Fighting Cancer: A survival guide

Dr Waleed Abdul-Wahab, MD, FRCSI, is a Bahraini doctor working at the Franziskus Krankenhaus-Charite University, Berlin, in the capacity of a consultant erologist.

In 2010, the university will celebrate 300 years in the field of health services and the urology unit celebrates 100 years next year.  The institution is a centre of medical excellence and cutting edge pioneering research and boasts a total of 13 Nobel Laureate to date.
Each month he will write an exclusive column for GulfWeekly readers and try to address readers’ concerns over cancer issues.

This is a continuation of our health series aimed at enhancing public awareness on different cancers.
This week we will discuss skin cancer. We aim at presenting these topics in a very basic non-medical style is to benefit the largest possible number of readers.
As I previously mentioned, cancers do not develop overnight and hence even this vicious disease needs time to progress, albeit some types grow faster than others. Therefore, one of the best tools for fighting cancer is TIME … the earlier you diagnose it, the earlier you start treatment, and naturally the better the outcome. Remember, the key is to always keep time on our side and not on the side of cancers.

What is the skin?
Some people are surprised to know that the skin happens to be the largest organ of the body. Surprised? In addition, we rarely appreciate the important role our skin plays in our lives. Without going into too much detail, the skin gives us a protective coat that defends our internal organs from the harsh outside world. Furthermore, it also plays a significant role in regulating our body temperature. No wonder, the old saying “get under my skin” attempts to compare proximity to others by removing the skin factor.

What is Cancer?
Cancer is a disease that occurs when specific cells within the human body rebel against the system and start to multiply out of control until they spread and ultimately cause death. Cancer is still the number one cause of death in the world. Scientists and doctors are fighting as hard as they can by developing new drugs and treatments. However, without public awareness, their chances for success are substantially weakened. It is here where we must strive hard to make a difference.

Is skin cancer common?
Believe it or not, skin cancer happens to be the commonest form of any cancer in humans. As a matter of fact, in the USA, about one third of all newly-diagnosed cancers happen to be skin cancers.

What are the symptoms?
Skin cancer generally develops in the epidermis, i.e. the outermost layer of skin.
Therefore, a tumour is usually clearly visible to the naked eye.
This makes most skin cancers detectable in the early stages and hence this disease does not require advanced X-rays or diagnostic tests to be detected.
All it requires is a little awareness: to be alert in case of any changes in the skin, and to promptly bring it to the attention of a specialist doctor when something suspicious is detected. You have no excuses!

What should we be on the look-out for?
There are a variety of different skin cancer symptoms.
These include sores or changes in the skin that do not heal, ulcers in the skin, discolouration, new moles, and changes in existing moles.

What are the causes of skin cancer?
The primary cause of skin cancer is ultraviolet radiation – most often from the sun, but also from artificial sources like sun-beds.
In fact, researchers believe that our quest for the perfect tan, an increase in outdoor activities, and perhaps the thinning of the earth’s protective ozone layer are behind the alarming rise we’re now seeing in skin cancers. In addition, ease of travel has allowed people to travel to sunny holiday destinations far more frequently than before.

How soon can unprotected sun exposure lead to skin cancer?
Surprisingly, sun damage may take many years to promote skin cancer.
It is therefore common for people who stopped being “sun worshippers” in their twenties to develop precancerous or cancerous spots decades later.

Is sun exposure the only cause for skin cancers?
The single most important factor in producing skin cancers is sun exposure. However, other less common factors predisposing to skin cancers include exposure to arsenic, hydrocarbons, heat or X-rays.
Some skin cancers can also arise in old scars. Suppression of the immune system by infection (HIV-Aids) or drugs are even less common causes. In certain kinds of skin cancer, even a genetic link has been discovered.

Who are at risk to developing skin cancer?
Almost anyone can develop skin cancer, however, the risk is greater in...
■ People with fair skin and light complexions.
■ People with light-coloured hair and eyes.
■ People with freckles.
■ People who have lots of moles, or in moles of unusual size or shape.
■ People who have/had a family member with skin cancer.
■ People who have suffered from blistering sunburn.
■ People living in the Equatorial zone.
■ People living at higher altitudes.
■ People living in places with intense, year-round sunshine.
■ People who spend lots of time in the sun for work or leisure.
■ People aged above 60 years old.
■ Chronic non-healing wounds, especially burns.

If I fit the list above, will I definitely develop skin cancer?
Please do not panic if you fit the list above since this does not necessarily mean you will develop skin cancer.
It only means that you have higher chances to getting this disease than people who do not fit the description. Therefore, this means that you have to be extra vigilant in noticing any changes to your skin and bring them to the attention of a specialist doctor as soon as possible.

Are all skin cancers similar?
No, there are three main types of skin cancer, each of which is named after the type of skin cell from which it arises. 
I will bore you with their names only because they look different and act differently as well. Of course, there are also other less common types but this is beyond the scope of this article.

What are the main types of skin cancer?
From the least to the most dangerous, they are:
■ Basal Cell Carcinoma (BCC).
■ Squamous Cell Carcinoma (SCC).
■ Malignant Melanoma
Basal Cell Carcinoma (BCC) is the most common type accounting for approx 90 per cent of all skin cancers.  It is not known to spread to other parts of the body and it tends to grow very slowly. 
However, this does not mean we should sit back and relax, since if left untreated, with time it destroys the neighbouring skin and is referred to as a “Rodent Ulcer” [Fig 2].

What does a BCC look like?
It usually looks like a raised, smooth, pearly bump on the sun-exposed skin of the face, neck or shoulders.
Sometimes small blood vessels can be seen within the tumour. Crusting and bleeding in the centre of the tumour frequently develops. It is often mistaken for a sore that does not heal.
Squamous Cell Carcinoma (SCC) is the next commonest type of skin cancer. However, unlike BCC, this type can spread to other parts of the body especially when they are located in the lower lip.

