An Introduction to Skin Cancer Treatment
Skin cancer is the most common form of cancer, encompassing several types that originate in the cells of the skin. The choice of treatment is highly dependent on the specific type of skin cancer—most commonly basal cell carcinoma (BCC), squamous cell carcinoma (SCC), or melanoma—as well as the tumor’s size, location, depth, and whether it has spread. The patient’s overall health and preferences are also important considerations.
The primary goals of treatment are to remove the cancer completely, prevent it from recurring, and preserve both physical function and cosmetic appearance as much as possible. For most skin cancers, which are localized, treatment is often straightforward and highly effective. For more advanced cancers that have spread, a more complex, systemic approach is required.
The Role of the Dermatologist and Multidisciplinary Team
A dermatologist, a physician specializing in skin diseases, is typically the lead doctor for diagnosing and treating skin cancer. They perform skin examinations, biopsies, and many of the necessary surgical and non-surgical procedures.
For more complex or advanced skin cancers, particularly melanoma, a multidisciplinary team (MDT) approach is essential. This team collaborates to ensure a comprehensive and coordinated treatment plan. An MDT for skin cancer may include:
- Surgical Oncologist: A surgeon who specializes in removing cancerous tumors, particularly for more invasive melanomas or those requiring lymph node surgery.
- Medical Oncologist: A physician who treats cancer with systemic medications, such as immunotherapy and targeted therapy, for cancers that have spread.
- Pathologist: A doctor who examines the biopsied tissue under a microscope to confirm the diagnosis, type of cancer, and key features like tumor depth and margins.
- Radiation Oncologist: A physician who uses radiation therapy to treat skin cancer in specific situations.
- Plastic Surgeon: A surgeon who may be involved in reconstruction after a large tumor is removed, especially in cosmetically sensitive areas.
Treatments for Non-Melanoma Skin Cancers (BCC and SCC)
Basal cell carcinoma and squamous cell carcinoma are the two most common types of skin cancer. They are often referred to as non-melanoma skin cancers. They tend to grow locally and, when diagnosed early, have very high cure rates with relatively simple treatments.
Surgical Excision
Standard surgical excision is the most common treatment for both BCC and SCC. The procedure involves numbing the area with a local anesthetic and surgically removing the visible tumor along with a small border, or margin, of surrounding healthy-looking skin. This margin is included to ensure all cancerous cells are removed. The removed tissue is then sent to a pathologist for examination to confirm that the margins are clear of cancer cells.
Mohs Micrographic Surgery
Mohs surgery is a specialized surgical technique that offers the highest cure rate for non-melanoma skin cancers. It is particularly valuable for cancers that are large, have indistinct borders, are recurrent, or are located in cosmetically and functionally important areas like the face, hands, feet, or genitals.
During Mohs surgery, the surgeon removes the visible tumor and then proceeds to remove a very thin layer of tissue around the site. This layer is immediately processed and examined under a microscope while the patient waits. If any cancer cells are seen, their exact location is mapped, and the surgeon removes another thin layer only from that specific spot. This process is repeated until no cancer cells remain. This technique ensures complete removal of the cancer while sparing the maximum amount of healthy tissue.
Curettage and Electrodesiccation
This simple procedure is often used for small, superficial, low-risk BCCs or early SCCs. The surgeon uses a spoon-shaped instrument (a curette) to scrape away the cancerous tissue. Then, a needle-like electrode is used to apply an electrical current to the area to destroy any remaining cancer cells and control bleeding. This process may be repeated a few times.
Non-Surgical Local Treatments
For very superficial cancers or for patients who are not good candidates for surgery, several non-surgical options are available.
Cryotherapy
Cryotherapy, or cryosurgery, involves spraying liquid nitrogen directly onto the skin cancer to freeze and destroy the abnormal cells. The treated area will blister and scab over before healing. It is most often used for pre-cancerous lesions called actinic keratoses, but it can also be an option for very small, superficial BCCs.
Topical Treatments
For some superficial BCCs and pre-cancers, medicated creams or gels can be applied directly to the skin. These are prescription medications that work in different ways to eliminate cancer cells. Examples include 5-fluorouracil (a form of topical chemotherapy) and imiquimod (which stimulates the body’s immune system to attack the cancer cells). Treatment typically lasts for several weeks.
Radiation Therapy
Radiation therapy uses high-energy X-rays to destroy cancer cells. It is a good option for treating patients who cannot undergo surgery due to other health problems or for treating large tumors or tumors in locations that are difficult to operate on. It can also be used as an adjuvant (additional) therapy after surgery if there is a high risk of recurrence.
