Sleep disturbances and dementia; caring for 'elder orphans'; explaining a common skin cancer: Upstate Medical University's HealthLink on Air for Sunday, March 12, 2023
Public health researcher Roger Wong, PhD, explains the connection between sleep disturbances and dementia. Geriatrician Sharon Brangman, MD, talks about caring for aging seniors who don't have children. Dermatologist Ramsay Farah, MD, discusses basal cell carcinoma and its treatment.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a researcher discusses the connection between sleep disturbance and dementia.
Roger Wong, PhD: ... People that had sleep initiation insomnia had about 51% significantly higher risk for developing dementia. ...
Host Amber Smith: A geriatrics expert talks about "elder orphans" and spouses who unexpectedly become caregivers.
Sharon Brangman, MD: ... It is so important as we get older to make sure that we create a support network. And you don't want to wait until there's a crisis. Because when there's a crisis, then your options may be limited, or your wishes may not be carried out. ...
Host Amber Smith: And a dermatologist explains how basal cell carcinoma is detected and treated.
Ramsay Farah, MD: ... A new spot, a growing spot, a spot that never heals. Those can be signs of basal cells. ...
Host Amber Smith: All that, and a visit from The Healing Muse, after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.
On this week's show, we explore the plans people can make now regarding their care as they age. Then we'll learn about the most common of skin cancers. But first, how are sleep disturbances connected to dementia risk?
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Older adults who frequently report sleep disturbances may have an increased risk of developing dementia. That was one of the findings in research that was recently published in the American Journal of Preventive Medicine.
Here to talk about that research is Roger Wong. He's the author of that study, and he's an assistant professor of public health and preventive medicine at Upstate.
Welcome to "HealthLink on Air," Dr. Wong.
Roger Wong, PhD: Thank you for having me, Amber.
Host Amber Smith: Do I understand correctly that researchers were already aware of a link between sleep disturbance and cognitive impairment, and you set out to look more closely at that?
Roger Wong, PhD: Yeah. We've kind of known about this for several years. But, last year when I was looking at the literature on the link between sleep disturbances and cognitive impairment, I had noticed there's a few problems with the current research on the topic. The first issue is that a lot of this current research is cross-sectional, which means that typically it's just looking at one year of data. So you're not really sure if it's the sleep disturbances that are causing the dementia, or maybe it's the dementia that's causing the sleep disturbances. So that's one problem.
And then the second problem, also, is that I noticed that a lot of this research is looking specifically at specific geographic regions. So for instance, there's one study I saw that was in Baltimore. There was another study in San Francisco, etc., etc. So it was a lot of city-specific research. But I noticed that there wasn't any research that both had, looking at long-term data -- longitudinal data is what we call it in research -- and also I didn't see any study that used a national sample. So that is the reason why I decided to investigate this.
Host Amber Smith: Interesting. So did you set out, did you have a hypothesis? Did you have something in mind that you thought you would find?
Roger Wong, PhD: Based on the current evidence, I pretty much expected that if they had any sort of sleep disturbances, that would increase their risk for dementia. And so, the three specific types of sleeping services that I looked at were sleep initiation insomnia. So that's defined as if they have trouble falling asleep within the first 30 minutes of hitting their pillow. And then the second type is sleep maintenance insomnia. So that is when, like if you wake up at night, but then you can't fall back asleep. And then the third sleep disturbance I looked at is sleep medication usage.
Host Amber Smith: So how many people were in your study?
Roger Wong, PhD: This is actually a study that's funded by the NIH, which stands for the National Institutes of Health. And this is a national sample of older adults who specifically, they have to be Medicare beneficiaries, so they're 65 years and older. And they started collecting this data in 2011, and then they interviewed these respondents in person every single year since 2011. So it's really neat to see and track their changes in their health.
Host Amber Smith: And for me, it's really neat to track how quickly they develop dementia based on whatever sort of lifestyle behaviors. So for me, in the study, I was focusing on sleep disturbances. In that study, I think it was only 6,000 people that were in my sample. But this is nationally representative, so that means that this is representing every single state in the United States except for Hawaii and Alaska. Let's talk about what you found: a 51% increased dementia risk in those who had trouble falling asleep, but a 40% decreased dementia risk in those who would wake up early and then have trouble going back to sleep. Can you explain that?
