Women in their 20s are seeing an increase in this skin cancer

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. It's less common than other skin cancers, but melanoma is more likely to grow and spread. Today I'm talking about melanoma with Dr. Daniel Thomas. He's an assistant professor of surgery at Upstate who specializes in complex general surgical oncology. Welcome to "The Informed Patient," Dr. Thomas.

[00:00:33] Daniel Thomas, MD: Thank you for having me.

[00:00:35] Host Amber Smith: Can you describe what melanoma skin cancer is?

[00:00:38] Daniel Thomas, MD: Melanoma is a type of cancer that starts in certain cells in a patient's skin. It's the cells called melanocytes, which are the cells in our skin that produce the pigmentation or the color. And sometimes these cells can grow out of control, which is when it becomes a tumor, or when it becomes cancerous.

[00:01:03] Host Amber Smith: Where on the skin are these typically found in women and men?

[00:01:09] Daniel Thomas, MD: So the majority of melanomas that are found occur in sun-exposed areas. And we know that in men that is usually on the upper back, certainly on the head and the neck. And in women, it's those same areas, but also they're more likely to have a melanoma diagnosed on their lower extremities, or their legs, also.

[00:01:37] Host Amber Smith: Interesting. Now, what about, are all races affected by melanoma, or do darker skinned people, are they protected from melanoma?

[00:01:47] Daniel Thomas, MD: We've shown that by looking back throughout history, that the highest risk of having a melanoma are lighter skinned patients, usually, most commonly of northern European descent that are then exposed to a lot of sunlight.

So we know that the, for example, people in Australia, in New Zealand have one of the highest incidents of melanoma, because much of the population is of northern European descent and then moved to an area with a lot of sun that they're exposed to. So that's, kind of a good instance of the risk of melanoma from sunlight, or UV rays. And so it does affect all races. However, lighter skin, fair hair are more prone to having a melanoma from sun exposure.

[00:02:47] Host Amber Smith: Are there any other risk factors, besides being fair-skinned, that put a person at risk for melanoma?

[00:02:53] Daniel Thomas, MD: Well, we know that it's things like having a family history of melanoma in your first degree relatives. Other things like having a lot of moles on your body. And that's just because many melanomas first were moles that developed into a melanoma. So just having more moles increases your risk of having it. But the, like I said, the main risk factor is the UV rays, causing damage to these melanocytes, which eventually develop into melanoma.

[00:03:31] Host Amber Smith: So with that in mind, is sun protection the way to prevent melanoma? Is that a sure thing?

[00:03:37] Daniel Thomas, MD: We wish it was a sure thing. It's definitely one of the best things.

Sun protection includes the best way that we would recommend is covering up, clothing, which can be difficult at times, certainly in recreation during the summer months. So we do certainly recommend using hats and shirts when able, however, sunscreen when you can't do that. We generally recommend an SPF (sun protection factor) of 50, however, some people are OK recommending an SPF of 30. It's important to make sure you have it on you reapply. It's not a perfect prevention. So even with sunscreen, your skin is exposed to those UV rays, but it is definitely something that is very helpful.

We know -- going back to the risk factors -- with sun exposure, we have shown through some good data that even as few as two or three sunburns, blistering sunburns, in childhood or adolescence can increase your risk of having a melanoma later in life. It's something that we call, or we think of as a cumulative sun exposure. So even exposure early in life, decades down the line, can increase the risk of all skin cancers, which are squamous cell carcinoma, basal cell carcinoma and melanoma, melanoma being the most worrisome and most difficult to treat.

So even children who get sunburned can have an increased risk. So that's why early in life, protection from the sun is also important.

[00:05:31] Host Amber Smith: So it sounds like most melanomas appear in older adults, not children, and because it's a cumulative thing, right?

[00:05:39] Daniel Thomas, MD: Right. Yes, exactly. And even saying older adults ... we're seeing it now in younger adults, women in their late 20s. It's the most common cancer of women in their late 20s, 25 to 29. It's the second most common cancer in women -- this is in the United States -- of women age 30 to 35 after breast cancer being the most prevalent. And melanoma comes in No. 2.

