S.afety O.n S.ummits
By: Rick Hartman
#40 Skin Cancer; Part One of Two
My sister, Rose, called this past week. Her husband Bruce died early this morning. He had that melanoma in his eye and about nine months later it spread to the liver. In spite of four different rounds of chemo, the cancer just took over. An active fellow, he never drank, smoked or even drank soft drinks. They were our camping buddies. Ann S.
All Highpointers are active folks, drawn to the great outdoors and especially high elevations, where skin cancer should be a concern. This maturing columnist now has a regular relationship with a dermatologist. The routine exams result in liquid hydrogen being applied and recently, part of one ear was carved off, after developing a basal cell carcinoma. All who are active in the outdoors should consider they are potentially a victim of this skin cancer epidemic, now recognized as the most common form of cancer in the United States. Once more S.O.S. touts: “Avoidance is the key.”
Previously considered an affliction of older humans, skin cancer is now recognized to have very little to do with seniority or just people. One albino humpback whale, known for 28 years off of Australia, has been recently photographed with pink discolorations around its dorsal fin. It is suspected to be skin cancer, which likely developed from its long periods of being on the surface, basking in the sun.
Recall that the epidermis (skin) is the largest organ of the human body. Current odds favor one in five Americans will develop skin cancer and there is strong evidence that skin cancer is growing among the young; here at least, the dermatologists are taking notice. A recent article in the Journal of the American Medical Association addressed the rise of carcinomas in those under age 40; defining the problem, however not so much the cause. The primary cause is ultraviolet (UV) radiation from excessive sun exposure and tanning beds. Other causes include exposure to sun lamps, chemicals, and petroleum by-products. The effects of the sun on our skin are lifelong and progressive, and older skin is more prone to sun damage, as the self-correcting processes of our cells wane with age.
The World Health Organization has declared ultraviolet radiation as a carcinogen. There are three types of ultraviolet rays:
-UV-A: penetrates deep below the skin surface, causing wrinkles and age spots.
-UV-B: burns skin and eyes.
-UV-C: the strongest and most dangerous UV ray, it is effectively blocked out by the Earth’s ozone layer.
UV-B radiation intensity increases with the time of day, it is more intense in summer, at the Equator, and at higher altitudes. UV-B radiation exposure will increase 4% for every thousand feet increase in altitude. Yet, at a mean elevation of 1,117’, Phoenix, Arizona is recognized as having the seventh highest UV Index level in the United States.
The UV Index Scale, developed by Canadians in 1992, is represented as: 0-2 “low danger”, for the average person; 3-5 “moderate risk of harm”, from unprotected sun exposure; 6-7 “high risk of harm”, protection against the sun is needed; 7-10 “very high risk of harm”, use extra precautions, skin will be damaged ; and 11+ “extreme high risk of harm”, take all precautions, skin can burn in minutes. If the forecast “UV index” is -3- or higher, we should protect ourselves. Keep in mind, infants under six months should be kept out of direct sunlight as much as possible and sunscreen and sunblock is not recommended to be used on them.
Studies reveal 80% of a person’s lifetime sun exposure occurs during childhood. Children’s skin is more delicate than adults’ and kids spend longer periods in the sun unprotected. Thus, learning as adults and teaching children quality sun protection behavior, we can address the increasing skin cancer rates. Simple protection behavior begins with the University of Arizona Skin Cancer Institute’s “ACE”: Avoid too much sun, Cover-up and Examine your skin. Their website is: www.azskincancerinstitute.org.
This can be accomplished by limiting exposure when the sun rays are the strongest (10 am to 4 pm). If outside seek shade; avoid tans and burns from the sun, as well as indoor tanning beds. Try to avoid reflective surfaces such as water, glass, concrete, sand and snow. Sunlight reflecting off of snow (80%) and white sand (17%) can nearly double the strength of UV rays. Cloudy days are deceptive as 80% of the sun’s UV rays will pass through clouds.
When outdoors, minimize your exposure by wearing long pants and long sleeved shirts (darker colors with a tightly woven pattern are best), cotton gloves, a large brimmed hat (offering greater ear and neck protection) and closed toe shoes.
