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Skin cancer; Squamous cell cancer; Basal cell cancer; Actinic keratosis; Nonmelanoma skin cancer
A number of options are available for treating nonmelanoma skin cancer, including:
Most basal and squamous cell cancers are treated with surgery or radiation. Research has found that surgery has the best results, but because it can have cosmetic effects, many patients opt for radiation.
The first step in nonmelanoma skin cancers is to determine the risk of aggressive types of these tumors. Basal cell tumors are considered high-risk.
Squamous cell cancers of the skin are considered to be high-risk if any of the following are present:
For any skin cancer and for some keratoses that need to be removed, surgery is the first treatment. One of the following surgeries is usually used:
Excisional Surgery. Cutting out the tumor and then assessing the tumor borders (margins).
Curettage and Electrodesiccation. This procedure involves scraping away the cancerous tissue, followed by electric cauterization to stop the bleeding.
Mohs Micrographic Surgery. Mohs surgery is a procedure used for skin cancers at high risk for returning or becoming invasive. The technique removes very thin layers of skin one at a time. Each layer is examined immediately under a microscope. When the layers are shown to be cancer-free, the surgery is complete.
Good candidates for Mohs surgery include:
Mohs surgery saves more healthy tissue than other procedures and is highly effective. It results in a 99% cure rate for primary tumors and a 95% cure rate for cancers that return. It can be safely performed in the doctor's office. Complications are uncommon but can include bleeding and infection.
Lasers. Laser surgery may be useful for certain basal cells and for keratoses that appear on the lips, although it is not clear whether lasers offer any advantages over other surgical treatments. Lasers do not appear to be very effective for thick or tough squamous cell cancers.
Cryosurgery removes skin cancer cells or actinic keratoses by freezing the affected tissue with liquid nitrogen. Studies have shown that cyrosurgery can be used to remove even wide areas of actinic keratoses, and that it may be more successful over the long term than treatment with 5-fluorouracil, the standard drug. Cryosurgery also appears to reduce the risk for squamous cell cancer in these patients.
Cryotherapy achieves good cosmetic results for many patients. However, it may cause blistering and ulceration, leading to pain and infection, as well as harmless, but undesirable, skin-color changes.
The disadvantage of cryosurgery is that no tissue is taken to examine under a microscope and show that the cancer was completely removed.
In unusual cases where the skin cancer may be in an inoperable position (such as the eyelid or the tip of the nose) or if cancer has come back multiple times, radiation therapy may be indicated. Radiation therapy is more often used in the elderly.
Radiation is directed at the tumor. It may take 1 - 4 weeks, with treatments done several times a week. One technique being investigated for basal and squamous cell cancer uses radiation implants (brachytherapy) and custom-made molds to specifically target the radiation to the cancer site. Studies suggest that this treatment is very effective with few complications.
Topical phototherapy with the drug aminolevulinic acid (ALA) is a nonsurgical method that is proving to be a good choice for treating actinic keratoses and nonmelanoma skin cancers. The technique involves shining blue light onto the cancer area after the patient has taken ALA. ALA accumulates in the skin cells. When the cells are exposed to intense light, the chemical causes them to die. This approach allows precise targeting of one or more lesions, leaving healthy skin unaffected.
It does not penetrate deeper than the epidermis (the top layer of the skin), so it does not produce scarring or changes in skin color, as cryotherapy or other more invasive treatments do. However, it can cause pain and irritation, including stinging, itching, and burning.
ALA Phototherapy for Actinic Keratoses. Phototherapy works best on flat lesions when it is performed in two treatments, and is more effective for clearing lesions on the face than those on the scalp. Phototherapy can also treat multiple lesions at the same time instead of one after another, as in cryotherapy. Studies suggest that it may work as well as cryotherapy and achieve better cosmetic results. (More patients report burning and itching with phototherapy, however.) Phototherapy is also equal to topical 5-fluorouracil in effectiveness and achieving a satisfactory appearance.
ALA Phototherapy for Nonmelanoma Skin Cancers. In patients with squamous cell cancer in situ, Bowen disease, and superficial basal cell cancer, phototherapy has been equal to cryotherapy, with better healing and appearance afterward.
Some studies have shown that about 10% of patients using phototherapy have a recurrence within 1 year. These recurrence rates are higher than with surgery and other standard treatments. Longer-term studies are required before ALA phototherapy can be recommended for most patients with nonmelanoma skin cancers.
