Despite there being a good public health campaign for sun protection, skin cancer is a very common condition in Australia and New Zealand. All types, including melanoma, basal cell carcinoma and squamous cell carcinoma are treatable, with some treatments even being non-invasive such as creams, gels or liquid nitrogen cryotherapy.
In this article, we are going to discuss the treatment options available for skin cancers and what the risks and benefits of them are.
Does skin cancer need treating?
For most patients yes. We do not want to leave any cancer left untreated if we can help it. However, not all patients will benefit from having their cancer treated.
As a GP and a skin cancer doctor, it’s a conversation I have with my patients occasionally. Even if the patient has a lot of skin cancers on their body, it may not be in their best interest to treat them, or at least to surgically remove them. An example of this is if a bed-bound patient in a nursing home has a suspected basal cell carcinoma – a relatively low-risk skin cancer.
We don’t always know what type of BCC it is from the clinical examination, although we can usually guess with a good degree of accuracy. We might agree with the patient that it isn’t in their best interest to have invasive surgery, especially if large. Sometimes they may not even tolerate the anaesthetic needle nevermind the actual surgery.
Even for conditions such as melanoma skin cancer, it may not be in the patient’s interest to have it treated surgically, if at all.
What types of skin cancer are there?
There are 2 broad categories of skin cancer, melanocytic and keratinocytic. Often referred to as melanoma and non-melanoma skin cancer (NMSC). Treatment options vary between the 2 main types. Keratinocyte skin cancers include Basal cell carcinoma BCC and Squamous cell carcinoma SCC. There are different subtypes of these conditions. For example, an SCC could be Kerataoacanthoma, or Bowen’s Disease (Intra-epidermal carcinoma, AKA Squamous cell in situ).
They affect different layers of the skin, and some are quite common cancers, others are rarer.
Treatment options will depend on the type and subtype of skin cancer. If you want to learn more about the types of skin cancer read here.
How do I know if I have skin cancer?
The symptoms can be something as seemingly harmless as a scaly patch of skin, or something more serious like a bleeding mole. Make sure you read up on how to do a self-skin check if you aren’t sure.
Who can treat skin cancer?
Your General Practitioner (GP) can treat most skin cancers on most parts of the body, but your GP may not be confident to deal with your specific skin cancer. There are skin cancer doctors in dedicated skin cancer clinics, or dermatologists, or of course plastics and general surgeons who deal with skin cancers also. The first contact should usually be your GP or skin cancer doctor.
When should I get treatment?
As early as possible. Early detection is the key to treating skin cancer successfully, and we know that the earlier you detect cancerous cells the better. You don’t need to rush to have the treatment that day. However, you will have a higher chance of a successful cure if it is removed sooner.
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Surprisingly surgical excision is not the only treatment option for skin cancer. Guidelines from authorities such as Cancer Council Australia advocate other treatments for many skin cancers, including gels, creams, liquid nitrogen, curettage and cautery, radiotherapy, or surgical excision.
Creams can be an effective treatment for certain types of skin cancer. For example, Basal Cell Carcinoma (BCC) – If it is superficial BCC, affecting just underneath the top layer of skin cells, then it may be amenable to treatment with a cream such as Aldara (Imiquimod). Another example is Squamous cell in situ (Bowen’s Disease).
The benefits of cream are many. It is the least invasive treatment option we have for skin cancer. This can be very useful for frail or elderly patients. It typically does not cause much, if any, scarring. Furthermore, it is often the cheapest treatment option also which is very important to some.
Cream can be used as an adjunct to treatment, after initial debulking treatment. This may be used if there is a mixed type, nodular and superficial BCC and the doctor. For example, if the patient and doctor have agreed on a curettage and cautery (C&C), but the superficial component appears to be spreading more than the doctor is willing to curette. They may suggest the use of cream after the curettage. It can also be used in reverse as a neo-adjuvant way, before any surgical treatment.
Creams may also be used to treat pre-cancerous cells such as Actinic Keratosis (Solar Keratosis). It is often used in large treatment areas such as the scalp.
Used for superficial BCC and SCC in situ (Bowen’s disease). Well tolerated usually. Can have high effective cure rates. Low chance of side effects or scarring. Cannot be used for raised lesions or melanoma.
Liquid Nitrogen Therapy (Cryotherapy)
This is using liquid nitrogen, usually in spray form, to treat skin cancers. Only certain skin cancers should be treated using a liquid nitrogen spray. The main danger is insufficient treatment. It can also make it very difficult for the pathologist to give you an accurate diagnosis if you perform a biopsy later.
Examples of skin cancers which can usually be treated with liquid nitrogen are:
- Superficial BCC
- Nodular BCC
- Squamous cell carcinoma in situ (Bowen’s disease / SCC in situ)
The use of liquid nitrogen therapy is not without risks. Other than the possibility of insufficiently treating skin cancer, there is a risk of scarring. Sometimes the treatment will not cause a scar, but the likelihood is that it well. The scar is usually a small, flat, round scar. Like any scar it can become hypertrophic or keloid, although this is rare.
Liquid nitrogen therapy can also sting quite a lot. Some patients tolerate it better than others, and afterwards, it can be very sore. It will usually blister up afterwards too but should resolve within a few weeks.
Liquid nitrogen should not be used to treat melanoma, squamous cell skin cancers, or large basal cell carcinomas.
Used for small superficial and nodular BCC in low-risk sites and Bowen’s disease. Can be uncomfortable but usually well tolerated. Will blister and cause discomfort. Very likely to cause scarring. Cannot be used for melanoma skin cancer.