Roger Wong, PhD: Actually, I think before I continue, I should probably also note that I am -- I will fully admit that I am by no means -- not a sleep researcher. I am a prevention scientist, so I am very interested in finding ways that we can best prevent dementia. And so, specifically I look at modifiable lifestyle behaviors such as physical activity, social contacts, substance use.
So the current focus of this now is sleep disturbances, which is one of the modifiable lifestyle behaviors to prevent dementia. So this is actually my very first paper and study looking at sleep research.
Going back to your question, I did find in my research that those that had sleep initiation insomnia, which again, is if you have trouble falling asleep within the first 30 minutes, those people that had sleep initiation insomnia had about 51% significantly higher risk for developing dementia through the 10-year window of the study. I'm not sure if I mentioned the end year was 2020, but I looked at a 10-year window. That's pretty consistent with a lot of the research out there that's currently looking at this topic.
And then regarding the sleep maintenance insomnia, so again, that's if you wake up at nighttime, but then like you can't fall back asleep, yes, you're right, I did find pretty substantial evidence that if you had more frequent sleep maintenance insomnia, you had about a 40% decreased risk for dementia over time. And that finding is kind of interesting because there's some research that shows sleep maintenance insomnia increases dementia risk, other research that shows that there's no association, and then there's other research that shows there's actually -- same thing as me -- sleep maintenance insomnia increases; dementia risk decreases.
So fortunately, there's been two recent studies that I can think of that found the same exact finding as me. One of them was using a different national sample of older adults. And then there's another national study that was -- I think it was done in Norway -- they also saw that people with sleep maintenance insomnia had a significantly decreased risk for, I think they were looking at cognitive impairment, not dementia specifically. It's really kind of reassuring for me to see that although I was really perplexed by this finding, it seems to actually be consistent with actually the most recent research looking at this.
And I talked about, in the paper, that I think that this might be due to something known as the cognitive reserve. Cognitive reserve is very, you can think of it as something like brain plasticity and brain resiliency. You can't really measure cognitive reserve, but oftentimes, ways that we can increase our cognitive reserve to prevent dementias through cognitively stimulating activities.
So for instance, what really prompted this whole study was actually my father. Right when the COVID-19 pandemic started, he started having sleep maintenance insomnia. So he was waking up at night, and he couldn't fall back to sleep. I was very worried about how this would affect his future cognitive risk, right? What's neat about my job is that I can look at the data and do this myself and find the answers to questions I have.
And so, as I mentioned, my father has sleep maintenance insomnia, and I found in my research that people with sleep maintenance insomnia have a significantly lower risk for dementia. So my theory is that I'm thinking the people that wake up at night and can't fall back to sleep, they're not just sitting there, right? They're actually engaging in activities that are stimulating their brain. So giving the example from my father, yes, he's waking up at nighttime, but he's actually doing activities such as reading the newspaper. Most often, he's actually in the garden gardening. I mean, this is like 4 in the morning; there's, like, some light, so he's actually engaging in activities that might be increasing his cognitive reserve in the long term and decreasing his risk for dementia.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. My guest is Dr. Roger Wong, an assistant professor of public health and preventive medicine at Upstate, and we're talking about research he did recently into the connection between sleep disturbance and cognitive function.
You also found that people who use sleep medications had a 30% increased dementia risk. Do you think something about the medications affects cognition?
Roger Wong, PhD: Yes. There's been quite a bit of research also discussing the mechanism and how sleep medications increase dementia risk. What's kind of the forefront of the theory is that there's certain classes of sleep medications that are what we call anticholinergic.
So, basically they kind of disrupt a neurotransmitter called acetylcholine in our brain, which is really important for learning and memory. And so that's kind of the proposed mechanism in how using certain sleep medications may increase our risk for dementia in the long term.
Host Amber Smith: Some people take medication to help them sleep, and some people take medication that causes drowsiness as a side effect. Did you differentiate between the two?
Roger Wong, PhD: That's a good question. So, again, these sleep questions are asked every single year from 2011. And I was analyzing the data in 2021. So up until 2020, the question for sleep medication, I believe, is something like, "do you use medications to help you fall asleep?" So it didn't differentiate between using medications for drowsiness. This question is more directed at sleep aids, like, "Do you use medications to help you fall asleep?"
