Online Health Chat with Philip Bailin, MD, MBA and Brian Gastman, MD
May 27, 2014
Skin cancer is the most common form of cancer in the U.S., with more than 3.5 million skin cancers diagnosed annually. Melanoma only makes up about four percent of skin cancers, but accounts for more than 80 percent of skin cancer-related deaths. Spotting and diagnosing a problem spot on your skin early can be critical, especially for those at a greater risk for skin cancer occurrences.
Skin cancer is a tumor or growth of abnormal cells in our skin, and is the most common form of cancer people get in the United States. There are several types of skin cancer: basal cell carcinoma, squamous cell carcinoma and melanoma. Both basal and squamous cell carcinomas are cancers that occur in the surface layer of the skin and can be easily cured when detected and treated early. Although it is not as common, malignant melanoma is the most serious type of skin cancer, and is more likely to spread.
If treated early, skin cancer often can be cured. It is important to know not only ways to protect yourself from developing skin cancers, but also how to determine when it’s time to see a doctor and what can be done once you have been diagnosed.
About the Speakers
Philip Bailin, MD, MBA is a dermatologist in the Department of Dermatology in Cleveland Clinic’s Dermatology and Plastic Surgery Institute. A medical school graduate of Northwestern University Medical School in Chicago, he completed his residency in dermatology at Cleveland Clinic. Additionally, he completed a fellowship in dermatopathology at the Armed Forces Institute of Pathology in Washington D.C., as well as a fellowship in Mohs micrographic surgery at the University of Wisconsin. Dr. Bailin’s specialty interests include laser surgery, cosmetic surgery, cosmetic injectable fillers and facial treatments, Mohs micrographic surgery, and cutaneous oncology. He has been listed in “Best Doctors in America” numerous times, and leads the use of the melanoma scanner, a handheld device that scans the skin for skin cancer.
Brian Gastman, MD is a board-certified plastic surgeon and otolaryngologist in Cleveland Clinic’s Department of Plastic Surgery in the Dermatology and Plastic Surgery Institute. Dr. Gastman helped to institute the Melanoma Clinic located in the Taussig Cancer Institute, which helps to diagnose and treat patients with complex melanoma concerns. Dr. Gastman completed his fellowship in head and neck surgery at Washington University St. Louis Medical Center, in St. Louis, Mo. He completed his residencies in plastic surgery and otolaryngology and his general surgery internship at the University of Pittsburgh Medical Center and Children’s Hospital of Pittsburgh, in Pittsburgh, Pa. Dr. Gastman graduated from medical school at the University of Michigan Medical School, in Ann Arbor, Mi.
Dr. Gastman’s specialty interests include comprehensive care of soft tissue malignancies such as melanoma, non-melanoma skin cancers, sarcomas and head and neck cancers. As a plastic surgeon Dr. Gastman specializes in complex reconstruction of the craniomaxillofacial skeleton, facial plastic surgery and is on the facial transplantation team. As an otolaryngologist, he uses his training to provide advanced treatment of nasal airway diseases as well as nasal reconstruction, e.g. rhinoplasty. Finally, Dr. Gastman also performs general reconstruction and cosmetic surgery of the trunk, abdomen and extremities and is an expert in non-surgical treatment of aging. Prior to arriving at CCF, Dr. Gastman was awarded a RO1 NIH grant which was a large basis for his laboratory specializing in tumor immunology and treatment resistance.
Let’s Chat About Skin Cancer and Melanoma – Your Questions Answered
Moderator: Welcome to our chat today with plastic surgeon, Dr. Brian Gastman and dermatologist, Dr. Philip Bailin. We are thrilled to have them here with us to share their knowledge about skin cancer and melanoma. Let's begin by chatting about some general information regarding today's topic.
Moles and Melanoma Diagnosis
JonCas: I had a facial mole removed 10 years ago and it grew back in the same spot. Should I see a dermatologist?
Brian_Gastman,_MD: Although this new mole may be nothing more than a mole, one should know about melanoma ABCDE: A = asymmetry, B = border (irregular), C = color (not homogeneous, or even color), D = diameter (equal to or greater than 6 mm), and E = evolution (change, such as growth, bleeding, etc.). If your mole does not match any of these, it is probably O.K. However, if you are prone to moles, have a strong history of sun exposure, have any reason to think your immune system is irregular, or have a family history of skin cancer, then I would seek a dermatologist.
