What Everyone Should Know About Skin Cancer: Risks, Myths & Prevention

Dr. Diane Reidy-Lagunes:

One in five Americans will face some kind of skin cancer in their lifetime. And it's not just those with fair skin who are at risk.

Jocelyn:

I didn't think that someone with my background being Hispanic or Latino would get skin cancer because I thought it would only happen to people who were fair skinned, people who had light colored eyes. I never thought that people with darker skin complexions could get skin cancer.

Dr. Diane Reidy-Lagunes:

The good news is that it's treatable when caught early. So how can you protect yourself? Let's talk about it.

Hello, I'm Dr. Diane Reidy-Lagunes from Memorial Sloan Kettering Cancer Center and welcome to Cancer Straight Talk. We're bringing together national experts and patients fighting these diseases to have evidence-based conversations. Our mission is to educate and empower you and your family members to make the right decisions and live happier and healthier lives. For more information on the topics discussed here, or to send us your questions, please visit us at mskcc.org/podcast.

We are thrilled to be joined today by Dr. Erica Lee, who is a dermatologist and Mohs surgeon here at MSK. Erica focuses on caring for people with basal cell, squamous cell, as well as early-stage melanoma. She'll break down the different types of skin cancer, what to look out for, and when it's time to see the doctor. Erica, thank you so much for joining us today.

Dr. Erica Lee:

Thank you so much for having me. So great to be here.

Dr. Diane Reidy-Lagunes:

I'd like to start with the basics. Can you just talk us through the different types of skin cancers and what we should look out for?

Dr. Erica Lee:

So the way I like to think of skin cancer is I put them into two broad categories:

We have the non-melanoma skin cancers, and they are derived from the top layer of the skin, which we call the epidermis. The most common form of skin cancer is called basal cell. So basal cell carcinoma, we're talking well over 3 to 4 million cases in the US alone every year. The lesions typically present anywhere from a sore, a pimple, it could even look like a scar, and these typically occur anywhere that you've had a lot of sun exposure. So you might have had cumulative intense sun exposures throughout your lifetime and then you manifest with a basal cell.

The second most common skin cancer is called the squamous cell, and these are probably close to 1 to 2 million per year in the US, and similarly they present on sun exposed area. The most common locations for both the basal and the squamous is the head and neck area. We typically see these on the face, the scalp, but we also see them anywhere that you've had sun exposure. It could be on your arms, your back, your legs.

The majority of these skin cancers are easily treatable if they're caught very early. We tend to think of treatment in two broad categories. You can treat them non-surgically if they are superficial and not deep. If they require a little bit more than that, we typically remove them with either a conventional excision or we also do a precise technique called Mohs surgery.

Dr. Diane Reidy-Lagunes:

Erica, what exactly is a Mohs surgery?

Dr. Erica Lee:

A Mohs surgery is an outpatient procedure. You'll come into the office under local anesthesia and the skin cancer is removed and it's checked in real time under the microscope while the patient is in the office.

I also wanted to talk about the third most common skin cancer, which is melanoma. There's an estimated incidence in the United States of about 100,000 cases or so. But despite the number being so low compared to non-melanoma skin cancers, which are in the millions, when you look at their mortality related to skin cancer, the vast majority are for melanoma. So if the melanoma tends to present a little bit deeper, if it's a little bit delayed in the diagnosis of them, these are the ones that can spread or metastasize to different parts of our body and cause a little bit more havoc than the non-melanoma skin cancers.

The standard treatment if it’s early is going to be an excision and we typically tend to remove them. But melanoma's a little bit different than the non-melanoma skin cancers. They're not only caused by the sun because we tend to see melanoma also on areas that never get any sun exposure. So you can see them on the palms of your hands, you can see them in the soles of your feet and also on the nail beds. But if they're caught early, then they're very easily treatable.

Dr. Diane Reidy-Lagunes:

Got it. And which skin attributes and ethnicities are more at risk?

Dr. Erica Lee:

So when we think of skin cancer, it's really going to be caused from the sun, ultraviolet radiation. It's the skin types that are lighter in color and are less protected with melanin in our skin; those are the skin types that tend to be more predisposed to getting a skin cancer. But it also depends on where you live geographically. If you live in an area that tends to be closer to the equator or have intense sunlight throughout the year, then you're going to be at higher risk in someone who doesn't live in that same area. And also it depends on your family risk factors. If you have family members who've had skin cancer or you have family members who've had melanoma, for example, especially first-degree relatives, then those are all risk factors for having a skin cancer.

But we also see melanoma in those who are of skin of color. The majority of what we see is going to be in the non-Hispanic white population, but we also see skin cancer in those of skin of color. So I think that's also something for us to be familiar with and aware of when you think about who's at risk.