Host Amber Smith: Why are racial and ethnic minorities at higher risk of developing dementia than the population at large?
Roger Wong, PhD: That is a separate area of my research. So, I mean, one area of my research I look at ways that we can prevent dementia. And then a second area of my research -- and probably this is actually where I spend most of my time -- is looking at racial and ethnic disparities in dementia risk.
So it's well known in the dementia literature that racial and ethnic minorities have a significantly higher risk for dementia. So specifically, for black older adults, they have about a two times significantly higher risk for dementia. And then for Hispanic older adults, typically the literature says that they have about a 1.5 times significantly higher risk for dementia. And a lot of this is related to something in public health, what we call social determinants of health. So these are oftentimes factors really outside of the individual. For instance, I had a paper I published that I found that racial ethnic minority older adults are more likely, significantly more likely, to live in neighborhoods with higher physical disorder and lower social cohesion. And I found that this might be the reason why it's kind of driving the disparities in dementia risk in later life for racial ethnic minorities.
Host Amber Smith: So disorder would be litter, graffiti, rundown neighborhood, sort of?
Roger Wong, PhD: Yeah. So the three measures that I was looking at, so again, this is actually the same data set that I was using for the sleep dementia paper. And I don't necessarily remember my, I think it was just 2011 through 2019, so it's nine years of data. And the questions about the physical disorder, it's litter, graffiti, and I think the third one is vacant buildings. So I found that if in 2011, the very first year in which that data was collected, if you were living in neighborhoods with higher levels of physical disorder, you had an 11% significantly higher risk for dementia. That's like the first year of the study.
But then I was also interested in, OK, so like later on, by like 2019, when you may have dementia, what is your physical disorder then? Does that also, is that significantly associated with dementia risk too? And it is. So later in life, if you're living in neighborhoods with more physical disorder compared to 2011, you also had a 10% significantly higher risk for dementia.
Host Amber Smith: Now you're not a medical doctor. You're a gerontologist working in public health. One of your research interests you mentioned is modifiable lifestyle behaviors that can help prevent Alzheimer's and related diseases.
What are the most promising modifiable lifestyle behaviors that you see some promise with, that might have an impact on reducing a person's risk?
Roger Wong, PhD: The common ones that are on the list are typically engaging in physical activity, social contact, so this is like interacting with other people. Diet has also been strongly linked to dementia risk, and as we've talked about earlier in the podcast, sleep is emerging in this field because it's a modifiable lifestyle behavior as well. So that's kind of now being included more often on the list as well, if you ever Google "best ways to prevent dementia."
Host Amber Smith: You attended Cornell for your undergraduate degree. How did you decide to study neurobiology?
Roger Wong, PhD: It's a long story, but both of my parents immigrated to the United States, and as a result, they typically were not really around during my childhood. And I was raised by, primarily, my grandparents. So, similar to a lot of other gerontologists, I ended up in the field of gerontology because of my grandparents. They were kind of really the foundation of my childhood because they were my primary caregivers since my parents weren't really around that much. And, it was especially my grandmother that was really, I felt like she was like the centerpiece to our whole family.
And, it was around my last year in high school that my grandmother fell down the stairs, and we later found out that it was because she was starting to develop symptoms from Parkinson's disease. So she was having a lot of difficulty trying to be able to, like her brain was kind of not linking with her legs to work properly. And so I remember in my last year in high school, I was just so surprised how little we knew about not only Parkinson's, but other neurodegenerative diseases. And so that is kind of the reason why I decided to study neurobiology when I did my undergrad at Cornell. And kind of later on I eventually decided to study Alzheimer's disease too.
Host Amber Smith: Well, I appreciate you making time for this interview, Dr. Wong.
Roger Wong, PhD: Yeah. Thank you for having me here.
Host Amber Smith: My guest has been Roger Wong. He's an assistant professor of public health and preventive medicine at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air".
How elder orphans can make plans for their care -- next, on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Many adult children find themselves providing care to their aging parents, but what happens to people who do not have children as they age? Who takes care of these so-called "elder orphans"?
For some ideas about how this might work, I'm talking with Dr. Sharon Brangman. She's a distinguished service professor of geriatrics and the chief of geriatrics at Upstate.
Welcome back to "HealthLink on Air," Dr. Brangman.
