Is it Skin Cancer or Just a Mole?

1. Is it Skin Cancer or Just a Mole? Christina Lewis, MN, RN, NP Certified Dermatology Nurse UCLA Arthur Ashe Student Health and Wellness Center May 31, 2012

2. Learning Objectives • Identify questions to review when presented with a student that has a concern about possible skin cancer • Compare and contrast the three most common types of skin cancer • Explain how UV exposure can affect the skin and how it may affect the Vitamin D levels of the average college student

3. Skin Cancer • Skin cancer is the most common form of cancer in the United States. • 2003 there was more than one million new cases of skin cancer in US and 9,800 will die of the disease (Scarlett, 2003) • Incidence of skin cancer has doubled each decade since the 1930’s (Wolf, 2003) • Who to screen? No randomized studies. • Discuss changes in behaviors with whom?

4. Goals Listed in Healthy People 2010 (Objective 3-8) • Increase to 75% proportion of persons who use at least one protective measure that may reduce risk of skin cancer: • avoid sun between 10-4 • wear sun protective clothing • use sunscreen with SPF of at least 15 • avoid artificial sources of UV light.

5. Patient History • Family history of skin cancer • Personal history of skin cancer • Number of blistering sunburns in the student’s lifetime -Tanning bed use -Where they grew up -Changes to any area of the skin and when the changes were noted. Including changes in areas of past burns and keloids

6. Types of Skin Cancer • Basal Cell-more common with intermittent “recreational” exposure. Unclear if sunscreen prevents BCC. Metastasis rate is less than 0.1% • Squamous Cell-more common with continuous sun exposure such as outdoor workers. “regular sunscreen can prevent SCC” (Lin, et al. 2003). Metastasis rate is 2-6% • Melanoma-more common with intermittent “recreational” exposure. Unclear if sunscreen prevents melanoma (Lin, et al 2003)

7. Basal Cell Carcinoma

8. Basal Cell Carcinoma

9. Basal Cell Carcinoma

10. Basal Cell Carcinoma

11. Basal Cell Carcinoma Dermnet images

12. BCC in People of Color • Appears “black, pearly” • Pigmentation is present in >50%. Compared to 5% in whites. (Bigler, et al, 1996) • BCC occurs most commonly after the 5th decade (Maguire-Elsen, 2011)

13. Squamous Cell Carcinoma

14. Squamous Cell Carcinoma • Predisposing Factors • Precursor lesions (actinic keratosis, Bowen disease) • Ultraviolet radiation exposure • Ionizing radiation exposure • Exposure to environmental carcinogens- Arsenic, Insecticides and herbicides, smoking/alcohol assoc with oral SCC • Immunosuppression • Scars • Burns or long-term heat exposure • Chronic scarring or inflammatory dermatoses discoid lupus, pilonidal cyst, hidradenitissuperativa • Human papillomavirus infection (HPV 16-head and neck, HPV 5) • Genodermatoses(albinism, xerodermapigmentosum, porokeratosis, epidermolysisbullosa)

15. Squamous Cell Carcinoma

16. Squamous Cell Carcinoma Fitzpatrick Color Atlas

17. Squamous Cell Carcinoma

18. Treatment of BCC and SCC • Surgical excision • Cryotherapy-97-99% cure rate in BCC • Mohs micrographic surgery • Topical chemotherapy (5-FU, interferon, retinoids) • Systemic chemotherapy • Laser therapy • Electrodessication and Curettage • Curettage (for BCC only) • Photodynamic therapy-uses light, oxygen and a photosensitizing chemical

19. Melanoma in People of Color • Different incidence, site distribution, stage at diagnosis, and histological type. Acrallentiginous melanoma is more frequent (Cress, Holly, 1997) • Lower extremity: • Hispanics-20% • Asians-36% • Blacks-50% • Nonhispanic whites-9% • Trunk is in all males but only in nonhispanic whites among females. (Weir, 2011)

