Skin Cancer Awareness Month: Addressing Misconceptions and Promoting Prevention
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Michael E. Kasper, MD, FACRO, discussed unmet needs in skin cancer treatment and addressed misconceptions among patients and health care providers.
While skin cancer is one of the most common cancers in the US and worldwide, with 1 in 5 Americans developing skin cancer in their lifetimes,1 unmet needs still exist. An estimated 90% of skin cancers are considered preventable,2 and gaps in the field include a need for more therapies for advanced disease, enhanced prevention, and early detection.
In an interview with Targeted OncologyTM, Michael E. Kasper, MD, FACRO, board-certified radiation oncologist and director of radiation oncology at the Eugene M. & Christine E. Lynn Cancer Institute at Boca Raton Regional Hospital, part of Baptist Health, discussed these topics for Skin Cancer Awareness Month.
Targeted OncologyTM: What are the most significant advancements in the diagnosis and treatment of skin cancer in recent years?
Michael E. Kasper, MD, FACRO
Kasper: There have been many advances throughout medicine, and many of those have spilled over into skin cancer and dermatology, not the least of which has been immunotherapy for things like metastatic melanoma and other advanced skin cancers. We also have targeted agents for very large basal cell cancers and other targeted agents in immunotherapy for squamous cell [cancer].
In my mind, what is probably been one of the best advances and an area for improvement in many places is the multimodality approach that we are able to take here at the [Eugene M. & Christine E.] Lynn Cancer Institute. Patients are seen by all the skin cancer specialists all at the same visit. Usually, the dermatologist refers them in especially difficult cases, like Merkel cell [carcinoma] or melanomas. We see a lot of those cases; whereas dermatologists may see 1 or 2 Merkel cell [carcinoma cases] in their whole career, we see maybe 20 a year.
[Once they have been referred], the surgical oncologist, the medical oncologist, radiation oncologist, all who have specialized in skin cancers see the patient at the same time. The patients may also be seen by the psychosocial [team] to deal with any family or logistical problems. They will be seen by a dietitian, if necessary, and the patient has a nurse navigator who can help with appointments that may be made in the future, surgical appointments or imaging appointments. Then, the physicians get together with radiology and pathology and review the case, all looking at the same images, the same pathology, the same MRIs and PET scans. That is rare in the dermatology world, but it is so important in these more advanced cases. Not many places have an advanced cutaneous malignancies multimodality clinic, and I think it is a shame, because so much of the time, it is difficult to pull together the different path[ology] reports. When you have a coordinated effort like this and an expert team, I think it can make a huge difference.
What are some of the persistent challenges for skin cancer prevention and early detection that you believe need more attention in the health care community?
We know the easy things we can do. In fact, in many cases, we know how we can prevent over one-third of all cancers. It is just a collective will and a focus in the medical community and a collective will by society to make it happen in skin cancer. We know that by limiting sun exposure, particularly in the first 20 years of life, we can dramatically reduce, if not eliminate, skin cancers. There will still be some rare cancers that develop, but by and large, most of the later-in-life basal cell and squamous cell [carcinomas] could be avoided by limiting sun exposure early in life.
That takes an education piece. Certainly, we can do a better job with education, and it takes a changing of norms in society, where it is okay to go to tanning beds and really sit out when you are 15 years old and get fried by the sun. We need to educate people to know that that may seem like a good idea now, but you are going to be paying for it later. We know that over 90% of our sun exposure usually comes by age 20. So, if we can have better protection as babies, as kids growing up, going to the beach, and as teenagers lying out in the sun, we can greatly impact what happens down the road. It seems simple, almost too simple, but it's still one of the greatest challenges. But it is something so doable; it just takes a change of collective will.
What are some common misconceptions or knowledge gaps about skin cancer that you encounter?
I hear this from my patients all the time, particularly patients who are referred in late for radiation. They say, “I wish I had known about this sooner.” There's no question that surgery, and [often] Mohs surgery, [is] the gold standard and the main approach to most skin cancers. But particularly for frail and elderly patients, or in sites where there is possibly functional or structural damage that could occur and the reconstruction is going to be complex, radiation should at least be considered as an alternative, and patients should be given that option. I am told it is never brought up. It is only after their 10th, 11th, 12th Mohs surgery, after they complain or it’s become a problem, [that radiation is an option]. It is a shame that radiation is not considered as an equivalent or a good alternative for managing skin cancers in the right positions. We know that it's not for everyone, and we would not recommend this for a 25-year-old who needs surgery. But in many cases, it is a reasonable and even a superior option for many patients.
More and more dermatology offices are putting in radiation, and there's a huge marketing push on “gentle” radiation or “soft” radiation, and it's come across as something that is new or different. It is superficial radiation that's been around for about 80 years, and it is one type of radiation that fits one tiny little scope of skin cancer. It comes off as perhaps a turf battle, but I think I can say with certainty that if you come into a radiation oncology office, you will get many different options of radiation treatment based on the exact specifications of the tumor. Deeper tumors may not be amenable to the superficial radiation, but patients are coming in and dermatologists are treating quite a few of these lesions that they may not be quite sure [about]. I do get a lot of referrals from dermatologists who do have their own radiation machines. If they're not sure, they do send them over. But I think that there is a misconception that this “soft” radiation or this “gentle” cure is something that's new or different or better for all skin cancers. Radiation should be given by radiation oncologists. We have extensive training in radiation biology and physics, and we have a career full of seeing radiation skin reactions and cancer care. That's not always the case in dermatology.
How has AI impacted skin cancer screening and diagnosis? What are the implications of its use?
I know in many dermatology practices that they are using new imaging tools to document and follow lesions across the body. I think that is great tool [because] we are able to find subtle changes and utilize AI now and make good choices about biopsying and targeting lesions that may be different or should be checked. There's no question that AI is going to have a huge role in in all of medicine, but dermatology and dermatopathology as well.
Do you see any disparities across racial and ethnic groups when looking at skin cancer incidence?
Northern European cultures who have migrated to South Florida are at great risk, so there's a huge disparity in in people with fair skin [and] blue eyes. They are much more likely to develop skin cancers, and they are at higher risk for melanomas and Merkel cell [carcinomas]. There is a misconception, however, that people of color do not develop skin cancers. That is incorrect. I think it is important to educate our patients of color that they also can be at risk and to not ignore suspicious skin changes and to not bake in the sun as well.