Dr. Diane Reidy-Lagunes:

Yeah, as you said, even though the risk is lower for people with darker skin types, the risk is still there. I want to hear from Jocelyn who we heard at the top of the episode. She's 33 years old, she's Latina and she was diagnosed with a low-grade melanoma back in 2022. Let's take a listen.

Jocelyn:

My name is Jocelyn Apodaca Schlossberg, and in 2022 I learned that I had melanoma on my ankle. I had this mole on my leg my entire life. It was smaller than the eraser of a pencil, it was symmetrical. Nothing tipped me off other than the color. It was turning black. When I took the initial picture and sent it to the dermatologist in 2020, they thought it looked normal. Fast forward two years later, the dermatologist was like, let's do a biopsy of this. One week later, I'm going back for an even more in-depth procedure and then a week later I was having a skin graft. So it happened really, really fast. It was really scary. I think anytime anyone hears the word melanoma, sirens go off. I had all these thoughts of like, what does this mean? Is there more cancer? What will this mean for my outlook? I had wanted to get pregnant and so that kind of pushed us forward a year, which is totally fine. We have a happy, wonderful 1-year-old little baby girl now. In my case, they took a piece of skin from my upper thigh and kind of stretched over the skin where my ankle is and sewed it into place. And now it almost blends in with my skin and I never think about it. I'm very grateful for that.

Dr. Diane Reidy-Lagunes:

I think she hits on something that we all fear. So when we focus on melanoma to start, what are the signs to look for? Because I think we all got the message that melanoma is the bad one and you really don't want to miss that. So anything you can share that would tip us off to say, okay, you really need to go see the doctor right now.

Dr. Erica Lee:

So what's interesting is that the classic melanoma is typically brown or black in color, but I think it's important to realize the melanoma does not always have to be brown or black. You can also have melanoma that's red in color. So it gets a little bit dicey and tricky with that.

I think there are a couple good points that Jocelyn made, the first being that she noticed a change. And when you're young – and she's only in her 30s – you're going to have moles and they might even change, especially depending on different hormones and imbalances. For example, if you're pregnant, you can see some changing moles. Oftentimes a patient may even say, “Oh, you know what? I had a looked at a couple of years ago. It's fine. I don't have to worry about it.” But there's something biologically happening because it's changing. So when you have a changing mole, there's something that's happening, and especially if the change makes a mole look different.

So we have these acronyms, these ABCDEs:

1. You look at a mole and you want to see if it's A) asymmetric. If you were to cut it in half, one half of the mole looks very different than the other half. It's not the same. It's asymmetric.
2. Also the border of the mole. If you look at the edges, typically a standard mole has a nice kind of smooth edge around it. But if you start noticing that it's kind of sticking out off to the side or something is a little bit irregular on the edges, that's another red flag that something might be going on there.
3. The color is C in ABCDE. Usually everything is homogeneous. You might see like a nice same pigment network across the mole is the same. But when you start noticing that there's a black splotch that wasn't there before, that's another reason why you might want to have it checked out.
4. Also the diameter. We use the diameter as saying that if you have a mole that might be bigger than the tip of an eraser pencil, then that might be something that you might be more concerned about or have monitored more closely than a mole that's very small.
5. The last one, which I think is probably the most important that Jocelyn also mentioned, is E for evolution. Change. So if you're noticing things are really changing in the mole, then that's something that you want to bring to somebody's attention. Some patients will have a lot of moles on their body, and they always ask like, “How am I supposed to keep track of these?” And there's a lot of different ways that you can do that. You can self-monitor them with photos. Sometimes you can get full body photography with it. There are different systems that are available at different offices and institutions. Also you can go to your dermatologist and have it monitored on a regular basis. If you're not sure, have a partner look at it as well. So there are a lot of different ways to see if things are different.

We also use the analogy of the ugly duckling. If you have a sea of moles and there's one the ugly duckling that looks really different than all your other moles, then that's also a sign that you might want to get it evaluated. So Jocelyn did everything right and she was able to get everything caught at a very early stage.

Dr. Diane Reidy-Lagunes:

As Jocelyn said, she was incredibly surprised to get this diagnosis because she's Latina. Let's hear from our colleague, Dr. Jennifer Hay. Jennifer's a psychologist here at MSK who works closely with the melanoma disease management team. Her research focuses on the decisions different populations make that may increase the risk of skin cancer.

