to Clinical Preventive Services, 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion; 1996:141-52.
Helfand M, Krages K. Counseling to Prevent Skin Cancer. Summary of the Evidence for the U.S. Preventive Services Task Force. Rockville, MD: Department of Health and Human Services, Agency for Healthcare Research and Quality. Available at http://www.uspreventiveservicestaskforce.org/3rduspstf/skcacoun/skcounsum.htm.
Ries LA, Kosary CL, Hankey BF, Miller BA, Edwards BK, eds. SEER Cancer Statistics Review, 1973-95. Bethesda: National Cancer Institute; 1998.
Elwood M, Jopson J. Melanoma and sun exposure: an overview of published studies. Int J Cancer 1997;73(2):198-203.
Walter S, King W, Marrett L. Association of cutaneous malignant melanoma with intermittent exposure to ultraviolet radiation: results of a case-control study in Ontario, Canada. Int J Epidemiol 1999;28(3):418-27.
Holly EA, Aston DA, Cress RD, Ahn DK, Kristiansen JJ. Cutaneous melanoma in women. I. Exposure to sunlight, ability to tan, and other risk factors related to ultraviolet light. Am J Epidemiol 1995;141(10):923-33.
Swerdlow AJ, Weinstock MA. Do tanning lamps cause melanoma? An epidemiologic assessment. J Am Acad Dermatol 1998;38(1):89-98.
Autier P, Dore JF, Schifflers E, et al. Melanoma and use of sunscreens: an EORTC case-control study in Germany, Belgium and France. The EORTC Melanoma Cooperative Group. Int J Cancer 1995;61(6):749-55.
Autier P, Dore JF, Cattaruzza MS, et al. Sunscreen use, wearing clothes, and number of nevi in 6- to 7-year-old European children. European Organization for Research and Treatment of Cancer Melanoma Cooperative Group. J Natl Cancer Inst 1998;90(24):1873-80.
Westerdahl J, Olsson H, Masback A, Ingvar C, Jonsson N. Is the use of sunscreens a risk factor for malignant melanoma? Melanoma Res 1995;5(1):59-65.
Huncharek M, Kupelnick B. Use of topical sunscreens and the risk of malignant melanoma: a meta-analysis of 9067 patients from 11 case-control studies. Am J Public Health 2002;92(7):1173-77.
Berwick M, Begg CB, Fine JA, Roush GC, Barnhill RL. Screening for cutaneous melanoma by skin self-examination [see comments]. J Natl Cancer Inst 1996;88(1):17-23.

 

 

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