And so yes, it increases later in life. But, even for patients that I don't consider too much older, in their 20s and 30s, have a significant risk. It's something certainly to look out for.

[00:06:28] Host Amber Smith: Is that tied to tanning salons?

[00:06:32] Daniel Thomas, MD: We think it is. You know, the data that showed that are in the last decade or so, and we know that tanning beds really hit their height in the 90s and 2000s. And so what I think we're seeing, certainly in the United States, is some of that now coming into play and not just tanning beds, but just the predilection for younger women to sunbathe, as well. So yes, I think that is what we're seeing there.

[00:07:00] Host Amber Smith: So do we know what makes melanoma develop? Why does it choose someone at age 20 and another person at age 70? Is there something else intrinsic in the body that makes it go into melanoma?

[00:07:14] Daniel Thomas, MD: We don't know. We don't have a great grasp on why somebody in their 20s with only a decade's worth of sun exposure would get a melanoma when somebody who lived into their 80s with lots of sun exposure, never had a melanoma.

I like to think of it as a similar situation where somebody who never smoked in their life gets a lung cancer at age 40, but then there's somebody who's in their 80s and smoked their entire life and never had a lung cancer. We don't have a perfect prediction tool of who's going to get it.

Like I said, having more moles and having fairer skin, that is more likely, the UVA rays are more likely to damage these melanocytes and cause a melanoma.

[00:08:06] Host Amber Smith: So let's talk about how melanomas are diagnosed. What do they usually look like?

[00:08:11] Daniel Thomas, MD: Most melanomas are diagnosed either by primary care doctors or dermatologists. And really what they are looking for are what we call the A B C D E rule. And so that's looking at a specific pigmented or dark mole and assessing the characteristics of how it works.

And our A B C D E rule is that the mole is Asymmetrical, or it's not a perfect circle or oval. And B is the Border; if it has what we call irregular borders, and that's if the edges of it aren't kind of confined, it can jut out and have kind of finger-like projections on it. The C is Color; if a mole has more than one different color, often if it's a melanoma it will be a light brown or maybe a medium brown mole that has an area or two within the mole itself that is much darker, darker brown, or even black. And then the D is for Diameter; most moles are within the size of about the end of an eraser tip on a pencil, which is about five to six millimeters, and so when they get larger than that, even in the absence of some of the other characteristics, it's something that many primary care doctors or dermatologists will just keep a close eye on, if not biopsy. And then the E is Evolution, which means that you had this mole, you know it was there, it's been there for years, or maybe just a few months, but then you start to notice it changes, or evolves. And really any change over the course of months to a year or two is something that should probably be brought to attention, because most moles don't change over the course of that short time period. People can have moles their entire life that change over many years or decades, but when they change in a shorter interval, it's something to bring up.

And then the last one, and this one is important for people who have many moles, is what we call the "ugly duckling" sign. It's you have a lot of moles and this one that you just noticed doesn't look quite like the others, for one reason or another. People who have a lot of moles, they tend to all look similar and scattered throughout whichever part of their body. But if there's one that just doesn't look like the other, the ugly duckling sign, that's something you should probably bring up as well.

And so these are usually, like I mentioned, diagnosed by primary care doctors or dermatologists who are performing thorough skin exams and really keeping track of a patient's moles and skin lesions over the course of, many visits so that we can get a good idea of what is changing and what's just staying the same.

[00:11:16] Host Amber Smith: So if there's a suspicious mole and it gets biopsied and it's found to be a melanoma, can you tell from that biopsy whether the cancer has spread?

[00:11:28] Daniel Thomas, MD: The main treatment for melanoma and the prognosis of a melanoma is determined primarily by the depth of the melanoma. It starts on the skin. And most melanomas spread what we call laterally, or on the surface of the skin. And the majority of melanomas don't penetrate deeply down into the skin. And it's the deep penetration into the skin layers, through what we call the superficial is the epidermis, and followed by the dermis underneath it. It's when melanomas grow downward, or vertically, that we become more concerned.