Photodynamic therapy (PDT)
This is the process of using UV light to activate creams that chemically destroy skin cancers. It can be done in 2 ways. Natural daylight activated PDT (ND-PDT) or artificial light PDT. Both use light to activate the chemicals that destroy skin cancer cells.
This is done usually in specialised skin cancer clinics, although some GPs offer this treatment as well.
It can be used to treat low-risk basal cell carcinomas and pre-malignant skin conditions like Actinic (solar) Keratosis.
It cannot be used to treat SCC or melanoma skin cancer.
With Daylight PDT you apply a cream and then stay outside for 2 hours to activate it. With artificial PDT you will have a bright light shone on to the area for around 15 minutes. Both are equally effective at treating skin cancer.
PDT is usually well tolerated but can cause some pain and discomfort (common), inflammation (common), blistering (less common) and scarring (uncommon). Colour change of the skin is also possible although this is rare.
Can be used to treat low risk BCC. 2 main types with similar effectiveness. Side effects include discomfort and blistering. Can cause scarring or change in colour of the skin. Cannot be used for SCC or melanoma.
Curettage and Cautery
This refers to the scraping off of a skin cancer and cauterizing afterwards. Usually this is done with either electrocautery (e.g. with a hyfrecator) or chemical cautery (silver nitrate).
Local anaesthetic is injected into the skin first to numb the area and then the skin cancer is scraped away. If a large piece comes away then it should be sent to the pathologist to be checked, otherwise if it is tiny bits or ‘slough’ then they may not send it away for testing.
The skin cancer cells come away very easily compared to normal skin and so this method is useful for determining how far a skin cancer has spread locally. Sometimes the doctor may end up scraping away more than they thought. This is because even if they they can’t see it, it may have grown on the skin further than originally thought.
It’s like scraping the seeds out of a rockmelon (canteloupe). The seeds (skin cancer) comes away very easily with a spoon (curette) whereas the flesh (healthy skin) is barely touched.Dr Suresh Khirwadkar
It is then cauterized to stop the bleeding and destroy any remaining skin cancer cells. The process is usually repeated 2-3 times in quick succession.
C&C is usually well tolerated with local anaesthetic, but it can be quite uncomfortable when it wears off. The process can cause quite marked scarring also, so it is not ideal in cosmetically sensitive areas.
Generally it has a good treatment success rate, in the region of 85-90%, but it should not normally be used for high risk zones like the ears or nose. Appropriate tumour selection is paramount.
Curettage and cautery is an effective treatment for many non-melanoma skin cancers. It has a good treatment success rate and is well tolerated, and can avoid difficulties in wound closure. It can however produce marked scars and so is usually inappropriate on cosmetic areas.
The ‘gold standard’ of skin cancer treatment. Surgical excision refers to cutting out the skin cancer, usually with a scalpel, and then closing the wound. An appropriate amount of healthy skin around the cancer is also removed (called a margin) to reduce the risk of missing anything.
The size of the margin depends on both the type of skin cancer, and the area of the body that it is removed from, although there are some standard guidelines. Cancer Council Australia guidelines for Melanoma, for example, suggest a 5mm margin for most Melanoma in situ (Grade 0/1), all the way up to 2cm margins for a Grade 4 melanoma. Suggested margins for BCC and SCC are typically smaller, but still may be 4-5mm.
After the skin tumour is removed it should be sent to the pathologist to be tested and the margins reported. If there are insufficient margins then the surgery should be repeated to ensure it is clear of the skin cancer.
There are currently no clear guidelines on what is deemed to be an acceptable ‘histological margin’, i.e. the distance from the edge of the tissue removed to the nearest skin cancer cell.
Not all skin cancers need surgical excision and there may be a more appropriate alternative
Sometimes surgery can be a difficult location, such as near the eye, and then advanced surgical closures may be required. A skin flap or skin graft may be required to close the wound without causing undue stress or tension on other structure.
For example, around the eye, the closure should not be pulling the eye or it can cause an Ectropion which may lead to chronic problems. It can also cause marked cosmetic defects which may be deeply unpleasant for the individual and is a leading source of complaints and litigation.
It may be preferable to use a cream or cryotherapy. For example when treating a superficial BCC near the eye, a cream might be preferable to avoid the risk of pulling the eye.
Surgery is usually very well tolerated with a quick recovery, although it will leave a scar. The scar is usually linear but if a flap is used the scar will be a different shape. If a graft is used the wound scar can look very different and may even be a different colour. Some areas of the body are quite prone to hypertrophic (thickened) or keloid scars.
Scars can be unpredictable, and it will take around 18 months for a scar to reach its ‘end stage’ (fully remodel). There are treatments that can be done to reduce the scar, such as dermabrasion or injections into the scars.
Treatment success rates are generally excellent with surgical excision, and it remains the gold standard of treatment for both non-melanoma skin cancer, and melanoma skin cancer.
Specific cure rates depends on the skin cancer but even for melanoma 10 year survival with surgical excision is extremely good at over 98% cure rate for melanoma in situ (early stage of melanoma skin cancer).
Surgical excision is the gold standard of skin cancer treatment, but will cause scarring. An appropriate amount of healthy skin will be taken from around the outside also to ensure a better chance of cure.
There are other treatments available for skin cancers although these are more specialised and usually performed by medical oncologists. Examples of these treatments are chemotherapy and radiotherapy.
All skin cancer surgical treatments carry risks and are deemed invasive procedures. Appropriate consent should be taken, including the option of the patient seeking a second opinion and they should be advised of their right to do so. Successful treatment (cure) cannot be guaranteed and cosmetic results can vary.