Treatment for Melanoma
Melanoma is a less common but more serious type of skin cancer because it has a greater potential to spread to other parts of the body. Treatment is critically dependent on the stage of the disease at diagnosis.
Wide Surgical Excision
For early-stage melanomas that are confined to the skin, the standard treatment is a wide surgical excision. Similar to a standard excision, the surgeon removes the melanoma, but a much wider margin of healthy skin is taken. The width of this margin is determined by the measured thickness of the melanoma (the Breslow depth), as determined by the pathologist from the initial biopsy.
Sentinel Lymph Node Biopsy (SLNB)
For melanomas that are over a certain thickness, a sentinel lymph node biopsy is often recommended to determine if the cancer has spread to the nearby lymph nodes. The sentinel node is the first lymph node to which cancer cells are most likely to travel. During the procedure, the surgeon injects a tracer dye near the original melanoma site to identify the sentinel node, which is then removed and examined by a pathologist. A negative result means the cancer has likely not spread. A positive result indicates the cancer has reached the lymph nodes (Stage III), which guides further treatment decisions.
Systemic Therapies for Advanced Skin Cancer
When skin cancer, most often melanoma, spreads to distant lymph nodes or other organs (Stage IV), it is considered advanced or metastatic. In these cases, local treatments like surgery are not sufficient, and systemic therapies that travel throughout the body are needed.
Immunotherapy
Immunotherapy has become the most important and effective treatment for advanced melanoma. These drugs, known as immune checkpoint inhibitors, do not attack the cancer directly. Instead, they block proteins that cancer cells use to hide from the immune system. This “unmasks” the cancer, allowing the body’s own T-cells to recognize and attack it.
Targeted Therapy
Approximately half of all melanomas have a specific mutation in a gene called BRAF. Targeted therapy drugs are oral medications that are designed to specifically block the effects of the abnormal BRAF protein, shutting down the signal that tells the cancer cells to grow and divide. Patients must have their tumor tested for this mutation to be eligible for this treatment.
Frequently Asked Questions
1. What is the most common treatment for skin cancer?
The most common and standard treatment for the majority of skin cancers (basal cell and squamous cell carcinomas) is surgical excision. This procedure involves surgically removing the tumor along with a small border of healthy skin to ensure all cancerous cells are gone, and it has a very high cure rate.
2. What is Mohs surgery and why is it recommended?
Mohs surgery is a specialized surgical technique where the surgeon removes skin cancer one layer at a time, immediately examining each layer under a microscope until no cancer cells remain. It is recommended for cancers in cosmetically or functionally important areas (like the face or hands), for large or recurrent tumors, or for tumors with indistinct borders. Its key advantages are having the highest cure rate and sparing the greatest amount of healthy tissue.
3. Does all skin cancer require surgery?
No, not all skin cancers require traditional surgery. Very superficial or early-stage non-melanoma skin cancers can sometimes be treated with non-surgical methods, such as cryotherapy (freezing), curettage and electrodesiccation (scraping and burning), or topical creams that are applied to the skin to destroy the cancer cells.
4. How is melanoma treatment different from treatment for other skin cancers?
Melanoma treatment is more aggressive due to its higher potential to spread. It requires a wider surgical excision margin than non-melanoma skin cancers. Furthermore, staging is critical and often involves a sentinel lymph node biopsy to check for spread. If melanoma becomes advanced, treatment relies on powerful systemic drugs like immunotherapy or targeted therapy, which are not typically used for common basal cell or squamous cell cancers.
5. What is a sentinel lymph node biopsy and why is it done for melanoma?
A sentinel lymph node biopsy is a surgical procedure to determine if melanoma has spread from the primary tumor to the nearby lymph nodes. The “sentinel” node is the first lymph node that drains fluid from the tumor site. It is identified, removed, and checked for cancer cells. The result is crucial for accurately staging the melanoma, which helps doctors determine the patient’s prognosis and plan the most appropriate follow-up care and treatment.
6. What is the difference between immunotherapy and targeted therapy for advanced melanoma?
Immunotherapy works indirectly by stimulating the patient’s own immune system to recognize and attack cancer cells. Targeted therapy works directly by interfering with specific molecules or genetic mutations within the cancer cells (like the BRAF mutation) that are driving their growth. A patient’s tumor must have the specific target for targeted therapy to be an option.