Samkin: I am 30 years old and have several oddly colored and shaped moles or spots— some of which are raised and some are not—on my back. I have frequently scratched these spots. Sometimes they reduce in size, but still grow back. Some bleed, and some just pop. I was wondering the effect this could have if they are indeed cancerous. If they are, what options are there now that I have had these for more than eight years. Some hurt, but some do not. Does this in itself mean anything?
Brian_Gastman,_MD: It's really hard to know based on this information whether these are nothing more than multiple nevi (moles). If they bleed without scratching, I would be more concerned. Your risks are related to the ABCDE's of each mole, health, environmental history and genetics. Luckily, 30 years old is an uncommon age for melanoma. We are seeing a rise in young women with melanoma and I am running a number of studies for that group of patients. So far we have studied almost 700 women between the ages of 16 and 45 (which is a lot for a single institution) with a history of melanoma. The first results of that study should be published this year.
Types of Skin Cancer
Billiallison: What is the difference between basal and squamous cell skin cancers?
Brian_Gastman,_MD: These are the two most common skin cancers. In patients who are not immunosuppressed, neither usually is deadly. Squamous cells do grow faster and if left unchecked can spread to lymph nodes and eventually can look like the more deadly cancers. Basal cells can do this too, but much more rarely. For most healthy people you really would have to be very non-compliant with your medical care to worry about these being deadly.
smartini: How serious are basal cell carcinomas in terms of their ability to progress to melanoma or spread to other parts of the body?
Brian_Gastman,_MD: Basal cell carcinomas can be caused by the same cues that melanomas are and can be found in the same vicinity, but are not the same and do not convert to melanoma. Unlike melanoma, they rarely metastasize and are rarely deadly.
misslottie: I wonder how common is skin cancer on the scalp. I live in Southern Arizona and I stay out of the sun now in my old age, but when I was young we cared less about sun protection. I have keratosis on my skin—they just keep popping up everywhere and the doctor said they are not cancer. I feel like I have some bumps or lesions on my scalp. To get a good look, it seems like you would have to shave your head, wouldn’t you?
Brian_Gastman,_MD: Amongst skin cancers the head and neck are relatively common locations, given their sun exposure potential. It would make sense then, especially in men with thinning hair that the scalp would be part of that anatomy. In my practice, in patients with a normal immune system, scalp skin cancers are mainly in the elderly, meaning those older than 65 years old—and definitely males more than females. Shaving your head is great for surveillance, but not so great for protection. In the end it's about having a great relationship with your dermatologist and being vigilant.
Basal Cell Carcinoma of the Ear
george1958: After two years of being misdiagnosed by doctors, it was determined that the lesion in the left ear canal anterior placed in the cavum concha was infiltrative basal cell carcinoma that was deeply invasive, The preoperative size was 1.1 x 0.8 cm with poorly defined borders and difficulty estimating depth. Three stages of Mohs surgery were performed a year ago until no tumor cells were identified. The postoperative size was 1.6 x 1.6 cm and extended into the conchal bowl cartilage. Can this type of tumor metastasize? Are there tests to determine if this tumor still exists? What are the symptoms to look for in the coming years that would indicate recurrence?
Brian_Gastman,_MD: I deal with this type of scenario every few months. It would be a rare basal cell if it metastasized. A good ear exam is important, but if the margins were close, I would recommend a yearly CT scan of the temporal bones. This usually covers this area well. Get a baseline scan and then after a year if there are changes, you may need another surgery. Although I am a big believer in Mohs surgery, it can be limited in these areas.
Recurrent Skin Cancer
daughterdear: My father has had all forms of skin cancer and multiple times. I feel like at least once a year he has to get another one removed. It really worries me. He is in his 60s and doesn't go in the sun that much. When he does, he makes sure to lather on the sunscreen. Is there anything he can do to try to prevent from getting a new spot? He does get checked by a dermatologist often, but is that all that can be done?
Brian_Gastman,_MD: Once these tumors start erupting it is not uncommon for this to be a life-long issue. Regardless, in comparison to those who are not diligent, this will just be an annoyance that should not affect his mortality. As long as he has a strong relationship with his dermatologist, and I would say he needs at least appointments twice yearly, he should be fine for the rest of his life.
