From What's That Spot?
It was a broiling, cloudless summer day in Dallas. I was 26 years old, sitting by the pool at my sister's house. Despite the white skin and green eyes I inherited from my English and Scottish ancestors, I loved the sun and had spent a Midwestern childhood hoping that maybe the freckles would eventually all merge and make me tan.Instead, I'd suffered several agonizing sunburns from summers at cold, sparkling (and highly reflective) Minnesota lakes, complete with blistering, peeling, and even a couple of trips to the emergency room.
Yet here I was, lounging in the midday rays so strong they hurt, and still harboring the futile hope that a little color would make me look healthier, thinner, sexier. I looked at my left thigh and focused on a sore, about the size of a dime, that would scab over but never quite seemed to heal. I'd noticed it for a few weeks -- or was it months? Then I'd put it out of my mind.
My sister's husband, a facial plastic surgeon with experience in skin cancer, came outside. "Hey, Richard, what is this?" I asked, pointing out the spot on my leg. "Could it possibly be a skin cancer?"
He squinted at it in the sunlight and said distractedly, "It's probably nothing. Don't worry about it." Right, I thought. People my age don't get skin cancer.
The sore seemed to heal for a while. But a few weeks later, it bled a little again and scabbed over. Something told me I couldn't ignore it any longer. The next time I was at my sister's, I asked my brother-in-law to take another look. "I've had this for months," I said. "And it comes and goes but never heals. I just have a gut instinct that it's skin cancer."
"You may be right," he said. "I think it should be biopsied." Those instincts proved correct. It was a basal cell carcinoma, the first of many more to come over the next 20 years.
A Growing Problem
Skin cancer used to be considered an affliction mainly of older people, and indeed, it is rising among those over 50. About 1 million Americans are diagnosed each year with non-melanoma skin cancer.Some 800,000 of these are basal cell, the most common type, and another 200,000 are squamous cell. If left untreated, these skin cancers may become invasive, requiring fairly major surgery. But these types rarely metastasize and are relatively easy to cure if caught early on. Then there's melanoma, the more dangerous type of skin cancer. Nearly 112,000 new cases of melanoma will be diagnosed this year, according to the American Academy of Dermatology, a scary 9 percent increase over 2005. Almost 8,000 will die of it. But while few studies have been done, there's new evidence that the instance of all three kinds of skin cancer is also growing among the young -- to an extent doctors haven't seen before.
"There's been a huge change in the age of skin cancer patients," says David Kriegel, MD, director of the Division of Dermatologic Surgery at Mount Sinai Medical Center in New York City. "When I started as a fellow in Mohs surgery (a skin cancer treatment) 12 years ago, the majority of patients were in their 70s and 80s. It was unusual to see someone under 45 or 50 with a basal cell. Most doctors still don't expect to see it in young patients."
Leslie J. Christenson, MD, a dermatological surgeon at the Mayo Clinic in Rochester, Minnesota, was lead author on a recent groundbreaking study in the Journal of the American Medical Association that showed a rise in the incidence of basal cell and squamous cell carcinomas in people under 40. The study got a lot of attention. Still, some have asked Christenson why we should worry about this increase, as these cancers are so often curable. "A basal cell or squamous cell skin cancer may not be deadly," she says, "but it is locally destructive. I mean quality of life. The treatment can be very disfiguring. A large percentage of these tumors occur around the head and neck. If you're a 30-year-old and now have a scar on your nose or upper lip or temple, it will impact you -- on dates, at job interviews. That's a big thing for a young person to live with for the rest of her life."
Dr. Kriegel says that on an average day now, probably 30 percent of the patients he sees with skin cancer are in their 30s and 40s. "I saw one girl who was 19 years old," he recalls, "and had her first basal cell on her upper eyelid. These cancers won't kill you, but there is significant morbidity, especially in young people."
My first two basal cell carcinomas were routine and superficial. The pathology report for the one on my leg showed clear margins, indicating that the biopsy had removed all the cancer. Nothing further needed to be done, and the scar was small. I had regular skin exams and kept an eye out for other spots that wouldn't heal. A couple of years later, a crusty spot on my left upper arm (driver's-side sun exposure, perhaps?) was also pretty easily treated. A local injection to numb it, then a few quick slices with a scalpel, a stitch or two, a bandage, and that was it. But not all skin cancers are created equal. Soon, a spot on my upper forehead proved much more aggressive. Although the biopsy indicated that the surgeon had gotten it all, just a few months later, it was back. The area would often bleed when I washed my hair or towel-dried my face, and I knew the cancer had returned. I was barely 30 years old.
