If skin cancer in America has become an epidemic, then Florida is Ground Zero. We have some of the highest rates of both non-melanomic and melanomic skin cancer in the nation. So, it is more important than ever that Florida doctors do everything we can to intervene in this public health crisis. And since May is officially “Skin Cancer Awareness Month,” this is a good time to remind our patients what they should be doing to protect themselves from developing skin cancer, what they need to know in order to detect the disease early, and the good news about some truly remarkable advances in treatment that have been made recently.
First, how bad is the problem? The answer: Pretty bad, and, unfortunately, it is getting worse.
Consider the numbers:
- Florida reports 8,000 new cases of melanoma – the deadliest form of skin cancer – each year; that is the second-highest number in the nation.
- Overall, more than 5 million cases of skin cancer will be diagnosed in the U.S. this year, according to the Skin Cancer Foundation.
- One in five people in the U.S. will develop skin cancer by age 70.
- In the past decade, the number of new melanoma cases diagnosed annually has increased by 53 percent.
- About 74,000 Americans will develop melanoma this year.
- About 90 percent of non-melanoma skin cancers and 85 percent of melanoma cases are associated with exposure to ultraviolet radiation from the sun.
The term “skin cancer” encompasses a broad array of diseases with important distinctions. The two most common forms of skin cancer are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). When talking to patients, it’s helpful to compare these skin cancers to something we’ve likely all had: a dental cavity. While these two versions of the disease are unlikely to prove fatal, they will not go away on their own without treatment, and they will destroy tissue as they grow. If caught early, these two “non-melanoma” skin cancers can usually be treated with simple procedures that can be administered in the outpatient clinic.
However, if these cancers are neglected or undiscovered, they can grow to such a stage that they require major surgery. And although death from these cancers is uncommon, it can and does happen. According to the American Cancer Society, it is thought that about 2,000 people in the U.S. die from these cancers each year.
The next most common form of skin cancer, in comparison, can be unanticipated, heartbreaking and lethal. Malignant melanoma’s incidence over the last few decades has witnessed a meteoric ascent, surpassing expectations and defying explanation. Thankfully, about half of reported melanoma cases are caught early as in situ (or non-invasive) disease that is readily curable. Still, melanoma kills about 10,000 Americans each year; that works out to more than one person dying of the disease every hour.
So how can Central Florida doctors help stem this rising tide of skin cancer in America? Here are a few suggestions:
First, talk to your patients, especially younger patients, about the dangers of over-exposure to UV radiation. Teach them that sunscreen is just one tool in the fight against skin cancer – broad-brimmed hats, sunglasses, cover-ups, umbrellas, and common sense are just as important.
Second, help your patients overcome common SPF misperceptions. For example, a higher SPF rating on the bottle does not necessarily mean a better sun protection. Here’s why. There are two kinds of ultraviolet rays that can damage skin: UVA and UVB. The SPF, or Sun Protection Factor, scale addresses only UVB. These rays cause sunburns and are largely responsible for SCC. Surprisingly, many sunscreens don’t do a good job of protecting us from UVA rays, which we believe cause wrinkles, basal cell carcinoma, and malignant melanoma.
The words “broad-spectrum” are key when looking for sunscreen. Sunscreens that contain zinc oxide provide especially effective protection against both kinds of UV rays. Zinc oxide is inherently natural, a quality many consumers are looking for, and nanotechnology can make it almost sheer. Dermatologists have recommended sunscreens with this ingredient for years, and it is safe—in fact, it’s a common ingredient in baby ointments.
Urge your patients to beware of marketing gimmicks that advertise SPF 100+. The SPF curve approaches full UVB protection at SPF 30; higher numbers don’t afford any meaningful protection. In fact, very high SPF sunscreens may be less balanced and less likely to provide broad-spectrum UVA-UVB coverage. Also, avoid spray sunscreens, because they provide poor coverage and could be harmful if inhaled.
Third, you can use the public’s growing interest in genetics (i.e. at-home mail-away kits) to initiate a conversation about genetic factors that may increase a person’s risk for developing skin cancer. This is not to say you should encourage patient to take tests of dubious medical benefit, but a patient’s interest in genetics can lead to a helpful discussion of skin types and other factors that may increase a person’s risk of disease, such as Fitzpatrick Skin Type. The Skin Cancer Foundation has a useful quiz to help you identify your skin type on its website SkinCancer.org.
It is sometimes surprising to Floridians to realize their bodies just are not genetically adapted for the UV index in our part of the world. Patients are often surprised to realize that Central Florida is on the same geographic latitude as North Africa. In fact, as we wrote this article, a patient planning a trip to Morocco was surprised to learn that her sun exposure risks there were no greater than when she drove to the office.