Sharon Brangman, MD: Hi. Thank you for having me again, Amber.
Host Amber Smith: Now, some people have spouses who become caregivers, and we'll be talking about that.
But there are also people who live happily on their own for decades, and then there's a health diagnosis or a fall down the stairs, and that suddenly upends their lives. So what happens when there are no adult children or no spouse to step in and help?
Sharon Brangman, MD: So that's a special challenge because we have found that caregivers provide a significant amount of care to people as they get older.
The government actually is happy to have somebody providing this care because it's not easily paid for by Medicare or even certain insurances unless you have long-term care insurance. So caregivers really help older people as they're aging, but increasingly we see people who either outlive all their relatives, or if they have relatives, they're not readily available.
But we also see people, especially women who never married or never had kids or maybe got divorced and have no kids. I also see people who have children who are either estranged or live far away, so they're not readily available to help when somebody starts to need care.
Host Amber Smith: And what happens if an older person with no family nearby arrives at the hospital and they're incapacitated?
Would social workers try to find that person's primary care doctor?
Sharon Brangman, MD: Well, it's more than finding the primary care doctor, because when somebody comes to the hospital in the midst of a medical crisis, there are decisions to be made. And if that person is not able to make those decisions, and if they haven't appointed a guardian or a health care proxy to make those decisions for them, then that creates a problem for the health care team to figure out what is the best thing to do.
So that's one of the reasons why it is so important as we get older to make sure that we create a support network. And you don't want to wait until there's a crisis. Because when there's a crisis, then your options may be limited, or your wishes may not be carried out. So, in particular, if you are what they call an elder orphan or a solo elder, you need to make sure that you start thinking about things way before you need it.
And these are very hard conversations to have, because we have to start thinking about a time when we may not be independent, or we may have an illness that doesn't have an easy cure or an easy fix. And these are tough things to start talking about because we have to kind of confront our mortality and exactly what may be the end of life.
But if you avoid it, you are making a decision. By avoiding it, you are making a decision that you're not going to talk about it right now. And then when something comes up as it inevitably does, the situation can easily get out of control.
Host Amber Smith: If planning ahead is key, what types of things does a person need to consider?
Sharon Brangman, MD: Well, it's very important for older adults who do not have immediate family to have a friend network. They need to create a group of friends, and hopefully some of them are younger than they are. They probably need to call an elder-care lawyer who can help guide them in organizing their finances, setting up a health care proxy.
Although you can set up a health care proxy without an attorney, a health care proxy is someone who steps in when you're not able to make decisions for yourself. And so that should be someone who knows you very well and knows what you would want because you want that health care proxy to not think about what they would want personally, but to really act on your behalf as to what you would want.
And that may involve a long conversation. Again, another tough conversation to have, but a conversation with that person so they really understand what your goals are and what you value.
Some people need to find a geriatric care manager, and a geriatric care manager is a professional who knows the resources in that region and can help arrange home care or a move even. They can help arrange someone to clear out their house if their house is cluttered. They can help you figure out what services you need.
And then you need someone you trust to be a backup for your finances. And that, again, could be an attorney or a trusted friend or even an official at the bank, for example.
So that you have somebody who can back you up financially, legally and in terms of your health decision-making, and then help you manage those decisions that have to be made to help you get through the day.
Host Amber Smith: What do you think about long-term care insurance? Is that a good deal?
Sharon Brangman, MD: So, long-term care insurance can be an important tool to help you finance your home care or your nursing home care. It is very expensive, so many people do not have the financial resources to afford it. And of course, the longer you wait to get it, the more expensive it is. So, that can be an important tool, and that would be something to talk with your financial adviser with to see how that would help.
Host Amber Smith: And I think a lot of people presume that Medicare will just take care of everything they need, but that's not the case, right?
Sharon Brangman, MD: That is the No. 1 conversation that we have with families because they think Medicare will pay for home care.
Medicare will pay for your hospital stay. It will pay for doctor visits. If you have Medicare Part D, it will pay for medications.
But for that day-to-day care that you need for someone to help you get dressed or take a bath or get to the grocery store, that is not covered by Medicare. Medicaid is a different program, and it's for people who are financially stressed and don't have any money, and Medicaid will provide some services, but usually not enough to meet most people's needs.