Skin Cysts vs. Skin Cancer
Twrite: Can abdominal skin cysts become cancerous or be a sign of possible cancer? If so, what are the warning signs? What type of specialist should be seen first? What type of test should be done?
Brian_Gastman,_MD: Skin cysts tend to be sebaceous cysts sort of up-side down pimples. They can represent other things too. Usually, typical skin cancers don't look like cysts. A good family practitioner or dermatologist should be able to diagnose these—either by visualization or by biopsy.
Melanoma and Genetics
clara: My father died of melanoma cancer. My brother had melanoma and is fine. My husband also had melanoma. My question is how often should my adult children be checked? My son has many moles.
Philip_Bailin,_MD,_MBA: It appears that you have a strong family history of malignant melanoma. In that setting, all genetically-related family members should at least have a full total body skin exam by a dermatologist on an annual basis.
Risk and Prevalence of Melanoma
patty: How do you know if you're at a high risk for melanoma? And if you get it once, is there any way to prevent melanoma—of any skin cancer—from recurring?
Brian_Gastman,_MD: Outside of rare genetic disorders, a strong family history or in those who are immunosuppressed, the lifetime risk for an American is about one in 35. It sounds high and should be concerning, although most cases are diagnosed in those who are older than 65 years old. If you get it, prevention is done through regular personal and dermatologic screening.
Skin Cancer Screenings
mattyb: How often should you get a skin check if your father has had skin cancer a few times, but no one else in your family has had problems?
Philip_Bailin,_MD,_MBA: Since there are several types of skin cancer and many causes, it is impossible to give a definitive answer. However, the most common forms of skin cancer (basal cell and squamous cell) are most common in light-skinned, sun-exposed individuals. These occur in relationship to the total accumulated amount of sun exposure over one's lifetime. Therefore, the older one is and the more total sun they have been exposed to, the greater the likelihood of developing skin cancer. An individual should be checked by a dermatologist who could then determine the relative risk and advice on the appropriate frequency of future skin checks.
irdie333: I read an article that Cleveland Clinic has some type of body scanner that can detect melanoma? What is this and how does it work? Do you need a referral to have it done?
Philip_Bailin,_MD,_MBA: The device is called MelaFind®. It employs a range of wavelengths of light which are applied via a handpiece to the skin lesion in question. This produces a computerized analysis of the lesion in terms of its likelihood of being benign or malignant. Those which have a high reading are then biopsied. This technique is non-invasive and is based upon a proven database of over 10,000 lesions. Referrals are not required, and we have a specific triage nurse to discuss this procedure with potential patients. A call to the surgical dermatology section will get the process underway.
Melanoma Progression and Metastasis
tonianne: I had these two moles my whole life with no problems. Recently, I got a new dermatologist and she removed them saying they looked suspicious. How is that possible for moles to just suddenly change? One left a pretty good scar on my chest because I have keloids. Is there any way to fix that or is it too late?
Brian_Gastman,_MD: The short answer is no one really knows that exact answer. Like all cancers, cells in the body are constantly put under forces that the cell's brain recognizes as bad and causes essentially cellular suicide. Eventually those suicide mechanisms can be overridden and these cells can transform and then go through a progression that can be called dysplasia (sort of a pre-pre-cancer), in situ (pre-cancer) or just malignant (cancer).
doglady: I do not understand melanoma. How can skin cancer which is on the surface turn deadly and get into your organs?
Brian_Gastman,_MD: One of the big differences between melanoma and other solid cancers is that it is usually visible and thus many are caught earlier than many other types. However, when the tumor is fast growing (for environmental or genetic reasons) or is caught late, then it becomes increasingly likely that it may have spread to regional lymph nodes. If it is still not caught early enough, the potential to spread all over the body further increases. Although melanoma can spread directly in the blood, the most common route is via small channels in the body called lymphatics. Think like this, arteries bring blood and fluid into tissues, veins take out blood and some of the fluid. The rest of the fluid comes through these lymphatics. Normally these channels end into structures call lymph nodes. This is great when a person’s body is trying to rid oneself of say bacteria, but melanoma can take advantage of this built-in system. Now think of these channels as a large street in your neighborhood, once in the area of the lymph nodes, these channels get larger, like small highways. If they escape and get onto the "major expressways" that's the equivalent of spreading all over e.g. organs, etc...
eileen: How fast can skin cancer spread? I have been trying to get an appointment to have a suspicious spot looked at, but they can't get me in for at least a month. Is that too long if it is something to worry about?