And so we look at the depth of invasion in the number of millimeters. And we classify them as what we call a thin melanoma, which is less than one millimeter, and then an intermediate melanoma, which is two to four millimeters, and then a thick melanoma, which is greater than four millimeters. And that really determines how worried we are, and it determines the aggressiveness of the surgery that we're going to do.

We know that once we have found a melanoma, and it's been biopsied, and that gives us the depth of the melanoma, and then we stratify it into those three thin, intermediate, and thick categories. We know that melanomas, when they spread, the most common place they spread is to the lymph nodes. We have clusters of lymph nodes underneath our armpits, in our groins, many other places, on the head and neck, along the neck and underneath your jaw. And so the first way that we look to see if there's any spread is by feeling those lymph nodes. If you have a melanoma on your arm, the first place I'm going to feel, or palpate, during a physical exam is underneath your armpit to see if there's any enlarged or firm lymph nodes. That's the first test to see if it has spread.

And like I mentioned, the majority of melanomas that we diagnose are early, or thin or intermediate melanomas, and those have a lower risk of going to the lymph nodes. And so most patients are treated for their melanoma with what we call a wide local excision, which is just taking the skin around the melanoma, cutting it out with the whole layer of skin and some of the tissue below. And then that is the only treatment that most patients get for their melanoma.

Now, of course, if there is concern for lymph nodes or we do a special test called sentinel lymph node biopsy on some patients, then once the lymph nodes are involved or concerned to be involved, then we start talking about bigger surgeries that involve the lymph nodes.

[00:14:46] Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, and I'm talking with Dr. Daniel Thomas, a surgical oncologist at Upstate. Our topic is melanoma.

I know a lot of dermatologists remove many skin cancers. Does a surgeon like yourself get involved when it's melanoma, or how do you determine who sees the patient, the dermatologist, or the surgeon?

[00:15:11] Daniel Thomas, MD: The answer would be both of us, both the surgical oncologists and the dermatologist, because most melanomas are thin, and dermatologists do a great job of removing those with that wide local excision we talked about. And when it's thin like that, there's less concern for lymph nodes being involved, and the primary treatment is to remove it, and dermatologists do a great job of that.

However, when it starts to get thicker into the intermediate area, we start to talk about having to do a biopsy of the lymph nodes to confirm that there is no melanoma in the lymph nodes, and at least in the United States, dermatologists don't routinely perform that. And so that's when dermatologists reach out to the surgical oncologists, and then we kind of take over the care of that melanoma by removing the primary melanoma and testing the lymph nodes.

And so that is usually done once you get to what we think of as the intermediate melanomas like we talked about, and certainly some thin melanomas.We have a really great dermatology community in Syracuse and the surrounding areas, which I've been fortunate to work with, and many of them send their melanoma patients to us here at the Upstate Cancer Center, just as routine so that we can have a multidisciplinary approach to these patients and get more than just one opinion on the next step in treatment.

It's also common to be referred to somebody like myself, a surgical oncologist, to talk about the melanoma, even once it's been completely dealt with by the dermatologists. It's just, it's part of what we do in surveying these patients going forward, to make sure that they're well taken care of and there is no concern for a recurrence of a melanoma.

[00:17:16] Host Amber Smith: What are survival rates like for melanoma?

[00:17:19] Daniel Thomas, MD: The survival rates for melanoma certainly vary. The majority of patients are diagnosed at stage one and stage two. Stage one and stage two melanomas are the thin and intermediate melanomas that have not spread to any lymph nodes. And those patients have what we call melanoma specific survival, which is the likelihood of them dying from their melanoma cancer. And so in patients with stage one and stage two cancers, it ranges from 85 to 99%. Of course the lower number there, and the 80 to 85%, are patients with thicker melanomas, and so into that intermediate zone.