So Medicaid is an incomplete way of getting care in your home. It is, however, the biggest payer for nursing home care.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Sharon Brangman. She's a distinguished service professor at Upstate and the chief of geriatrics.
If an older person who has a spouse becomes ill or injured, the spouse may be thrust into the role of caregiver, especially if there are no children who are able to help. Do you see that happen often?
Sharon Brangman, MD: So, yes, that is a very common phenomenon that comes up. Long-term spouses, for better or for worse, for sickness and in good health, are the ones to provide that support.
Now, even with the best of intentions, sometimes that spouse is not able to provide that support because of their own age or health problems. Or what we see is that we'll have two spouses or two partners who have health changes that happen on a different trajectory. So one may be further down the path of needing help than the other.
So this is another situation where you have to have that clear conversation. As tough as it can be, you have to have that conversation to start to make good decisions. For example, I've had some couples where they decide that, they want to stay in their own home, and one of them may need home health assistance, but the other one doesn't.
Or both of them may need home health assistance, but one may need more than the other. So, they, again, may need help identifying a person who could come in. This is where a geriatric care manager can be very helpful. And you can have two people in the same household getting some assistance, but each one has different needs.
Another option is to move into assisted living, where one person can get more care than the other. So we have a number of assisted living facilities in our area, which range from totally independent care, where you live in your own apartment, to more enriched care, where you have somebody come in to either give you medications or to help you get started in the morning or get ready for bed or whatever the needs are.
And again, one partner may need more care than the other, but they're in the same place.
Host Amber Smith: Sudden life changes, like we're talking about, can be difficult and challenging for all involved, and there's a lot of medical considerations as people age, but there's also emotional issues that come up, and I wanted to get your input on a couple of situations that listeners may be able to relate to.
The first one is a husband who was a working professional was married to a wife who kept the household. The husband had surgery and suffered a stroke, and since then, as the man has declined, the wife has been angry toward him to the point of verbal abuse, something a close friend has recognized.
What could this close friend do to help the situation?
Sharon Brangman, MD: So, this is actually not an uncommon situation. Even if somebody has the best of intentions, caregiving is very, very hard. And if you are working or have other responsibilities, it is extremely stressful. So to me, that is a caregiver who needs help.
There are, again, people who can come in and help assess the situation and see exactly what the care needs are.
You need an assessment of the financial resources to see what is affordable and then figure out a way to give that caregiver some respite or relief. You need to have a breather. Caregiving can be 24/7, 365 days a year, and many caregivers put the needs of their loved one ahead of themselves, so we have had caregivers who don't sleep well, don't eat well, may miss their own doctor's appointments because they're taking care of their loved one. And they are not healthy either, physically or emotionally. Everyone needs a break, and we need to help them figure out how to make that happen. It doesn't mean that you are weak or incapable, it just means that you're human, and you can't do it all by yourself.
Host Amber Smith: Another couple are retirees for more than 10 years, and both have been very active over the years. Now all of that activity has taken a toll on one of the partners, requiring repeated joint replacement surgeries, plus the development of an autoimmune disease that leaves this person fatigued. So, the partner who remains healthy is finding it hard to be gracious about declining abilities and thinks about all of the things they can no longer enjoy together and fears that the world is closing for them, too.
Is there anything that can help in this situation?
Sharon Brangman, MD: So, again, very common for two people to have a different health trajectory. So this is another opportunity for a discussion to talk about a way for one person to maybe maintain some of those previous activities that they enjoy doing and provide some respite for that person to get away and enjoy those activities and maybe the relationships associated with it, but make sure that the person who needs the care isn't being neglected and can get that support also.
It is hard. Most people can't do it on their own, and that resentment can often make people feel guilty. It makes feel like they're a bad person or they're selfish.
But it's a very normal reaction when you are faced with a huge, overwhelming problem to solve, and it just highlights that you need help to work it through. People feel like they're in it alone, and nobody has ever gone through something like this before, when in actuality it's very, very common and you don't have to reinvent the wheel, because most of us who do this kind of work every day have seen so many of these situations. And there is support and there are resources out there. And we happen to live in an area, in Central New York, where there are resources that people can draw upon.
Host Amber Smith: Regarding mental and emotional problems of patients and of their caregivers. I'm talking about depression, anger, envy, others. These things might arise as the situation changes, but is it best to be proactive in some way or to wait and see if these things become a problem?