Brian_Gastman,_MD: Every lesion is different. We have seen large tumors be indolent (slow to develop) and small ones spread to distant body parts. If you have a suspicious lesion, then the faster the better. However, a few weeks of waiting will at worst make you more anxious, but unlikely have an impact on outcome.
asgalian: If a male in his 40s had melanoma on his arm that was removed by a surgeon and did not spread to any other tissue, what is the chance that he will develop it again or propensity to more melanoma development?
Brian_Gastman,_MD: This depends on many factors, the largest was the original staging, e.g. how deep it was, negative features of the tumor (like ulceration), and whether a sentinel node biopsy was performed. And then there are other issues, like you are 40 years old. You have many years to develop a new melanoma. For most thin melanomas, by the statistics you should be cured, but even then you need to have a life-long relationship with a competent dermatologist and do regular skin and lymph node checks.
Non-surgical Treatment of Skin Cancer
terad: Is there any non-surgical way to treat skin cancer? If so, does it have to be a certain type of skin cancer (for example, can’t be as dangerous as melanoma)?
Philip_Bailin,_MD,_MBA: Melanoma and pre-melanoma skin lesions are best treated by surgical removal. However, for other types of skin cancer (basal cell and squamous cell) there are some non-surgical alternatives. Among these are cryotherapy (deep freezing); topical anticancer medications (such as 5-fluorouracil or Aldara® [imiquimod] cream), and photodynamic therapy, which employs application of a light sensitizing liquid or cream followed by a specific amount of blue or red light exposure to the area.
Plastic Surgery vs. Dermatologic Surgery
ctrixy45: How do you know if you’re going to need a plastic surgeon to remove a mole? Should large moles be removed, or is it more about shape and color and not size?
Brian_Gastman,_MD: As I am a rare plastic surgeon who basically treats cancer (mainly of the skin), you do not have to use one of my colleagues for a simple mole removal. Although we love to hear that we close wounds the best, there is no surgery that does not leave a scar. Many dermatologists like to work with plastic surgeons and in that arrangement it makes sense. But a good dermatologist should be able to remove a mole and leave at least a reasonable closure. For larger lesions, if the closure will be under tension or in cosmetically complex areas, a plastic surgeon can be very helpful.
periwinkle: What is Mohs surgery?
Philip_Bailin,_MD,_MBA: Mohs surgery is a specialized form of skin cancer surgery used for basal cell cancer, squamous cell cancer and some other more unusual forms of skin cancer. It provides a very high cure rate while at the same time being very sparing of non-involved surrounding skin and deeper tissues. The cancer is removed in layers which are mapped and examined microscopically by the Mohs surgeon. This is very different than the more common routine "frozen sections" done in most hospital laboratories.
smartini: What are the key questions to ask a surgeon before Mohs surgery for a basal cell carcinoma (BCC)?
Brian_Gastman,_MD: There are actually guidelines when Mohs surgery is appropriate, like when the tumor is on the face, when used on BCC greater than 2 cm or recurrent tumors. Mohs has many advantages including a high cure rate without removing extra tissue. However, it can be time consuming, is usually done awake (so you cannot be afraid of needles) and is not accessible in all parts of the U.S. Finally, depending on a number of factors, you may also have to coordinate the Mohs surgery with a plastic surgeon.
susieQcumber: Would you recommend Mohs for melanoma on the face?
Brian_Gastman,_MD: Currently, Mohs surgery is not standard of care for melanoma of any body part. There are some dermatologists who will use Mohs for melanoma-in situ and fewer for melanoma itself. The problem is that many times special stains are needed to actually determine if melanoma is present on the margins. Without those being able to be done with the same speed and quality of typical Mohs surgery, it is hard to justify its use. Combine that with the possible need of a sentinel node biopsy (which are not done by Mohs surgeons), I would not recommend this approach.
pam86: I have had a large mole (a little larger than the size of a quarter) on my back pretty much my whole life. I have had it looked at before, and they didn’t think it was anything to worry about. How do I know if that changes? I can’t see it very well, so it’s hard to monitor changes. Should I continue to get it checked? What if I want it removed so I don’t have to worry about it anymore, will it leave a scar? Should I just leave it alone?