20. Melanoma in People of Color • Male Hispanics in Florida had a 20% higher incidence than male Hispanics in the U.S. Female Hispanics in Florida had a lower rate than other areas of U.S. Female Blacks had 60% higher incidence than the U.S cohort. Total of 109,633 pts in study.(Rouhani, 2010) • Mucosa, palms, soles and nail beds are equally frequent in whites and blacks and have remained constant unlike melanomas in other body areas. (Wolff, 2008) • Melanoma education to ethnic people may be improved by using skin cancer photographs of early melanoma in people with dark skin, providing guidance on how to inspect hands and feet for suspicious moles.(Robinson, 2011)

21. Melanoma by Gender and Age

22. Melanoma 15-29 y.o. by site b

23. Melanoma

24. Melanoma

25. Melanoma

26. UV Exposure • UV accounts for approximately 93% of skin cancers (Gallagher, 2010) • UV light is addicting. UV light releases endorphins

27. UVA and UVB • UVA penetrates the stratum corneum but is poorly absorbed by DNA • Has a longer wavelength • Accounts for about 95% of UV rays that reach the earth • More efficient than UVB in immediate and delayed pigment darkening and delayed tanning. (Korak, 2011) • UVB-partially penetrates the stratum corneum and is absorbed by DNA • Primarily associated with erythema and sunburn • Can cause immunosuppression and photocarcinogenesis

28. Cellular Effects of UV Light on SkinCarcinogenesis Cycle Ultraviolet radiation makes chemical change in DNA The abnormal cell expands into a clone Change in DNA causes muta-tion of P53 Mutation alters function of the gene The clone becomes the target of further DNA damage Gene function leads to a new cell phenotype

29. What Effects UV Exposure • Latitude • Altitude • Ozone-UVB • Season/cloudiness • Exposure time • Time of the day • Sunscreen • Shade • Tanning bed • Herbal preparations • Low fat diet • Behavioral Therapy

30. Latitude • Latitudes above 35o have little UVB exposure • Albuquerque, N.M.35 • Birmingham, Ala.33 • Bismarck, N.D.46 • Boston, Mass.42 • Charlotte, N.C.35 • Chicago, Ill.41 • Minneapolis, Minn.44 • Nashville, Tenn.36 • New York, N.Y.40 • Philadelphia, Pa.39 • Salt Lake City, Utah40 • Squamous cell carcinoma appears to double with each 8-10 degree decline in latitude

31. Altitude • Affects UVB more than UVA

32. Ozone Layer • UVB is somewhat blocked by the ozone

33. Season/Cloudiness • In the summer, UVA is 96.5% of the UV rays that reach the earth and UVB is 3.5% • Seasonal change accounts for about 1/5 of a change in Vitamin D production (Perez-Lopez, 2010) • Clouds affect UVB more than UVA

34. Exposure Time High school white students who never wore sunscreen when out in sun >1 hr, increased from 57.5%to 69.4% from 1999-2009 (Jones, 2012)

35. Time of the Day • UV is strongest between 10 am and 4 pm • 2/3 of the UV radiation comes between 10 am and 2 pm

36. Sunscreen • Used most common in women, less common in black women. SPF 30 protects from 97% of UVB • People in the U.S. only apply about 25% of the recommended sunscreen (Thieden, et al, 2005) • Nambour (Queensland) sunscreen trial-first randomized clinical trial with regular sunscreen users and control group

37. Sunscreen (cont) • 17 approved agents in the U.S. (Maguire-Elsen, 2011) • Blocking sunscreen reflect UV rays • zinc oxide and titanium dioxide. Scatter UV light. Good for sensitive skin, not skin of color. • Chemical sunscreens absorb the UV rays • Chemical sun blocks only block narrow regions of the UV spectrum so they are used together. Most block UVB.