Sharon Brangman, MD: Well, it really depends on the person, because sometimes we worry about things that never happen. But it's also good to know what the possibilities are and what your options would be should they arise.
So this is where education is very important to kind of understand the disease trajectory, the care needs that might come up, so that you're aware of the options that are out there, and that you can sometimes get help predicting when you might need it. And that's one of the things that happens when you get a geriatric assessment in our office, is that sometimes we can help you see when those red flags may be waving.
So we do what's called anticipatory care, and we have things in place in anticipation of a need. Sometimes we can all be taken by surprise. Then you'd be able to gather those resources as quickly as you can.
Host Amber Smith: Dr. Brangman, I thank you so much for making time for this interview.
Sharon Brangman, MD: You're welcome. It's always a pleasure.
Host Amber Smith: My guest has been Dr. Sharon Brangman. She's a distinguished service professor of geriatrics and the chief of geriatrics at Upstate.
I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air" -- what to do about basal cell carcinoma.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Basal cell carcinoma is the most common form of skin cancer, and we'll learn all about it from my guest, dermatologist Ramsay Farah. Dr. Farah is an associate professor and division chief of dermatology at Upstate.
Welcome back to "HealthLink on Air," Dr. Farah.
Ramsay Farah, MD: Thank you. It's good to be here.
Host Amber Smith: Basal cell carcinoma was in the news not too long ago when first lady Jill Biden had surgery to remove a spot, and her doctor wound up discovering and removing a second spot at the same time. Is it typical for there to be more than one of these skin cancers that need to be removed?
Ramsay Farah, MD: Yes. I would say it is quite common. It's common in the sense that if you've had one skin cancer, you've had enough kind of DNA damage to your skin to produce sufficient DNA changes, that it's going to be much more likely, statistically, to get a second skin cancer. So usually people with one skin cancer, I would say, very often have another skin cancer down the line when more time has passed.
But I have seen many times in our practice, the concurrence of two simultaneous basal cells. So it does happen fairly frequently.
Host Amber Smith: How serious is basal cell carcinoma?
Ramsay Farah, MD: Well, of all of the skin cancers to get, it's probably the one that is the most favorable to get. And the reason I say that is because it's very slow growing. It rarely, if ever, metastasizes, which means it spreads to other parts of the body.
Now, that's not to say that it can't do that. It can. So certain basal cells that are neglected for many years, like, five years or 10 years, and of course, how easily they metastasize also depends on where they occur. So if it's occurring on the back, it's much less likely to spread.
But if it's occurring anywhere on the head and neck area, near the eyes, or the ears, for example, then it can actually spread and track down some of the fascial planes of the face and so forth. So the bottom line is, if you want to say, it's a good cancer to have, I suppose you could say that in the sense that it's very slow growing, and if it's not neglected, by and large, it's easily treated without a problem.
But again, the qualifier is if you neglect them, they can be trouble. And metastasis is one way that they can be trouble. But the more common way they can be trouble is they can be locally destructive. So for example, If you have a basal cell on the nose, while it may not spread to other body parts, it can certainly degrade the nose and involve a large part of the nose so that the surgery could be very, very extensive.
Host Amber Smith: What is a basal cell, anyway? What is its job in our body? Why do we have basal cells?
Ramsay Farah, MD: Basal cell is the bottom most cell in your skin. There are several layers to the skin. There's the epidermis, the top part; the dermis, the middle part where all of your collagen is; and then there's the fat layer. Oftentimes people don't think of the fat as part of the skin, but it is. So if we go back to that very top layer, the epidermis, the epidermis itself has multiple layers, the bottom of which is comprised of these basal cells. And they are defined as pluripotent cells. So in other words, they are the cells from which your skin is made.
They are the cells that differentiate into the different parts that make up your skin. So that is their job. They are kind of like the stem cell of the skin. And, they can get DNA damage as well. And when they do, they proliferate in an uncontrolled manner. Proliferate means they kind of grow, and grow, and grow and they never stop. And that's when you get a basal cell.
Host Amber Smith: So how would somebody know that they have basal cell carcinoma?
Ramsay Farah, MD: Clinicians are -- specifically dermatologists, of course -- are trained to recognize the clinical features of basal cells. And I can go through those characteristics that clinicians use.
