Overview of Skin Cancer Detection and Prevention for the Primary Care Physician

Skin Cancer in Solid Organ Transplant Recipients: A Review for the Nondermatologist

Solid organ transplant recipients (SOTRs) are at increased risk for the development of skin cancer compared with the general population, which requires consistent monitoring and management from a multidisciplinary team. The aim of this review is to provide a comprehensive overview for nondermatologist clinicians, outlining skin cancer diagnosis, treatment pearls, and skin cancer prevention strategies as they relate to SOTRs. A comprehensive search of the literature was conducted through the MEDLINE database with search terms including organ transplantation, transplant recipient, skin cancer, cutaneous neoplasms, management, and therapies. The search was limited to the English language and dates ranging from January 1, 2011, to December 28, 2021. All studies were reviewed for inclusion. Skin cancer will develop in more than half of SOTRs at some point in their life, most often nonmelanoma skin cancer such as basal cell carcinoma or squamous cell carcinoma. Melanoma and rarer cutaneous malignant neoplasms, such as Merkel cell carcinoma and Kaposi sarcoma, are also more frequent among SOTRs. A multidisciplinary effort at skin cancer screening and patient education is invaluable to prevent skin cancer-related morbidity and mortality in this population of patients. Reduction in immunosuppressive medications and surgical intervention are effective therapeutic approaches, and more novel systemic therapies including G protein-coupled receptor inhibitors and immune checkpoint inhibitors are possible options when traditional treatment approaches are not feasible. Checkpoint inhibitor therapy, however, comes with the risk of allograft rejection. With a growing and aging SOTR population, it is essential that SOTRs have support from dermatologists and nondermatologists alike in skin cancer prevention and treatment.

Ultraviolet radiation and the athlete: risk, sun safety, and barriers to implementation of protective strategies

Ultraviolet (UV) radiation plays a pivotal role in the development of both melanoma and non-melanoma skin cancers. Numerous factors potentially place athletes at high risk for developing these cancers. Various prevention strategies ameliorate this risk, including avoiding sun exposure during peak UV exposure hours, applying sunscreen with a sun protection factor of 30 or above before participating in outdoor sports, wearing hats and sunglasses, and reducing exposure with long pants and long-sleeve shirts. The literature, however, cites several barriers to these prevention approaches, including sports' competition rules, the lack of availability of sunscreen, and the lack of information about sun safety behaviors. Sun safety education programs prove effective in getting athletes to participate in prevention strategies. This article reviews the effect of UV radiation on athletes' skin and provides sports medicine clinicians with suggestions to improve the sun safety behaviors of their athletes.

Surgical management of facial skin cancer

Surgical excision is the gold standard for management of cutaneous basal cell carcinoma or squamous cell carcinoma. Surgical management of nonmelanotic facial skin cancer requires preoperative planning and an in-depth understanding of reconstructive techniques, including primary closure, skin grafting, and local tissue flaps. The decision regarding the method of treatment of nonmelanotic skin cancer is highly individualized and depends on patient age, cancer size, histologic subtype, and site. No single therapy or technique can be used in every situation. The goals of treatment include complete removal of the lesion with preservation of normal tissue, function, and cosmesis. In this article we discuss the principles and techniques of surgical excision and reconstruction of site-specific facial skin cancers.

Clinical presentations of cutaneous melanoma

Cutaneous melanoma is responsible for the majority of skin cancer deaths. Early and accurate detection are the most important means to improve patient survival. This article reviews the common clinical presentations of head and neck cutaneous melanoma, and discusses lesions that might be clinically mistaken for melanoma.

Sun-protective behavior among high-school and collegiate athletes in Los Angeles, CA

OBJECTIVES

To evaluate the use, knowledge, and perceptions of sun-protective behavior (SPB), among young athletes in Southern California.

DESIGN

Cross-sectional survey, assessing various measures of SPB, sun exposure, attitudes, and knowledge.

SETTING AND PARTICIPANTS

A total of 1006 students from 2 public high schools and 1 public university in the Los Angeles area volunteered. Athlete volunteers were recruited during sports preparticipation examinations. Nonathlete controls were recruited from physical education classes (high school) and from an introductory lecture class (university).

MAIN OUTCOME MEASURES

Use of SPB during sports and nonsports activities, sun exposure, sun-protection knowledge, and attitudes. Results from athletes were compared with those from controls at each site.

RESULTS

Overall rates of SPB were low. During nonsports activities, university athletes had higher rates of sunscreen (37.7% vs. 32.3%, P = 0.03) and hat use (34.7% vs. 17%, P < 0.001) than did controls. However, university athletes had lower rates of use of long shirts (27.9% vs. 39.8%, P < 0.001), long pants (38.8% vs. 63%, P < 0.002), and had higher total sun exposure (16.1 vs. 10.1 h/wk, P < 0.001). Similar results were seen among the high-school subjects. Despite having good knowledge of the potential dangers of ultraviolet radiation exposure, approximately 1 in 5 subjects overall had experienced a blistering sunburn within the past year.