While we should always counsel our patients to avoid over-exposure to the sun today, we should remember that most skin cancers happen decades after overexposure to the sun. Once sun damage occurs in patients who are in their 20s and 30s, there’s not much one can do except to wait and watch.
This phenomenon underscores the tremendous importance of skin checks and melanoma screenings. Given the shocking increase in all skin cancers, including potentially-deadly melanoma, an annual skin exam should be routine for most Floridians.
With this in mind, I’m proud to direct our new multi-specialty Melanoma and Skin Cancer Center at Orlando Health UF Health Cancer Center. Not only is our new clinic raising awareness about our community’s skin cancer epidemic, it’s providing a valuable resource to patients with a history of or those who are at genetic risk for aggressive melanoma.
Orlando Health’s approach is to bring together specialists in all areas of skin cancer treatment, including dermatology, medical oncology, surgical oncology, radiation oncology, and reconstructive surgery. With this collaborative approach, we are able to provide our patients with a 360-degree perspective to evaluation and diagnosis, and do it more efficiently, reducing the uncertainties and anxieties that inevitably arise when patients must endure lag times between appointments. This kind of multi-specialty approach to melanoma and other skin cancers is unique in Central Florida.
And this brings us to what can be done if someone has developed melanoma. The advancements that have been made recently are dramatic.
The FDA recently approved the use of T-VEC (Imlygic®), a genetically modified herpes virus therapy, to treat melanoma lesions that cannot be surgically removed. The therapy is injected directly into skin lesions, where it causes cancer cells to rupture and die. T-VEC is a first-of-its-kind melanoma treatment and marks the first time the FDA has approved this type of therapy.
In those with skin and lymph node only lesions, T-VEC resulted in 52 percent tumor shrinkage along with a near doubling of the median overall survival compared to those who received an old drug called GM-CSF (41.1 months vs 21.5 months). Of the patients with a complete response to T-VEC, the disease had not progressed after 3 years in 72 percent.
T-VEC has several side effects, such as flu-like symptoms, fatigue, fever and nausea. Since the treatment uses a form of the herpes virus, it’s also possible that anyone who uses it may get herpes infection. For that reason, this treatment isn’t recommended if you are pregnant or have a compromised immune system.
There are also significant improvements in the treatments for patients with even more advanced melanoma. Six years ago, a Stage IV melanoma diagnosis was a virtual death sentence. Treatment options were few and not very effective; the survival rate was only about 5 percent. But in 2011, a new form of therapy emerged that helped the body’s own immune system attack melanoma cells. These new drugs are called immune checkpoint inhibitors. Two of these drugs – Keytruda and Opdivo – activate T-cells, which are like the immune system’s Marine Corps, in a way that allows the T-cells to attack melanoma cells.
The indications so far have been extremely encouraging, with 40 to 50 percent of patients responding favorably to the treatments.
Perhaps even more exciting, we have discovered that by combining T-VEC with Keytruda we are seeing even better responses. At Orlando Health, we have been part of clinical trials currently underway on this approach. We have treated four patients in the trial and several others outside of the trial. The results lead us to believe this approach will be very promising and that it may become the preferred approach for Stage IV melanoma because it is so well tolerated by patients.
Another study currently underway shows a great deal of promise for melanoma patients who have a mutation in the BRAF gene. About half of melanoma patients have a BRAF mutation, which drives the growth of the mutation. We are testing a combination of immunotherapy with BRAF/MEK inhibitors which have had astounding results. Tumors seem to melt away impressively within days in some cases and also looking durable. The long-term effectiveness of these treatments, however, is less certain, and more study is needed.
We are currently enrolling patients to a new protocol where T cells, which are the marines of the body, are harvested from patient’s own tumor, cloned by the billions and infused back into the patient along with additional medications to stimulate these cells to work better. This is a treatment for patients who have had progression of the melanoma after prior treatment with immunotherapy and targeted therapy.
The responses are very encouraging. In a preliminary study where patients had a complete response to this new treatment, the responses appeared durable long-term. We will also open a new protocol looking to this one-time treatment in the first-line setting. Patients are encouraged to seek clinical trials wherever possible.
While the rates of skin cancer and melanoma have increased in troubling numbers, the recent advances we have made and are continuing to make in treating both non-melanomic and melanomic skin cancer gives us much to feel confident about.
Skin cancer affects almost every family in Central Florida. As doctors, we can do a lot to fight this devastating enemy by encouraging prevention, vigilance and early treatment. For more information or to schedule an appointment at the Melanoma and Skin Cancer Center at Orlando Health UF Health Cancer Center, call 321-841-6299.
By J. Matthew Knight, M.D., Chief of Dermatology, Orlando Health and Sajeve S. Thomas, M.D.
Hematology & Oncology, Orlando Health