A look at two forms of skin cancer: Upstate Medical University’s HealthLink on Air for Sunday, Aug. 4, 2024
Dermatology chief Ramsay Farah, MD, addresses basal cell carcinoma, the most common form of skin cancer. Surgeon Daniel Thomas, MD, provides an overview of melanoma, which is less common and more likely to spread.
Transcript
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," we'll explore two different types of skin cancer.
A dermatologist discusses basal cell carcinoma, one of the most common types of skin cancer.
Ramsay Farah, MD: ... 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. ...
Host Amber Smith: And a surgeon tells about an uncommon but potentially deadly form of skin cancer called melanoma.
Daniel Thomas, MD: ... 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 think of as a cumulative sun exposure. ...
Host Amber Smith: All that, and a visit from The Healing Muse, coming up 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'll hear from a surgeon about melanoma, which is showing up in a growing number of young women. But first, Upstate's chief of dermatology addresses basal cell carcinoma, the most common form of skin cancer.
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: So the removal might cause some disfigurement in that case?
Ramsay Farah, MD: Well, we've gotten a lot better at avoiding disfigurement, but if it's large enough, then yes, it could be disfiguring, even with the best surgical techniques of repair. I would say it rarely gets to the point of disfigurement, but of course, also, you have to keep in mind that a scar is in the eye of the beholder. A minor scar for one patient may be something that they're distraught about, and they might not like it a lot. There could be a more extensive scar on another patient, and they're not at all bothered by it. So when we use the terms disfigurement and things like that, we have to keep in mind that it is in the eye of the beholder. I just want to qualify that.
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.
Host Amber Smith: Can your trained eye tell the difference between a basal cell carcinoma that's caused by sun exposure, regular sun exposure, versus indoor tanning machines?
Ramsay Farah, MD: No, they would look the same. So the basal cell carcinoma is kind of the end point of DNA damage, and those cells have become malignant, and they turn into the basal cell. How you get that DNA damage doesn't necessarily change the appearance of the basal cell. Once you've got enough DNA damage to get the basal cell, they'll all look like basal cells. So I can't look at a basal cell and say, "Oh, you got that because you were on the beach," versus "Oh, because you were in a tanning salon." So no, it doesn't work that way.
Host Amber Smith: But will they show up in areas of your body that would've had sun exposure?
Ramsay Farah, MD: Yeah, 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 No. 2 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 (ear, nose and throat) 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%.
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: When people go to their primary care provider for their annual exam, is this something they should bring up to their primary care provider, or do they need to see a dermatologist regularly to have marks or moles or things that seem to pop up on their skin looked at regularly?
Ramsay Farah, MD: Patients have two options. They can go to their primary care, or they can go directly to a dermatologist. I mean, I think the fact of the matter is, primary care doctors need to be very well versed in these skin cancer issues, at least the top three skin cancers -- basal cells, squamous cells and melanoma -- because a lot of people go to primary cares. More people go to primary cares than go to dermatologists simply because there are more primary cares, and they've established wonderful relationships with them, trusting relationships.
Primary cares are in many ways on the front line. I think they need to be doing skin cancer screens, and then if they see something that they're suspicious of, then they should send it to a dermatologist for sure.
But of course people have the choice of going directly to a dermatologist, and dermatologists, really all they do is they do skin, so I think they've become quite expert at seeing lesions, all kinds of lesions with all kinds of nuances and are able to make a very accurate diagnosis. So obviously I'm a little bit prejudiced. I'm a dermatologist, so I think people should go to a dermatologist because that's what we do. But I guess what I was trying to say with the primary care is, primary cares also have a role in screening and then getting those patients to us if they find something suspicious.
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".
Next on Upstate's "HealthLink on Air," melanoma is becoming more of a risk for young women.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." It's less common than other skin cancers, but melanoma is more likely to grow and spread. Today I am 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 "HealthLink on Air," Dr. Thomas.
Daniel Thomas, MD: Thank you for having me.
Host Amber Smith: Can you describe what melanoma skin cancer is?
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. 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.
Host Amber Smith: Are all races affected by melanoma, or do darker skinned people, are they protected from melanoma?
Daniel Thomas, MD: We've shown that, by looking back throughout history, that the highest risk of having a melanoma are lighter-skinned patients, 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 and New Zealand have one of the highest incidence 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 (ultraviolet) rays, and so it does affect all races.
However, lighter skin, fair hair are more prone to having a melanoma from sun exposure.
Host Amber Smith: Are there any other risk factors besides being fair skinned that put a person at risk for melanoma?
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 also increases your risk of having it. But like I said, the main risk factor is the UV rays causing damage to these melanocytes that which eventually develop into melanoma.