Dr. Jennifer Hay:

We've done some work both in our randomized control trials funded by the NIH, and we've also done some focus group interviews in Northern Manhattan to look at Hispanics’ awareness of skin cancer risk. And what we really find is that the darker skin populations have just decided that they're not at risk for developing skin cancer. And in fact, that risk for melanoma and skin cancers exist in all of us. What that means is that there are no populations that don't need to think about sunscreen. There are two elements here. One is skin protection, and then the other is skin awareness. If you've got a change in your skin, it's really worth bringing that to the attention of your primary care doctor because even though the frequency of these diagnoses are low, they make up a much larger proportion of those advanced diagnoses because people are waiting and waiting, they're not diagnosed or they're diagnosed incorrectly. And so darker skin populations end up with more advanced disease.

Dr. Diane Reidy-Lagunes:

That's a little scary. Any additional precautions that you would recommend for our patients of color?

Dr. Erica Lee:

It's complex. I think the presentation in both Hispanic and Black patients are different, as well as in Asian and Pacific Islanders, for example, and Native Americans. When we talk about melanoma, the primary locations of these melanomas will include the palms, the soles, as well as the nail beds in addition to the mucosa. When we say the mucosa, that includes for example, the genitalia, the mucosa of the genitalia. It can also be the mucosa of the lip area and areas that are not classic for the non-Hispanic white population who tends to get them in different areas of the body. So I think one is the location of it.

The teaching is that if you’re skin of color, you're less likely to get sunburned, you're less likely to get affected by this, but that's not true. We know that skin of color can also get sunburned and have peeling and have the later and the worst effects of sun exposure. It's just not as prevalent as in the white population. But in these groups, it's really important for us to realize that it's not only the presentation of it, but it's also access to care.

So I think if you are a skin of color, you should be wearing sunscreen and you should be looking in areas that are not classic. It's in areas that you're less likely to even look at. These areas are also areas that we might be a little bit embarrassed to show a physician. For example, if they are at the bottom of our feet or on our toenails or if they're in our genitalia, we're less likely to show them to our physicians. So I think it's important for physicians and for training to be aware that skin cancer can develop in these areas.

Dr. Diane Reidy-Lagunes:

I'd like to talk about the prevention part. In the summer months, we know that we often hear sun protection, sunglasses, hat, sunscreen. But as you've taught me, it's really year-round. So what are your tips for sun protection throughout the year in addition to the typical stuff?

Dr. Erica Lee:

The way that we like to counsel patients or educate them is that sun protection is multifactorial. You want to make sure when you're outside that you're going to protect yourself with a hat and wear sunglasses. But for areas that are exposed and not protected in the same way, you want to wear sunscreen.

Sunscreen is pretty universal in the sense that you want to wear it all year round. It also reflects off of snow and water, so you want to make sure you're wearing it through all the seasons. You want to make sure that it's broad spectrum. What that means is you want to make sure that it covers the type of rays that are coming through the atmosphere, which are UVA and UVB. That is going to be covered if you have a broad-spectrum sunscreen.

When you look at the numbers, it gets really tricky. I think there's the misconception that if you’re wearing SPF 100, you are so protected. But to be quite honest, when you have an SPF 15 and an SPF of 30, there is a difference in the percentage of rays that are being protected from you. But when you go from 30 to 50, the difference is marginal. And when you go from 50 to 100, it's basically the same. So to wear an SPF of 100, I tell patients it's great that you're putting it on, and you can continue to put it on, but it doesn't mean you're not going to get a sunburn if you don't reapply it. And it also means that you have to make sure that you're doing other things beyond just putting on sunscreen.

You want to make sure you're not going to be out at the peak hours if you can avoid it. But if you are going to be out during those hours, you want to make sure you're practicing sun protective behaviors.

When it comes to sunscreen, we get a lot of questions about what the best sunscreen is. There are two main categories: we have what we call physical blockers and chemical blockers. The physical blockers, you might see them in the drugstore as mineral sunscreens. Those are the ones that have titanium and zinc oxide. Those are great because they really are a physical barrier, and if you have a sensitive skin, if you have eczema, if you have a skin condition, then you definitely want to consider using a sunscreen that is a mineral sunscreen because you won't get sensitivity, or you're less likely to with those sunscreens. But the downside to that is that they tend to be a little bit thicker and a little bit white and chalky. So for the elegance of it, it might not be as elegant as a chemical sunscreen which gets absorbed into the skin.

Dr. Diane Reidy-Lagunes:

Super helpful. All right, this is my mea culpa and my penance here in saying that for some of us, myself included, sunscreen was just not top of mind growing up. So I want to hear from Jocelyn again, who had a similar upbringing. Let’s hear what she has to say.