A number of medications are being used for keratoses and some may be helpful for skin cancers as well. Besides cryotherapy, 5-fluorouracil is the other most commonly used treatment for actinic keratoses. Other medications are also available.
Medications for Keratoses and Common Skin Cancers
|Medication||Skin Conditions Affected||Oral or Topical||Comments|
Bowen's disease and small nonmelanoma skin cancers.
Topical cream (Efudex, Fluoroplex) or injected gel containing 5-FU and epinephrine (AccuSite).
5-Fluorouracil (5-FU) removes actinic keratoses and is useful for some patients with a large number of lesions. It requires twice daily application for 3 - 4 weeks. It can cause significant redness, irritation, swelling, and crusting, which takes 2 - 4 weeks to heal. Newer preparations are reducing these side effects. It is still unclear whether this medication protects against recurrent keratoses or future skin cancer. Of concern is the possibility that 5-FU will clear the top of a skin cancer and obscure the rest of the cancer that lies beneath the surface of the skin.
Diclofenac and hyaluronan (Solaraze)
Actinic keratoses (approved). Investigated for basal cell.
Topical gel applied twice a day.
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID). When used to treat actinic keratoses, it is delivered to the skin with hyaluronan, a water-seeking molecule that helps maintain skin tension. It has modest effects and when healing occurs, it may not be evident for at least a month after treatment ends. However, it causes less irritation than 5-FU and may be useful for some people.
FDA approved for the treatment of superficial basal cell cancer. Previously approved for treating actinic keratoses. Investigated for Bowen's disease and squamous cell cancer.
Imiquimod is a topical cream. Frequency and duration of application continues to be studied.
Applied 1-2 times per week for 16-24 weeks for AK.
Imiquimod triggers the production of immune factors that help fight cell proliferation. Aldara should be used only when surgery for basal cell cancer is inappropriate. It is not approved for use on the face.
|Alpha-Interferons||Basal cell cancer, squamous cell cancer.||Require injections administered three times a week.||Interferons are immune factors that are being used to treat a number of serious conditions. Alpha-interferon injections may be effective against skin cancers that are hard to treat using conventional surgical measures. Cosmetic results are reported by 83% of patients to be good or very good.|
Non-facial actinic keratosis
Gel applied for 2-3 days.
Extracted from the Euphorbia peplus plant, ingenol mebutate breaks down the lesion and has anti-tumor activity by stimulating antibodies. It is not intended for use on the face.
Abbasi NR, Yancovitz M, Gutkowicz-Krusin D, Panageas K, Googe P, King R, et al. Utility of lesion diameter in the clinical diagnosis of cutaneous melanoma. Arch Dermatol. 2008;144:469-474.
American Cancer Society. Cancer Facts and Figures 2008. Atlanta, GA: American Cancer Society; 2008.
Anderson L, Schmieder GJ, Werschler WP, et al. Randomized, double-blind, double-dummy, vehicle-controlled study of ingenol mebutate gel 0.025% and 0.05% for actinic keratosis. J Am Acad Dermatol. 2009;60(6):934-43.
Basal cell and squamous cell cancers: NCCN Medical Practice Guidelines and Oncology;V.1.2009. Accessed July 15, 2009.
Braathen LR, Szeimies RM, Basset-Seguin N, Bissonnette R, Foley P, Pariser D, et al. Guidelines on the use of photodynamic therapy for nonmelanoma skin cancer: an international consensus. International Society for Photodynamic Therapy In Dermatology, 2005. J Am Acad Dermatol. 2005;56:125-143.
Brantsch KD, Meisner C, Schonfisch B, Trilling B, Wehner-Caroli J, Rocken M, et al. Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study. The Lancet Oncology. 2008;9:713-720.
Clinical practice guideline for melanoma: NCCN Medical Practice Guidelines and Oncology;V.2.2009. Accessed July 15, 2009.
Cyr PR. Atypical Moles. Am Fam Physician. 2008;78(6):735-40. Review.
deBerker D, McGregor JM, Hughes BR. Guidelines for the management of actinic keratoses. Br J Dermatol. 2007;156:222-230.
Eggermont AM, Suciu S, Santinami M, et al: EORTC Melanoma Group. Adjuvant therapy with pegylated interferon alfa-2b versus observation alone in resected stage III melanoma: final result of EORTC 18991, a randomised phase III trial. Lancet. 2008;372(9633):117-26.
Garcia C, Polette E, Crowson AN. Basosquamous carcinoma. J Am Dermatol. 2009;60(1):137-43.