But for the layperson, basically you want to watch out for a new spot on your skin, a spot that bleeds very easily. And by that I mean if you're toweling your face off after a shower, and you've got a spot that consistently bleeds, that's not a good sign. A spot that is eroded and just keeps coming and going, healing, and then gets eroded again, that's another sign. And then, a spot that's actually growing. So a new spot, a growing spot, a spot that never heals. Those can be signs of basal cells.
So almost certainly they will show up in sun-exposed skin, the most DNA damaged skin from the sun. So the rates of basal cell are going to be more common on the head and neck area than they are on the foot, for example. Now that doesn't mean you can't get a basal cell anywhere on your body. You can -- even in the groin area, that's of course, covered much more than the face. So, sun is the major driving force for basal cell cancers, and that's why sun-exposed areas are going to have them more commonly than non-sun-exposed areas. But I do want to make clear that anywhere where you have skin, you have the potential of getting a skin cancer.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Ramsay Farah. He's the chief of dermatology at Upstate, and we're talking about the most common of skin cancers, basal cell carcinoma.
I'd like you to compare basal cell carcinoma with squamous cell carcinoma. We hear about that, as well. What is the main difference between those two types of skin cancers?
Ramsay Farah, MD: So basal cell is the most common skin cancer in the skin. It's also, incidentally, the most common human cancer. Squamous cell is number two in terms of its frequency in the skin. And one of the main differences is the cell of origin. So basal cells come from basal cells, and squamous cells come from keratinocytes, which is another skin cell in the epidermis of the skin, that top layer of the skin. So, basal cells kind of tend to look a little more pearly. And what I mean by that is, when you shine a light on it, they sort of reflect the light the way a pearl would. Also, you can sometimes get the illusion that you're looking through the skin when you're looking at the basal cell. And basal cells have very tiny telangiectasias on them, or kind of very tiny broken capillaries that you can see.
Squamous cells, on the other hand, look keratotic, more keratotic, which means they produce a lot of scale. They can produce what looks like a horn on the skin. They can tend to be a little bit more painful clinically, and they tend to grow faster on the skin than basal cells do. And squamous cells have more of a propensity or more of a chance of spreading than basal cells do. So they grow faster, and they can metastasize or spread more easily than basal cells, and they look like they've got a lot of hard, sort of crumbly-like scale on top of them, versus the basal cells.
Host Amber Smith: Do you have to differentiate which one you're dealing with before you start treatment?
Ramsay Farah, MD: Yes. So it's always a good idea to know what kind of a skin cancer you're dealing with so that you can focus your treatment most accurately.
There are so many factors that dictate what kind of treatment you're going to get, whether you're going to have a surgery, what kind of surgery, what kind of clinical margins you want to excise, whether you are going to elicit the help of colleagues in a multidisciplinary approach, like an ENT colleague, a plastic surgery colleague, an oncology colleague, which is a cancer doctor. All of those things are means by which we can approach and treat a skin cancer. And, we use them to varying degrees, depending on the cancer. So I'm much more likely, for example, to have the help of an oncologist when I have a melanoma on my hands than when I have a basal cell.
So yes, it's actually not just nice to know what skin cancer you're dealing with. I think it's an absolute necessity for the doctor.
Host Amber Smith: So what are the treatment options for basal cell carcinoma?
Ramsay Farah, MD: They are many, and they range from old treatments to new treatments. They range from creams to surgeries. But, in short, one of the older -- I'll start off with the older treatments that's really fallen out of favor, just for completeness -- but in the past they used to freeze basal cells. So if you froze a basal cell with liquid nitrogen, which is a very, very cold spray, you basically froze the skin that was involved with the basal cell, and you killed that skin, and it basically scabs off, and it takes the basal cell with it. So that is an old way of treating it, but it's fallen out of favor because it results in unacceptable scars in terms of today's standards, and also the cure rates are not really acceptable given some of the better treatments we have.
Freezing is one thing. You can also, depending on the subtype of the basal cell, meaning if the basal cell is a very thin basal cell and it's not occurring on areas of skin that have hair, you can do an electrodesiccation and curettage, which means that you can basically burn and scrape it off.