CONCLUSIONS

Young athletes in the Los Angeles area reported low rates of SPB, high levels of ultraviolet radiation exposure, and high rates of sunburns, despite knowing the risks of sun exposure. Specific educational and behavioral interventions should be directed toward improving SPB in this high-risk group.

The Diameter of Melanomas

BACKGROUND

The mnemonic ABCD, which stands for asymmetry, border irregularity, color variation, and diameter greater than 6 mm alerts physicians to features that suggest melanoma. Although the ABCD criteria are guidelines for diagnosis, clinicians may overlook many melanomas that do not follow the ABCD rule.

OBJECTIVE

We examined the sensitivity of the diameter portion of the ABCD rule.

METHODS

Retrospective study examining the pathology reports of 383 melanomas. Data were compiled for each melanoma regarding its diameter, depth, body location, patient age, and sex. A 95% confidence interval (p=0.05) was used to identify the proportion of melanomas less than or equal to 6 mm in diameter. A two-tailed p value approach (p value =0.05, degrees of freedom=28) was used when evaluating two independent populations, lesions less than or equal to 6 mm and lesions greater than 6 mm in diameter.

RESULTS

A total of 38.21% of melanomas were less than or equal to 6 mm in diameter after processing. Melanomas greater than 6 mm in diameter occurred in significantly older patients and at a greater Breslow's thickness than smaller melanomas.

CONCLUSIONS

We demonstrated that a significant proportion of melanomas may be smaller than 6 mm. The ABCD criteria are not absolute; melanomas have many different appearances and start as small lesions.

Epidermal COX-2 Induction Following Ultraviolet Irradiation: Suggested Mechanism for the Role of COX-2 Inhibition in Photoprotection

The cyclooxygenase isoforms, COX-1 and COX-2, are involved in the biosynthesis of prostaglandin E2, a major prostaglandin involved in epidermal homeostasis and repair. Cancer originating in the epidermis can develop when keratinocyte proliferation and apoptosis become dysregulated, resulting in sustained epidermal hyperplasia. COX-2 inhibitors, which demonstrate significant in vivo selectivity relative to COX-1, suppress both ultraviolet-induced epidermal tumor development and progression, suggesting that prostaglandin regulation of keratinocyte biology is involved in the pathogenesis of epidermal neoplasia. In this study, we characterized the expression of COX-1 and COX-2, as well as keratinocyte proliferation, differentiation, and apoptosis, following acute ultraviolet irradiation in the hairless SKH-1 mouse. Following acute ultraviolet exposure, COX-2 expression was predominantly induced in the basal keratinocyte layer coincident with an increase in keratinocyte proliferation and apoptosis. The role of COX-2 was further evaluated using a selective COX-2 inhibitor, SC-791, as well as the traditional nonsteroidal COX inhibitor, indomethacin. Following acute ultraviolet irradiation, inhibition of COX-2 with either inhibitor decreased epidermal keratinocyte proliferation. Likewise, keratinocyte apoptosis was increased with COX-2 inhibition, particularly in the proliferating basal keratinocyte layer. There was also a modest inhibition of keratinocyte differentiation. These data suggest that COX-2 expression is probably necessary for keratinocyte survival and proliferation occurring after acute ultraviolet irradiation. We hypothesize that selective COX-2 inhibition, as described herein, may lead to enhanced removal of ultraviolet-damaged keratinocytes, thereby decreasing malignant transformation in the epidermis.

The management of melanoma and nonmelanoma skin cancer: a review for the primary care physician

In the United States, the incidence of skin cancer is greater than that of all other cancers combined, and early diagnosis can be lifesaving. A substantial public health concern, skin cancer is increasingly being diagnosed and managed by primary care physicians. Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) (known collectively as nonmelanoma skin cancer) and malignant melanoma are the most common cutaneous malignancies. Shave biopsy is usually performed if BCC is suspected; punch biopsy is preferred if SCC is thought to be present. The choice of biopsy techniques depends on the presumed depth of the lesion. Treatment has 3 goals: complete eradication of the cancer and preservation or restoration of normal function and cosmesis. Risk of recurrence or metastasis determines whether the tumor is high risk or low risk. Based on the level of risk, treatment options are considered, including whether the patient can be treated by a primary care physician or should be referred to a dermatologist. Choice of treatment approach depends on the tumor's location, size, borders, and growth rate. The standard treatment approaches are superficial ablative techniques (electro-desiccation and curettage and cryotherapy) used primarily for low-risk tumors and full-thickness techniques (Mohs micrographic surgery, excisional surgery, and radiotherapy) used to treat high-risk tumors. Removal of the entire tumor is essential to limit and prevent tumor recurrence.