Covering-up also includes our eyes, which are susceptible to serious damage from UV radiation. Purchase and wear sunglasses that block 99-100% of UV-A and UV-B rays (see: S.O.S. #31, “This and That”/ Sunglasses). Good eye protection is not a luxury; it is a crucial necessity. Here again, buyer beware, as there is no standardized testing and labeling of sunglasses. Some expensive sunglasses offer little UV protection and cheap ones can be very good! Serious vision problems can result from cumulative eye damage from unprotected sun exposure, even on cloudy days. The sun’s UV rays can create solar-induced cataracts on the lens of the eyes, benign growths on the white part and cornea of our eyes (known as: pinguecula or pterygium), and can penetrate to the back of the eyes, where ocular melanoma can occur and the retinas may suffer damage as well. Also, there are eyelid malignancies recognized to be caused by sun exposure. Refer to: www.thevisioncouncil.org for further information.
For our skin, apply a broad-spectrum sunscreen on all exposed areas with a Sun Protection Factor (SPF) of 30 or higher and a lip balm with a high SPF (See next Quarters’ Part Two topic: “Sunblocks and Sunscreens”).
Recent advances have created sun-protective clothing (hats and garments) which are designed to block both UV-A and UV-B radiation. Their ability to protect is affected by weave, color, weight, stretch and wetness. Synthetic fabric materials such as polyester, Lycra and nylon protect well by absorbing UV radiation. Some products may have UV absorbers added in during the manufacturing process. Simply stated, the more dye (darker color) the better protection; the open/less dense the fabric, the worse protection. Getting the fabric wet reduces the protection by as much as half, except for silk. UV blocking clothing is rated by a “UPF” (Ultraviolet Protection Factor) from a 1996 designation. By Federal Trade Commission standards, these ratings are more accurate as to fabric’s ability to block UV radiation than the Sunblocks/Sunscreens’ SPF ratings are. A rating of UPF15/24 is deemed “good”, blocking 93-95% of UV radiation; UPF25/39 is deemed “Very Good”, blocking 96-97.4% of UV radiation and UPF40/50 is deemed “Excellent”, blocking 97.5-99% of UV radiation. Washing the fabric requires following the laundering directions on the garment, however chlorine bleach is not recommended and line drying is preferred across the board. Some items may specify hand washing only and too, could be stained by contact with sunscreen lotions. No information was found on how many washings UV blocking fabrics could sustain until their properties were diminished. As a consumer consider darker colors and heavier weaves will be a heat retention (disadvantage) issue, while ventilated weaves, moisture wicking, and antibacterial properties will aid in breathability. Manufacturers are: Coolibar, Patagonia and Solar Tex. A final note, garments with the lowest UV protection are: bleached cotton, polyester crepe, viscose, knits, undyed/ white jeans (denim), lightweight linens and worn, old fabrics.
Our skin should be examined once a month. Early detection of skin cancer usually results in very successful treatment. Common moles are smooth, symmetrical, with even borders and usually have a single shade of brown color. If need be, compare any questionable spot to your own common mole to self-identify a concern. Many times the questionable spot is where you cannot see it (ears and back of neck, for example), so your exam should include another’s help. Finding any questionable spot on yourself or mate requires a doctor’s exam right away. Pay attention to any spot that forms a scab, re-scabs and fails to heal. Suspect: scaly, thickening skin that develops in a small area, often on the face, neck or hands or a mole-like growth that increases in size, darkens, becomes ulcerated or bleeds easily. Finally, be concerned about any sore, blister, skin patch, blemish or pimple that does not heal in two to three weeks. Take particular note of strange color, shape, size and edging.
Basal and squamous cell are the two categories of non-melanoma carcinomas (95% of cases). These are diagnosed in a million new cases annually. Most are sores or bumps found on habitually exposed skin that scab over and never seem to heal; they can be pink, red, white or yellowish in color. It is easy to forget about them, until they become bothersome, bleeding and scabbing once more. These rarely metastasize, and are easily cured if caught early. But if untreated, they can become invasive and could require major surgery. Most occur on the head or neck, with the ears, eyelids, lips and the nose all being prominent sites. Thus, being on exposed areas, any required medical treatment can be very disfiguring, ultimately becoming a quality of life issue.
Mohs surgery is a micrographic surgery for basal and squamous carcinomas. It combines tumor removal surgery with the pathology lab work, to ensure it is all removed. Simultaneous pathology reports advise the surgeon how superficial the carcinoma is. Looking for clear margins presents proof that all of the cancer was removed during the surgery. However, it can return after the surgery. Much like a tree’s roots, if all of the cancer is not removed it can come back, so the surgery often goes deep. Mohs can result in a lengthy surgery, as the process may need to be repeated until the laboratory slides indicate “all is clear”; the goal being total removal of all the carcinoma.