Jocelyn:

I'm from New Mexico and I spent a lot of time in the sun outdoors. Skin cancer was nothing we ever talked about, thought about. We would put baby oil on our skin. We loved to be tanned and I never wore sunscreen, my parents never wore sunscreen. We just didn't follow any sun safe behaviors. Nobody tells you that you need to be checking your moles. Nobody tells you to look for certain things, at least not from my background. Nobody I knew had even had a skin check.

Dr. Diane Reidy-Lagunes:

There's some data that I just recently read that if you'd gotten a sunburn and were sunburned enough that you actually had a burn, that you're like two times as likely to develop skin cancers. And people were out using baby oil like Jocelyn, and tinfoil. Anything additional at this point, in addition to now putting in sunscreen? It's not too late, I assume, but anything additional for the folks that just didn't have a top of mind?

Dr. Erica Lee:

It's crazy what was done in the past and it still continues. People love to have a tan. It makes us feel good, our endorphins go up when you're in the sun, like there are so many good benefits to being out in the sun. It's never too late to start doing sun protection and wearing sunscreen. But there are certain behaviors that I just also want to just kind of emphasize.

For example, indoor tanning is an absolute no. You never want to do indoor tanning because it is not regulated. They say that no tan is safe, but when you do indoor tanning, especially if you start at an early age, there have been so many studies that have shown that starting indoor tanning before the age of 20, let's say, the more that you add over time really significantly increases your risk of getting melanoma.

Another myth is: “I need the sun for vitamin D production.” We always hear that we make vitamin D with the sun, but you don't need to be out in the sun for a very long time to make vitamin D. If you're concerned about vitamin D deficiency, you should see your primary care physician and get your vitamin D levels checked. And if you are sort of on the borderline or if you are deficient, then a vitamin D supplement is more appropriate than having excessive sun exposure.

It really is never too late because every time we're getting a sunburn or we're damaging our skin with sun, you are really causing DNA damage. And at some point, as we get older, that DNA damage is going to accumulate over time and it's going to continue to lead us to have more skin cancers in the future.

In addition to all the skin cancer risks, it also leads to things such as hyperpigmentation and photoaging. So for young patients – because a lot of people feel invincible that, “I'm not going to get skin cancer, I'm too young, it's not going to happen to me, I'm not going to worry about it,” – but one message that I think is important is that a lot of photoaging or freckling or wrinkles is caused by the sun.

Dr. Diane Reidy-Lagunes:

What about spray tans? Any concern there?

Dr. Erica Lee:

So far, the data isn't really there. If people are really keen and they feel like they have to have that suntan glow, there hasn't been any studies to show that spraying it on is going to lead to a skin cancer. If you inhale them, it's definitely going to be an insult and it can cause some irritation. You can get a little bit of a contact dermatitis if your skin doesn't react well to it, but nothing in terms of a carcinogen.

Dr. Diane Reidy-Lagunes:

Let's end with Jocelyn sharing what she's learned and what others can take away from her experience.

Jocelyn:

It's impacted my lifestyle in that I have adopted new behavior. I pay attention to the weather in a way that I didn't before. I wear sunscreen every day, whether I'm going to be outside for a little bit or a long time. I make sure that my baby has sunscreen on, which I'm not sure that's something that I would have done prior to this. I look at the ingredients in sunscreen. I make sure that we have a hat, we have an umbrella, mindful of how much time we're spending in the sun. I also do routine skin checks on myself just because that's something that my doctor suggested that I do. And I talk to people.

My hope is that other Hispanic and Latinos will talk to each other. Talk to your friends and your family, your aunts, your uncles, anyone who will listen about sun-safe behaviors, about checking your skin, noticing if anything has changed, taking a look for you because there are so many places on your body – your back, in between your hair – that you can't check. And so just having someone do a quick scan, maybe the back of your body, and just noticing if anything looks different because it's really important.

Dr. Diane Reidy-Lagunes:

Well said, Jocelyn. Erica, thank you so much for joining us. I learned a tremendous amount.

Dr. Erica Lee:

Thank you, Diane, for having me. This was really exciting and fun to be on.

Dr. Diane Reidy-Lagunes:

Thank you for listening to Cancer Straight Talk from Memorial Sloan Kettering Cancer Center. For more information or to send us your questions, please visit us at mskcc.org/podcast. Help others find this helpful resource by rating and reviewing it on Apple Podcasts or wherever you listen. Any products mentioned on the show are not official endorsements by Memorial Sloan Kettering. These episodes are for you but are not intended to be a medical substitute. Please remember to consult your doctor with any questions you have regarding medical conditions. I'm Dr. Diane Reidy-Lagunes. Onward and upward.