Philip_Bailin,_MD,_MBA: Moles which are over 6 mm in diameter are more likely to be problematic, but certainly are not definitely going to become malignant. The fact that you have had it examined previously and that it has been there for years are both good signs. I would continue to have it checked annually. A good idea would be to have it photographed, so that any changes can be documented. Surgical removal will definitely result in some scar formation.
Surgery for Recurring Nevi
xdwl: My husband who is 65 years old has two nevi in his left cheek for over 20 years. Ten years ago, a doctor removed them with laser therapy. In the first few years, they looked all gone. However, in the last four to five years, they slowly grew up again. One is 7 mm in diameter. The other one is 4 mm, black and higher than the surrounding skin with no hairs on the top. We are concerned about the regrowth of nevi in the face. Should we continue monitor them, or we should have them removed with excision?
Philip_Bailin,_MD,_MBA: In view of the fact that the original nevi were removed with laser, there was probably no pathological examination of the specimens to determine their exact nature. If there is now re-pigmentation at the sites, I would advise that they be removed surgically and that a biopsy be performed on each. Re-pigmentation of normal moles after removal is not uncommon, so that alone does not mean that either of these is malignant.
Carson: Would you clarify the use of sunscreens? Many people have different opinions such as:
- Anything over SPF 30 is useless.
- You cannot get the recommended vitamin D from the sun when wearing sunscreen.
- Should sunscreen be waterproof or water resistant?
- Do dark-skinned complexions need to wear sunscreen?
Philip_Bailin,_MD,_MBA: These are great questions.
- Sunscreens which block ultraviolet B (UVB) rays are numerically graded. There has been some controversy as to whether the very high numbers are really meaningful, but certainly numbers over 30 are more protective than lower numbers. Remember that the ultraviolet A (UVA)-blocking sunscreens are not numerically graded. It's best to get a broad spectrum (UVA and UVB) sunscreen of at least 30 SPF.
- The vitamin D question is very controversial. We all need it, but the degree to which sun protection reduces it and what the really appropriate level should be are still in question. If you are of a light skin type and get exposed to lots of sun, then the relative risk of skin cancer is likely greater than the risk of low vitamin D. Also, the vitamin D can be supplemented.
- Sunscreens are more likely to be water resistant. These will stay on and effective with swimming and sweating, but do need to be re-applied if exposure is for several hours. The true waterproof sunscreens are less common, and much less cosmetically acceptable to most people.
- Finally, darker complexions have relatively less risk of cancer from sun exposure. However, it can still occur, so some form of sun protection is a good idea.
Recent Melanoma Treatments
susieQcumber: What developments in treatment of melanoma have there been in the last five years?
Brian_Gastman,_MD: Great question, and if I had a few hours I would be happy to delineate them! As someone who runs a melanoma center as well as a basic science laboratory devoted to discovering cures for melanoma, the last four to five years have changed everything. A melanoma patient in 2009 had the same options as someone in 1990. Today there are so many FDA-approved and soon-to-be approved drugs. The immunotherapies seem to be the closest to providing long-term cures. Targeted drugs though have also given us new weapons in the fight against this tumor. Combine that with new detection capabilities, prevention plans and improved surgical options, and there is much to become optimistic about.
Moderator: I am sorry to say that our time with plastic surgeon, Dr. Brian Gastman and dermatologist, Dr. Philip Bailin is now over. Thank you for sharing your expertise and time to answer questions today.
Brian_Gastman,_MD: I would like to thank the audience for these important questions. One of the missions of building our melanoma and skin cancer clinics (beyond giving the best care in the U.S) is to educate the public and our patients. We therefore appreciate these opportunities.
Philip_Bailin,_MD,_MBA: Thanks for all the great questions today.
To make an appointment with Dr. Gastman or Dr. Lucas, please call 216.444.5725 or call toll-free at 800.223.2273, ext. 45725. You can also visit us online at www.clevelandclinic.org/DPSI.
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