Similarly, those very thin basal cells not found on hair-bearing areas -- so, for example, on the forehead would be an example of a non-hair-bearing area. You can also use one of two chemotherapy creams, and you can use a cream against it. So you can use a cream, you can burn and scrape it off. In the past we used to freeze them off.
But, more and more the standard of care is becoming surgery, right? So you would just cut it out, and again, how you cut it out depends on where it is. So generally speaking, if you have a basal cell on the head and neck area, meaning anywhere from the neck up, you can do a special kind of surgery called Mohs surgery, M O H S. And what's special about Mohs is that it has the highest cure rate, anywhere between 98% to 99% for a first time basal cell. And, it's tissue sparing. So it means we can achieve that cure rate without cutting off a lot of extra skin, which is, of course, more important on the head and neck area than it would be on your back, where there is lots of extra skin. So you can do Mohs surgery. You can also excise them, meaning you can cut them out in a more traditional way that is non-Mohs.
And finally, two other options for very large basal cells or inoperable basal cells for whatever reason, whether they're large or the location or the age of the patient and their underlying medical conditions, which would make them a poor surgical candidate. You can use radiation against basal cells.
And then the very last modality is to give an oral chemotherapy agent, and there are a couple of new medicines out that increasingly have been used in basal cell, and they're used either as a primary treatment. Or even to shrink the basal cell down, if it's one of those very large neglected tumors that we were talking about earlier, you can shrink them down with these medicines and then do a surgery, which would be far less heroic when it's smaller. There's really a large selection of possible treatments.
Host Amber Smith: And when you say "cure rate," that means it doesn't grow back after it's removed?
Ramsay Farah, MD: Yeah, exactly. So it doesn't grow back. Now that doesn't mean you can't get another one at a different location, right? Because that depends on how much DNA damage is in your skin. But for a lesion itself that is a first time basal cell treated with Mohs, yes, that cure rate can be 98 to 99 percent.
Host Amber Smith: And then we talked a little about this at the beginning, but if someone has basal cell carcinoma, never has it diagnosed, therefore never has it treated, what might happen to that basal cell carcinoma? Will it keep spreading?
Ramsay Farah, MD: Yeah, I mean, it'll keep spreading essentially forever. So it'll keep going and going and going. And that's the kind of scenario where you can get into trouble, depending on where it is, right?
So if it's a basal cell that's close to your eye, then, in fact, it can metastasize. It can go into the eye and then potentially into the brain.
If it's on your scalp, it can start to erode away at the bone. So those scenarios are the scenarios that result in the most trouble and morbidity, and even mortality, meaning death for a patient. Again, for a basal cell, it's rare, but the point you're trying to make is very important. If you don't treat a basal cell, it's not going away. It's going to keep growing forever.
Host Amber Smith: Well, Dr. Farah, I really appreciate you making time to tell us about basal cell carcinoma. Thank you.
Ramsay Farah, MD: My pleasure.
Host Amber Smith: My guest has been dermatologist Ramsay Farah. He's an associate professor and division chief of dermatology at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Alice Irwin is a poet and a cancer survivor from Manlius, New York. Her poem "A Visit to the Emergency Room" gives a damning portrait of what it means to say our hospitals are understaffed and over-busy. We need to do better.
"A Visit to the Emergency Room"
I found my brother at the end of the corridor
on a gurney shoved up against the wall,
hooked up in a space with a number,
docile, dazed, pale and confused,
needing help to fill in the blanks.
I staked my claim on a folding chair
and a tiny patch of hallway,
prepared to stand guard for another siege:
the endless weight between tests and results
and the usual barrage of redundancies.
He struggled to rise from a seizure fog and
make sense of what was happening to him.
We waited for hours, overlooked and ignored
amidst the constant drone of buzzers and beepers,
also unheard and unnoticed.
I finally managed to corner a nurse who
tracked down the doctor in charge.
Discharge papers were stuffed in my hand with
"So sorry, so busy, go follow up elsewhere."
Beside me, my brother limped down the hall,
out into the dark, a forgotten phantom.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," how patients can navigate crowded hospital emergency rooms.
Deirdre Neilen, PhD: If you missed any of today's show or for more information on a variety of health, science and medical topics, visit our website at HealthLinkonAir.org.
Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Bill Broeckel.
This is your host, Amber Smith, thanking you for listening.