Goodson AG, Grossman D. Strategies for early melanoma detection: Approaches to the patient with nevi. J Am Acad Dermatol. 2009;60(5):719-35: quiz 736-8. Review.
Guadagnolo BA, Zagars GK. Adjuvant radiation therapy for high-risk notal metastases from cutaneous melanoma. Lancet Oncol. 2009;10(4):409-16.
Hexsel, CL, Bangert SD, Hebert AA, et al. Current sunscreen issues: 2007 Food and Drug Administration sunscreen labelling recommendations and combination sunscreen/insect repellent products. J Am Dermatol. 2008;59(2):316-23. Review.
Lachiewicz AM, Berwick M, Wiggins CL, Thomas NE. Survival differences between patients with scalp or neck melanoma and those with melanoma of other sites in the surveillance, epidemiology, and end results (SEER) program. Arch Dermatol. 2008;144:515-521.
Lange JR, Fecher LA, Sharfman WH, et al. Melanoma. In: Abeloff MD, Armitage JO, Nierderhuber JE, Kastan MB, McKenna WG, eds. Abeloff's Clinical Oncology. 4th ed. Philadelphia, Pa: Churchill Livingstone; 2008:chap 73.
Lautenschlager S, Wulf HC, Pittelkow MR. Photoprotection. The Lancet [early online publication]. May 3, 2007.
Markovick SN, Erickson LA, Rao RD, Weenig RH, Pockaj BA, Bardia A, et al. Malignant melanoma in the 21st century, part 1:epidemiology, risk factors, screening, prevention, and diagnosis. Mayo Clin Proc. 2007;82:364-380.
Markovick SN, Erickson LA, Rao RD, Weenig RH, Pockaj BA, Bardia A, et al. Malignant melanoma in the 21st century, part 2: staging, prognosis, and treatment. Mayo Clin Proc. 2007;82:490-513.
Morton CA, mckenna KE, Rhodes LE:British Association of Dermatologists Therapy Guidelines and Audit Subcomittee and the British Photodermatology group. Guidelines for topical photodynamic therapy: update. Br J Dermatol. 2008;159(6):1245-66. Review.
Morton DL, Thompson JF, Cochran AJ Mozzillo N, Elashoff R, Essner R, et al. Sentinel-node biopsy or nodal observation in melanoma. N Engl J Med. 2006;355:1307-1317.
Olsen CM, Zens MS, Stukel TA, et al. Nevus density and melanoma risk in women: to test the divergent pathway hypothesis. Int J Cancer. 2009;124(4):937-44.
Ridky TW. Nonmelanoma skin cancer. J Am Acad Dermatol. 2007;57:484-501.
Savel MS, Wong SI. Review of evidence-based support for pretreatment imaging in melanoma. J Natl compr Canc netw. 2009;7(3):281-9. Review.
Suh KY, Bolognia JL. Signature nevi. J Am Acad Dermatol. 2009;60(3):508-14. Review.
Telfer NR, Colver GB, Morton CA. Guidelines for the Management of Basal Cell Carcinoma. BJD. 2008;159:35-48.
Tran KT, Wright NA, Cockerell CJ. Biopsy of the pigmented lesion-when and how. J Am Acad Dermatol. 2008;59(5):852-71. Review.
Treatment for Metastatic Ocular Melanoma. NCI Cancer Bulletin. March 7, 2006;3(10):8.
Vestergaard ME, Macaskill P, Holt PE, et al. Dermoscopy compared with naket eye examination for the diagnosis of primary melanoma: a meta-analysis of studies performed in a clinical setting. Br J Dermatol. 2008;159(3):669-76.
Warycha MA, Zakrzewski J, Ni Q, et al. Meta-analysis of sentinal lymph node positivity in thin melanoma. Cancer. 2009;115(4):869-79.
Wood GS, Gunkel J, Stewart D, et al. Nonmelanoma skin cancers: basal and squamous cell carcinomas. In: Abeloff MD, Armitage JO, Nierderhuber JE, Kastan MB, McKenna WG, eds. Abeloff's Clinical Oncology. 4th ed. Philadelphia, Pa: Churchill Livingstone; 2008:chap 74.
Zeichner JA, Stern DW, Uliasz A, et al. Placebo-controlled double-blind randomized pilot study of imiquimod 5% cream applied once per week for 6 months for the treatment of actinic keratoses. J Am Acad Dermatol. 2009;60(1):59-62.
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