The incidence of most skin cancers increases the older we get. They tend to occur on sun- exposed parts of the body. Often sun exposure early in life will result in a skin cancer many years later. With excessive sun exposure and an ageing population, plastic surgeons recognise that there will be a large increase in the amount of time spent treating skin cancer in the next five-to-ten years.
Plastic surgeons commonly treat skin cancer because they have the techniques to close wounds sometimes by skin grafts or flaps, but often by simpler means. This means that we can confidently remove the tumour knowing that the wound can be repaired. The priorities for treatment are complete removal of the cancer, achieving rapid healing, getting you back to normal and getting the best possible appearance.
There are three types of skin cancer that people need to be aware of. These are basal cell cancer and squamous cell cancer; both of which are classified as non-melanoma skin cancer, and the third, which is known as melanoma.
Basal cell cancer is the most common and is easily treatable. Squamous cell cancer is less common and can be more problematic, while malignant melanoma is serious and needs to be treated urgently. In the case of squamous cell cancer and malignant melanoma, early diagnosis and intervention are essential.
2. What do the main conditions involve?
Basal cell cancer
Basal cell cancer is very common in the UK. It is usually found on the head and neck, but can occur at other sites. It usually results from exposure to the sun; the incidence increases with age. The patient will usually notice a spot, red patch or scaly crusted area. It may itch or bleed. As it grows very slowly and does not spread, basal cell cancer generally causes few problems. However, it does need to be treated, as the cancer can slowly get bigger and cause problems.
Squamous cell cancer
Squamous cell carcinomas are less common. They are often a scaly patch or ulcer. Also caused by long-term exposure to the sun, squamous cell cancer is more serious. That said, most patients will present with an early, small, thin lesions that can be cured by a simple local anaesthetic operation. More advanced lesions do carry a risk of coming back even after complete removal, and can spread to other parts of the body.
Over the past few decades, the incidence of melanoma has risen steadily throughout the world. It is caused by short, intense bursts of exposure to the sun.
Melanoma is the type of skin cancer that arises in brown spots. It is less common than the other sorts, but can be more serious. The majority of patients are still cured by simple removal, but melanoma can come back after removal and spread elsewhere in the body.
The main risk factors for developing melanoma include:
Sun exposure, particularly during childhood
Fair skin that burns easily
Blistering sunburn, especially when young
Previous non-melanoma skin cancer, such as basal cell or squamous cell cancer
Family history of melanoma, especially if two or more members are affected
Large numbers of moles (especially if there are more than 100)
How to spot melanoma
The most important symptom in melanoma is a history of change so you should keep an eye on your moles. It is normal for moles to gradually change through your life. Usually they become slowly raised and get paler. They may grow hair. These gradual changes are not of serious significance.
However, perhaps a brown spot changes shape, developing an irregular edge or irregular colour over a few weeks or months. It may itch or bleed. It will usually be larger than 5mm diameter.
If you think a mole is changing you should show it to your doctor.
3. What surgery is available, and what techniques are involved?
Different types of treatments are available depending on the type of skin cancer you have, and the stage at which your cancer is diagnosed. In all three cases, excision surgery, whereby the cancer is removed, is the mainstay of treatment and by far the most definitive option.
Basal cell cancer
If you are diagnosed with basal cell cancer, you should be assured that, in accordance with NICE Guidelines, you will only be seen by a designated specialist with an interest in skin cancer. Your consultant will make a diagnosis upon examination, or may take a small biopsy to confirm the diagnosis. The important thing at the diagnosis stage is that the rest of your skin is examined to check for other possible sun-related problems.
Excision surgery for basal cell cancer is simple and safe. You will be treated on an outpatient basis, meaning that you will be seen, treated and discharged all in the same day. The surgery requires local anaesthetic only, and involves a simple excision and stitching procedure. There will be scarring, but surgeons will do all they can to keep this scarring to a minimum.
Radiotherapy, creams and freezing techniques are also available, but by and large surgery is the preferred and most effective treatment option. You should also receive information about sun protection to avoid any recurrence in the future.
Squamous cell cancer
The surgical procedures for the treatment of squamous cell cancer are much the same as those for basal cell cancer. Excision surgery is usually straightforward, but in some instances when surgery is required on the face, surgical grafts or flaps may be needed to fill the hole or repair the defect made during surgery. A flap is a piece of living tissue that is transferred from one part of the body to another, along with the blood vessels that keep it alive.
Following the diagnosis of melanoma, a pathologist will examine and measure the thickness of the tumour. The thicker the tumour, the more difficult it is to treat. From this measurement, and based on how severe or advanced the melanoma is, the pathologist will arrive at a prognosis.
Melanomas are removed surgically. The extent of surgery depends on the thickness of the melanoma and its location on the body. Most thin melanomas do not need extensive surgery. The tumour is removed using a local anaesthetic, and the defect is stitched up. A small area of normal skin around the melanoma is also excised to make sure that all the melanoma cells have been removed – this procedure is known as a wide local excision. Often this is done as a second procedure (re-excision) when the pathology has confirmed the diagnosis of melanoma.
For thicker melanomas (those over 1mm or so in thickness), a wider area of skin is cut out. A skin graft or flap might be necessary, which replaces the removed skin with skin taken from another part of the body. A sentinel node biopsy may also be carried out on the lymph glands in the area, and these glands may be removed depending on the result. If the melanoma is widespread, other forms of treatment may be necessary, but these are not always successful in eradicating the cancer.
4. What should I expect in terms of treatment, procedures and outcomes?
For basal cell cancer and squamous cell cancer, surgical and treatment success rates are high. If you are treated for these non-melanoma skin cancers, you should be discharged on the day of surgery and should be able to return to work the following day. For patients with squamous cell cancer, you will be kept under review for two years, with appointments at six- monthly intervals to check on your scars and lymph nodes.
For patients with melanoma, 80% will follow the treatment procedures outlined above and will be fine. They will be kept under review for five years and will receive regular check-ups. The remaining 20% may experience further recurrence.
However, patients should be reassured that cure is by far the most likely outcome if the thickness of the tumour is less than 1mm at the time of diagnosis. Early diagnosis and intervention is therefore critical, so if you are concerned about a patch of skin or a lesion, get it checked out by your GP straight away.
5. Skin cancer prevention
Skin cancer can be prevented by reducing sun exposure. You should protect yourself from the sun at all times, and use a high factor (at least SPF 15) sunscreen on all exposed skin in the summer months. This is particularly important for children, those with fair skin, and those with a family history of melanoma. The rules are:
Do not sunbathe
Do not use sunbeds
Cover up – wear a hat and long loose clothing when in the sun
Avoid the midday sun
Use a high factor sunscreen – at least SPF 15
6. Where should I go for more information and support?
Cancer Backup is a great source of information about all cancer-related conditions.
National Institute for Clinical Excellence - NICE guidelines on skin cancer
BAPRAS website - British Association of Plastic, Reconstructive & Aesthetic Surgeons
BAD - British Association of Dermatologists