38. New FDA Sunscreen Guidelines June 2011 • “Broad spectrum” means UVA and UVB protection • Skin cancer/skin aging alert on sunscreens <15 • Capped SPF value of 50+ • “Sunblock”, “sweatproof”, and “waterproof” can not be used. • Clear time frames for “water resistant” (40 minutes) and “very water resistant” (80 minutes) • New Drug Facts box • Will include “do not use on damaged or broken skin”

39. Shade • UVA is not filtered by window glass (UVB is) • 50% of exposure to UVA occurs in the shade • Shade use-most common in women-less common in white women • Hat with brim, long sleeves • Clothing to the ankles-most common in men • Sunglasses with UV-absorbing lenses • Darker colors are slightly more protective. • Plain white cotton T-shirt has about SPF 7 • Dark green T-shirt has about SPF 10

40. Tanning Beds • In the past, because UVA did not cause sunburn, only tanning, it was not considered harmful to skin. • Tanning bed regular and early (high school and college) use increases risk of skin cancer. • Tanning 4 times a year increases risk of non-melanoma cancer by 15% and melanoma by 11% (Sun & Skin News, 2011) • One tanning session a year in high school increased risk of BCC by 10%. (Zhang) • 6.7% of high school males and 25.4% of females use indoor tanning.(MMRW 2010) • WHO recommended minors be prohibited. 36 states have put into law as of April, 2012. • No protective benefit to getting an artificial tan before exposure to natural light (Miyamura, 2011)

41. Herbs/vitamins/herbal preparations • Herbs and herbal preparations protect from UV exposure generally through their antioxidant activity • Plant peptides protect skin proteins (our natural sun blockers). Topical application of sesame oil blocks 30% of UV rays. Coconut, peanut, olive and cottonseed oil block about 20%, mineral oil does not block UV.

42. Herbs/Vitamins/Herbal Preparations Oral • Proanthocyanidin-grape seed (DNA mutation inhibitor) • Resveratol -grapes, wine, cranberries, peanuts • Quercetin-many fruits and vegetables-is the most common flavonol • Apigenin-cumin, fruit, and vegetables (carrots), marigolds • Silymarin-milk thistle • Curcumin-tumeric

43. Herbs/Vitamins/Herbal Preparations Oral (cont) Vitamin E-(tocopherol)-in wheat germ, pumpkin seeds. Vitamin C-rosehip seed extract Carotonoids-(sea buckthorn, fruit oil [ie Avocado oil], fish oil). Fish oil may increase sun protective effect in some cases up to SPF 5.

44. Herbs/Vitamins/Herbal Preparations Topical • Green tea and black tea • Aloe vera • Walnut extract • Krameria triandra (Kameria triandra root extract) • Borage oil • Evening primrose oil • Tea tree oil (increases blood flow only) • Porphyra (red algae)

45. Low Fat Diet • Low fat diets. High fat diets shorten the time between UV exposure and tumor formation

46. Behavioral Counseling • Behavioral counseling can increase sun protection by decreasing: • Indoor tanning • Objectively measured pigmentation in college students • midday sun exposure • increase sunscreen use in young adults • (Lin,2003)

47. What About Vitamin D? • Vitamin D insufficiency (range being 20 or 30) is common among: • Elderly • Institutionalized • Dark skinned • Wearing of protective clothing or consistent use of sunscreen causing limited effective sun exposure • Obese • Malabsorption issues (Dawson-Hughes, 2012)

48. Vitamin D and UVB 7-dehydrocholesterol Diet/supplements UV light skin Ergocalciferol (Vitamin D2) Cholecalciferol (Vitamin D3) Liver

49. Vitamin D From the Sun vs Skin Cancer • Grant (2009) supported sun exposure. “Although a few thousand extra deaths per year might occur from melanoma and skin cancer, the avoided premature death rate could be near 400,000/year.”

50. Vitamin D From the Sun vs Skin Cancer • Recommendation for short (15 minute) sun exposure, outdoor sport and leisure activities is needed as a vitamin D rich diet generally provides only about 10% of the needed vitamin D (Perez-Lopez, 2010) • The difference in the sunlight can be made up with supplements.