Then there is Melanoma, which accounts less than 2% of the carcinomas, but most of the skin cancer deaths. This is the dangerous skin cancer. It is the most common skin cancer for those under age 30 and melanoma cases are increasing faster in young women (15-29 years) than men of the same age. The annual expectation for new cases of melanoma runs consistently at 6,000, with over 9,000 victims dying of it annually. Over the last 30 years the number of cases has increased by 3% annually. If detected “locally” the five year survival rate is 97%, detected “regionally” the rate is 60%, and detected in the metastatic stage the survival rate is just 14%. Melanoma arises from the melanocyte cells (which are responsible for making pigment) at the bottom layer of the skin’s epidermis. Melanoma can occur anywhere on the body. It is renowned for developing under finger and toe nails, thus removal of nail polish, if doing any formal medical exam, is highly recommended. It has also been known to develop in the palms of the hands, the bottom of feet and in the scalp. Considering eye melanoma, benign lesions around the retinas (known as: choroidal nevus), have a 10% possibility over ten years of becoming malignant eye cancer. Comparing photographs of the lesion can help determine if it is growing. Anyone diagnosed with choroidal nevus is well advised to participate in yearly eye exams.
Melanoma’s ABCE’s are:
Asymmetry: In early stages melanomas are asymmetrical. If a hypothetical line were drawn through the middle, it will fail to create matching halves.
Border: The borders of early melanomas are often uneven, having scalloped, blurred or notched edges.
Color: Melanomas present varied shades of brown, tan or black; progression will see a “spotty” appearance with dashes of red, white and blue.
Diameter: Early melanomas tend to grow larger than a common mole; growing to at least the size of a pencil eraser (6 m/m or ¼ inch). Do be concerned at any growth of a mole!
Evolving: Suspect “spots” that show any of these changes over time: shape, size, shades of color, sensation (an itching or tenderness) or surface bleeding should be reason for a medical exam.
Surgery remains the best course of treatment for melanomas. A complete lymph-node dissection was the previous accepted co-procedure, but this always left patients with many side effects. Since the early 1990’s the standard of care for localized melanomas with a significant risk for a metastasis into the lymph-nodes, is surgery combined with a sentinel-node biopsy. The sentinel-node biopsy focuses upon cancer’s known tendency to spread through the lymphatic system. Metastatic identifies a skin cancer that spreads into other parts or organs of the body, first by moving through one or two “sentinel” lymph-nodes (the nearest nodes) that the tumor has drained into. The surgically removed sentinel nodes are sent to pathology where tests determine if the cancer has spread into the lymphatic system.
In May of 1981, 36 year-old Raggae/musician Bob Marley of Kingston, Jamaica died from Metastatic Melanoma. First seen as a lingering painful “sore” under his toenail in May of 1977, this “non-classic” (meaning unusual location, presentation or patient) melanoma continues to be a challenge to this day for early diagnosis. Simply stated, no one considers people of color being at-risk for skin cancer and that a melanoma could occur under a toe nail. Add in the Rastafarian sub-culture/religion disapproves of amputation, and the inability to use the best course of medical treatment, sealed Marley’s fate. This is likely also true in the lead-in story of Bruce, where a delay to remove his one eye, allowed the liver metastases to develop. In both of these illustrations the best course of medical treatment had cosmetic ramifications that presented huge quality of life issues and an untimely death for each patient.
Finally, sunlight elevates our mood; sunny days are always a joy! Our bodies naturally create Vitamin D (which is actually a steroid hormone) when skin is exposed to direct sunlight and for most of us, our Vitamin D needs are met in this way. Vitamin D maintains strong bones, a healthy immune system and aids the muscles within our bodies to move. Vitamin D helps the body absorb calcium from food or supplements and protects the elderly from osteoporosis. Low Vitamin D levels are associated with diabetes, autoimmune disease, cancer, obesity, possibly depression (one may influence the other!), and soft bones, known as: “rickets” in children and “osteomalacia” in adults. A CDC study in 2006 determined 25% of the US population was deficient in Vitamin D. Levels of Vitamin D often become depleted in our body during winter, as we stay inside and the sun is not as intense. The American Academy of Dermatology recognizes Vitamin D is required for good overall health. So here is the crux: avoiding the sun either outright, by use of clothing or by using sunblock/sunscreen is certainly prudent to avoid skin cancer, but it risks a Vitamin D deficiency. A simple blood test can determine one’s Vitamin D level. All of us should be certain we have an adequate and safe supplemental intake of Vitamin D to maintain the body health required for our demanding hobby.
Remain Sun Safe!