And somebody who has a thin melanoma, under one millimeter, and we don't have any concern for lymph nodes, they have a very, very good prognosis. Those are the people that we look at and say, you have 10 years down the line, there's a 95 to 97, 98% chance that you're not dealing with this melanoma, and we're just keeping a close eye on you, and you don't have much to worry about.

It's when the melanoma spreads to the lymph nodesthat we really start to see the melanoma specific survival numbers go down, and that can be into the 50s to 60s. When we look 10 years down the line, of course those numbers are changing because we're getting better and better therapies for melanoma. But it is still something, like we talked about at the beginning, it is still the most aggressive form of the skin cancers and something that we need to keep a very close eye on.

[00:19:07] Host Amber Smith: What about recurrence rates?

[00:19:09] Daniel Thomas, MD: The recurrence rates for melanoma are not very high when we talk about the thin and intermediate melanomas. Similar to the overall survival, you have a higher recurrence rate when you have it in your lymph nodes.

And so when we do a risk / benefit conversation with the patient. If we know that it's in your lymph nodes, through that biopsy that we sometimes do, the sentinel lymph node biopsy, If it's in your lymph nodes, we have a conversation about using what we call adjuvant treatment, or follow up treatment. We've done the surgery and we've removed all the visible melanoma that we can, but we know that you still have a higher than average risk for that to return. An adjuvant therapy helps to reduce that risk. And in melanoma, that is the mainstay of treatment, which has been groundbreaking in the last decade or so, is the use of immunotherapy.

And so that has been a huge help in helping those numbers that I talked about before in patients with spread to the lymph nodes, that has been a huge help in helping those patients overcome their melanoma and continue to have a great overall prognosis after they've been fully treated with surgery and the immunotherapy.

[00:20:41] Host Amber Smith: I imagine the thinner melanomas can be removed in an outpatient procedure or in a doctor's office, but do you ever have the more extensive cases that have to be done in the hospital where the patient ends up staying overnight?

[00:20:58] Daniel Thomas, MD: Yes. Most melanomas if they're removed in the office are done under local anesthesia, just numbing up the area nicely and removing it.

If the patient's referred to me, most of my operations I do in the operating room. And that's because I have to take for even some of the thin melanomas and certainly anything thicker than that, we have to remove the skin for several centimeters below the superficial skin. And so we've found two things. One, the patient is certainly more comfortable. We use some anesthesia with our anesthesia colleagues, not to the point where you're completely asleep or having to have the anesthesiologist breathe for you with any tube in your lungs. But, it's just kind of like you go to sleep and wake up within a few minutes after we're done. And so it's more comfortable for the patient.

And secondly, some of these are in sensitive areas, so on the head, the neck, certainly on the arms and legs, it can be a little more tricky to do those operations. In order to do the full surgery and remove the melanoma and close the skin so that it heals nicely, it takes a little bit more surgery. And so we found that that works better in the operating room. And certainly if we have to do any procedures like the sentinel lymph node biopsy on the lymph nodes or a complete lymph node surgery, that should be done in the operating room.

Now that being said, the majority of patients that we see and do these operations go home the same day. This is usually a same-day surgery.

[00:22:50] Host Amber Smith: Are your patients concerned about scars?

[00:22:52] Daniel Thomas, MD: I certainly have patients who are concerned about scars. The main issue that we run into is melanomas on the head and neck. When you think about having the margin around the melanoma, or the area of healthy skin that we have to take around to make sure we get all the melanoma cancer cells, can be one to two centimeters. And that doesn't sound like a lot, but when it's in a sensitive area on the head, on the neck, or sometimes when it's on the arms or legs near the joints, that can be a little more difficult to remove that amount of skin and have it heal nicely. And so we certainly have patients who are concerned about their scars, and we work closely with our plastic surgery colleagues.