"It's like a tree with roots," explains Dr. Kriegel. "If you cut a tree down and leave part of the roots behind, over time those roots are going to cause the skin cancer to grow back. At that point, it's a much more difficult treatment plan because the tumor is much larger. That's where Mohs surgery comes into play."
Mohs micrographic surgery, mostly used for recurring basal and squamous cell carcinomas, combines the removal of the tumor and the lab work at the same time. It's a multistage process, which can mean a long day for the patient, but at the end of it, all the cancer is gone.
Here's how it works: After the lesion is identified, the doctor will inject a local anesthetic and then remove the entire lesion. It goes to the laboratory, where the tissue is sliced and slides are prepared. Then the surgeon examines the slides under the microscope, looking for the skin cancer cells. Sometimes that first cut, or layer, will completely treat the cancer. "But getting back to the example of the tree," says Dr. Kriegel, "often there will be roots, or cancer cells, left behind. We map the roots, then go back to the patient and remove that area of tissue without removing any normal skin." The process is repeated until the slides indicate that all is clear.
In my case, the surgeon removed the lesion, and I was shocked at the silver-dollar-sized crater on my forehead. Luckily, the microscope slides gave an all clear from that first round, so the doctor bandaged me up, and I headed to the office of my brother-in-law, the plastic surgeon. He explained that he would be able to stretch and pull the wound up into my hairline for a minimally visible scar, but I was concerned about looking lopsided. He assured me that my elastic, young skin would even itself out. After the surgery, I looked a tad asymmetrical for a while, and was sore and swollen too. But eventually my eyebrows did level off. Was all this worth the sun-worshipping I'd done in my younger days? Not on your life.
Why the Increase?
No one knows for sure why skin cancer is increasing so rapidly. Is it the ozone hole?Dr. Christenson says, "Our study defined a problem but did not find a cause. Still, we know the main cause is sun exposure, UV rays. I think we're getting more intense, intermittent sun exposure. And in the young, there's more tanning for the prom than ever. Tanning beds are at least as bad as the sun!"
No, they're even worse, says Deborah MacFarlane, MD, associate pro-fessor of dermatology and a Mohs surgeon at M. D. Anderson Cancer Center in Houston. She mentions Paris Hilton on the reality show The Simple Life actually taking the camera inside the tanning bed. "That's being projected out to all these millions of young people as the cool thing to do," she says. "It's not just girls. Boys are doing it too. They think they're going to last forever." Dr. MacFarlane explains that many of the young people she sees with skin cancer have used tanning beds. This was especially true when she was practicing in Vermont, where tanning centers were very popular. One woman in her 20s had five basal cell skin cancers on her front and back in the same areas she'd been darkening at a tanning salon.
Another young patient had been using a tanning bed to get bronzed for a friend's wedding. Although she says this is only anecdotal evidence, Dr. MacFarlane discovered two "really nasty melanomas on her torso, exactly in the areas she'd been tanning, and they were deep. When you remove a melanoma, you have to take out a large amount of skin, and you have to go all the way down to the muscle. She was a pretty girl. So much for looking good for the wedding."
Studies have also linked squamous cell skin cancers to the human papillomavirus (HPV), the group of viruses that cause warts, genital warts and cervical cancer. "We will often see patients with a skin cancer in an area where, as they say, the sun don't shine," says Dr. Kriegel. "The comment is always 'Well, I get no sun there, so how can I have skin cancer?' There are tumors that perhaps have a greater HPV role than an ultraviolet radiation role. But we still have a lot to learn about it."
There's also the genetic link. The propensity to develop skin cancer is passed on genetically, but, Dr. Kriegel says, the cells need ultraviolet radiation to activate them to start to develop into a skin cancer. "So for those who have the genetic predisposition," he says, "if they are compulsive about using sunscreen and careful about not getting sunburns, they may never develop the skin cancer."
The experts like to remind us that skin cancer is largely preventable. As I write this, I can see the newly healing scar on my upper left arm, about an inch and a half long, the result of recent Mohs surgery for recurrence of that basal cell I had years ago. I hope this is the end of it. But I'm only 47.