Host Amber Smith: So with that in mind, is sun protection the way to prevent melanoma? Is that a sure thing?
Daniel Thomas, MD: We wish it was a sure thing. It's definitely one of the best things: sun protection. 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. But it's important to make sure you have it on, you reapply. Like I mentioned, 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 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.
Host Amber Smith: So it sounds like most melanomas appear in older adults, not children, because it's a cumulative thing, right?
Daniel Thomas, MD: Correct. Yes, exactly. We're seeing it now in younger adults. 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.
Host Amber Smith: Is that tied to tanning salons?
Daniel Thomas, MD: Yeah, we think it is. The data that showed that are in the last decade or so, and we know that tanning beds really hit their height in the 1990s 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.
Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Daniel Thomas, a surgical oncologist at Upstate, and our topic is melanoma.
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?
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. So we don't have a perfect prediction tool of who's going to get it.
Host Amber Smith: So let's talk about how melanomas are diagnosed. What do they usually look like?
Daniel Thomas, MD: So 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 the 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 fingerlike 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. We think of most moles are within the size of about the end of an eraser tip on a pencil, which is about 5 to 6 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 sure 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.
These are usually 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.
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?
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 the, 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.
We know that melanomas, when they spread, the most common place they spread is to the lymph nodes. And the lymph nodes are, usually, we have clusters of lymph nodes underneath our armpits, in our groins, many other places on the head and neck. It's 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, firm lymph nodes. And that is usually, 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.
Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but please stay tuned for more about melanoma with Dr. Daniel Thomas, a surgical oncologist at Upstate.
Welcome back to Upstate's "HealthLink on Air." I'm your host, Amber Smith. I'm talking with Dr. Daniel Thomas. He's a surgical oncologist at Upstate, and we've been talking about melanoma.
So I wanted to ask about the surgery. 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?
Daniel Thomas, MD: The answer would be both of us, both the surgical oncologist 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 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. So that's something that 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 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.
Host Amber Smith: What are survival rates like for melanoma?
Daniel Thomas, MD: The survival rates for melanoma certainly vary. The majority of patients are diagnosed at Stage 1 and Stage 2. Stage 1 and Stage 2 melanomas are the thin and intermediate melanomas that have not spread to any lymph nodes. Those patients have very good overall survival or or what we call melanoma-specific survival, which is the likelihood of them dying from their melanoma cancer. And so in patients with Stage 1 and Stage 2 cancers, it ranges from 85% to 99%.
Of course the lower number there, in the 80% to 85%, are patients with thicker melanomas, and so into that intermediate zone. And somebody who has a thin melanoma under, 1 millimeter, and we don't have any concern for lymph nodes, they have a very, very good prognosis.
It's when the melanoma spreads to the lymph nodes that 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.
Host Amber Smith: What about recurrence rates?
Daniel Thomas, MD: The recurrence rates for melanoma are not very high when we talk about the thin and intermediate melanomas. It's when we -- similar to the overall survival -- it's you have a higher recurrence rate when you have it in your lymph nodes.
And so when we do, it's 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 removed all the visible melanoma that we can, but we know that you still have a higher than average risk for that to return. And 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.
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?
Daniel Thomas, MD: 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 found two things -- 1., the patient is certainly more comfortable. We use some anesthesia 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. And so we have to, 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. We have some instances when we get into the lymph nodes that we're talking about, the patient stays overnight one night, but usually they have one night in the hospital, have some breakfast, and go home the next day.
Host Amber Smith: Are your patients concerned about scars?
Daniel Thomas, MD: I certainly have patients who are concerned about scars. The main issue that we run into is our melanomas on the head and neck, which can, 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 1 to 2 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 after surgery.
Most patients I talk to say, "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.
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?
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'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 familially 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 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 BRCA gene. We don't have anything quite like that for melanoma.
Host Amber Smith: 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?
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 surgery, and the next step is to do two things: 1. 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's similar, 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 of 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 the 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 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 that if you have one melanoma, you are 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 every -- 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 if 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.
Host Amber Smith: Well, Dr. Thomas, thank you so much for making time to explain so much about melanoma.
Daniel Thomas, MD: Great. Thank you so much. It's been wonderful. Thank you for having me.
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. 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: James Dwyer is a philosopher and bioethicist at the Center for Bioethics and Humanities in Syracuse. He sent us a series of haiku that take us through the many phases one life can contain. Here is "Haiku from Start to Finish":
first cold day
she adds two layers --
to please grandma
adults talking
about the weather
children not
cloudy sky
same hike with
older knees
blue spruce
dusted with snow --
nursing home
stapled to his
health care proxy
a list of passwords
clothes set out
for the morning
that never came
remembrance dinner
long flight back
with leftovers
maple leaves
afloat on the lake --
for now
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.
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.