We have a specialized team here of head and neck surgeons, or ear, nose and throat surgeons who specialize in melanoma of the head and neck and do different types of what we call reconstructions or moving skin around, doing what we call flaps to improve the cosmetic outcome of these after surgery. So most patients I talk to say, "I, you know, I don't care what it looks like. I just want this gone." We want that as well, but we know that we can do both. We can reduce the cosmetic issues after surgery when it's carefully planned out and you have the right team involved.

[00:24:29] Host Amber Smith: Should patients who are diagnosed with melanoma let blood relatives know about the diagnosis because they might be at an increased risk?

[00:24:39] Daniel Thomas, MD: Certainly. Yes. Having a thorough understanding of your family history of cancer in first degree relatives, second degree, really as much as you can, as much as you're able to get, is important.

Melanoma isn't a cancer that we think has a huge genetic component to it, but we certainly have tracked families where it happens down the line of family members. The majority of melanomas are what we call sporadic, or just arose because of many of the risk factors we already talked about.

But we certainly know that a proportion of these are somewhat familialy related. We have a few genes that we've looked at, that are associated with melanoma, but nothing to the point so far where we've said, if you have this gene, we've really got to keep a really close eye on you because you're at an increased risk. We've certainly done that with other cancers, like breast cancer and the B R C A gene. We don't have anything like quite like that for melanoma.

[00:25:51] Host Amber Smith: Well, before we wrap up, I wanted to ask you about medical care and what that's like after melanoma treatment. Is there anything that you do or advise patients to do to reduce the risk of recurrence?

[00:26:05] Daniel Thomas, MD: When I think about follow up after melanoma, I think of things in two different buckets. The first would be we've completely removed the melanoma that we can see with a surgery. And the next step is to do two things.

One, talk about lowering the risk of this coming back. And that's done with usually immunotherapy, which is given by our medical oncology colleagues. And immunotherapy is a medical treatment that goes throughout your whole body. So it has similarities to chemotherapy in that it can treat a cancer cell wherever it is in your body but is much better tolerated than chemotherapy. It uses your body's own immune system to fight cancer cells wherever they are in your body. And so it ramps up your immune system to fight those cancer cells. And Melanoma has been one of the types of cancer that. Immunotherapy has taken the forefront of treatment because it works so well in melanoma, compared to some other cancers where it doesn't work as well.

And then the second thing, after you've had your treatment for your primary melanoma is to keep a close eye on you. And that is truly where it becomes a multidisciplinary approach because we follow patients every three to four months. And I follow the patients every three to four months to check up on the area where they had their surgery. Because one of the areas you can have a recurrence is in the scar around where we did surgery. And then I also keep a close eye on those lymph node basins that we talked about before by doing ultrasounds and palpating, or feeling, those lymph nodes for any concerning new lumps or bumps. And so that's my part of it.

And then we know, one thing I didn't quite say before, we know that if you have one melanoma, you are at an increased risk to have another one in your life. And so that's where our dermatology and primary care colleagues come in with thorough skin exams. Some people use different protocols, every three to six months after you've been diagnosed with melanoma. And it's very important to keep up with those because of that increased risk of having another melanoma. And so that's where I am in constant contact with our dermatology colleagues and primary care doctors to make sure we're all coordinated in keeping a close eye. And we do that for five years, where you get those really close examinations, and then we recommend after five years after your diagnosis, we keep a close eye on you yearly, and of course you have any new concerning moles, lumps or bumps that you feel, it's important to reach out to us.

We always want to hear from a patient with any concerns because they know their body best. They know when something changes better than us checking in every three to six months. They're usually the first person to truly pick it up, or a loved one.

[00:29:23] Host Amber Smith: Well, Dr. Thomas, thank you so much for making time to explain so much about melanoma.

[00:29:28] Daniel Thomas, MD: Great. Thank you so much. It's been wonderful. Thank you for having me.

[00:29:32] Host Amber Smith: My guest has been Dr. Daniel Thomas. He's an assistant professor of surgery at Upstate who specializes in complex general surgical oncology. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.