What does SCC typically look like?
It is commonly a skin-coloured or red, scaling (Squama, meaning latin for scales of a fish), thickened patch on sun-exposed skin.
However, they can also develop in scars. Ulceration and bleeding may occur. When SCC is not treated, it may develop into a large mass.
Malignant Melanoma   arises from the melanocytes (cells which give skin their colour) and happens to be the most dangerous type of skin cancer and is responsible for approximately 80 per cent of skin cancer deaths.
It has a tendency to grow quicker than the other types and also spreads to other parts of the body quickly too like the liver and brain.
This form can be fatal if not treated early but luckily they comprise only a small proportion of all skin cancers. Since this type is extremely lethal we will discuss it in greater detail.
They are typically brown to black looking lesions. Signs that might indicate a malignant melanoma include a change in the size, shape, colour or elevation of a mole.. 

Should the presence of any moles be of any significance?
The appearance of a new mole during adulthood, or pain, itching, ulceration or bleeding of an existing mole should be checked by a doctor to rule out skin cancer.

What are signs and symptoms of melanoma?
Often, the first sign of melanoma is a change in the size, shape, or colour of an existing mole.
It can also appear as a new, abnormal, or “ugly-looking” mole.
Thinking of “ABCD” can help you remember what to look for:
A  Asymmetry – The shape of one half does not match the other.
B  Border – The edges are ragged, notched, or blurred.
C  Colour – The colour is uneven. Shades of black, brown, and tan may be present. Areas of white, gray, red, or blue may be seen.
D  Diameter – There is a change in size greater than 6mm.
When melanoma develops in an existing mole, the texture of the mole can change. For example, it can become hard, lumpy, or scaly.
Although a melanoma may feel different and may itch, ooze, or bleed, it usually
does not cause pain.

How can we reduce the possibility of getting skin cancer?
Although there are no 100 per cent guarantees, the likelihood of developing skin cancer can be reduced significantly by adhering to the following steps:
■ Reducing exposure to ultraviolet (UV) radiation, especially in the early years
■ Avoiding sunburns avoiding unprotected sun exposure during the hours surrounding noon (usually from 10am to 3pm), when the sun is highest in the sky.
■ Wearing protective clothing (long sleeves and hats) as well as sun-glasses when outdoors.
■ Limiting recreational sun exposure.
■ Using a broad-spectrum sunscreen that blocks both UVA and UVB radiation with SPF number of 15 or higher.
■ Apply copious amounts of sun-block to guarantee the required effect.
■ Using a waterproof or water resistant sunscreen if swimming.
■ Reapplying sun block every 2-3 hours and after swimming.
■ Performing regular self-examinations and bringing any suspicious-looking or changing lesions to the attention of a specialist doctor.

What happens at the doctors’ office?
First and foremost, the specialist doctor (Dermatologist) will be able to reassure you whether what you are worried about warrants any further investigation.
That’s right! He may tell you right then and  there that there is nothing more to worry about and send you straight home.
However, in some cases, the doctor may need to do a further test known as a biopsy to be able to determine the proper diagnosis.

What is a biopsy and how is it performed?
A biopsy is a procedure where the doctor surgically removes part or all of the suspicious-looking growth.
This can usually be done in the doctor’s office using a local anaesthetic so it’s really not as painful as it sounds. The specimen is then sent to a pathologist who examines the tissue under a microscope to check for cancer cells. Therefore, a biopsy is the only method of making a definite diagnosis and is hence an essential step before starting treatment.

How are skin cancers treated?
Treatment will depend on a number of factors such as the type of cancer and whether or not it has spread.
If it has spread, how far it has reached is also relevant.
Age and general health of the patient as well as site of the cancer are also taken into consideration. With this information, the doctor can then devise a treatment plan most suited to the patient’s condition.
Most skin cancers can be treated by surgical removal of the lesion, making sure that the edges (margins) are free of tumour cells. This method provides the best cure.
Moh’s Microsurgery is a technique where the cancer is removed with the least amount of surrounding skin and the edges checked immediately to see if a tumour is found. This provides the opportunity to remove the least amount of skin and provide the best cosmetic effect, especially when excess skin is limited in areas such as the face. Cure rates are equivalent to regular surgical excision.
Other treatment modalities include radiation therapy and cryotherapy (freezing the cancer off) and both can provide adequate control of the disease; both, however, have lower overall cure rates than surgery.
In the case of disease that has spread to other parts of the body further surgery or chemotherapy may be required.

Are there any new scientific developments?
A promising new drug called “Dimericine” is currently under research.
It comes in the form of a cream and aims to identify and repair skin cells after the damage has occurred. This is in stark contrast to sun-blocks which aim to prevent damage but cannot help once the damage takes place. Therefore, this new drug may offer a back-up in preventing damaged skin cells from developing skin cancer.

Is there any message to take home?
From a scientific view point, we always talk about cancer in terms of numbers and percentages. However, we unfortunately overlook the people who make up those numbers.
When we say a type of cancer affects 0.0001 per cent of the population we forget that that one person who develops the disease is affected 100 per cent. In a recent issue of GulfWeekly we saw how a young boy’s life was completely shattered when he lost his mother to breast cancer. As a tribute to her, we will discuss this terrible disease during World Breast Cancer Month in October and what can be done to control it.
It is truly a shame to know that lives could have been saved had people been more aware of diseases and presented themselves to doctors earlier. Please remember, TIME is a double-edged sword. Let us use it to fight cancer before cancer uses it to fight us.

Can readers send in questions or comments?
Of course, I am more than happy to help you with more specific enquiries. You can email me on drelansari@hotmail.com.