Advanced Non-Melanoma Skin Cancer: Tackling Obstacles to Care

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Advanced Non-Melanoma Skin Cancer: Tackling Obstacles to Care from Patient Empowerment Network on Vimeo.

While advanced non-melanoma skin cancer treatments are available, some patients may still encounter difficulties accessing quality care. Dr. Diwakar Davar discusses common obstacles to care, social determinants of health, and the future of advanced non-melanoma skin cancer research. 

Dr. Diwakar Davar is the Clinical Director of the Melanoma and Skin Cancer Program at UPMC Hillman Cancer Center. Learn more about Dr. Davar.

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Transcript:

Katherine:

It’s not always easy to access the latest treatments or to find a specialist. I’m wondering what the common obstacles patients face in accessing the best care. 

Dr. Davar:

Some of the major issues are access to highly specialized treatment centers. Across the entire United States, there are clearly comprehensive cancer centers where the NCIS designated these places as being areas where patient care can deliver clinical trials available.  

Oftentimes, there is the breadth of research all the way from population research all the way to clinical trials. Not everybody has access to a comprehensive cancer center. Some patients may be living in a geographical location that is remote. Some patients could be living in a location that is not necessarily remote from a comprehensive cancer center, but may have social determinants of health that make it hard for them to access these comprehensive cancer centers. The only way around this is information.  

Patients need to be able to access information in a fashion that is both trusted, and up-to-date, and secure so that they are enabled and equipped with the right information for them to be able to have informed discussions about their care with their providers. 

Katherine:

This is all such great information, Dr. Davar. As we wrap up, I would like to get your thoughts.  

How do you feel about the future of advanced non-melanoma skin cancer research? 

Dr. Davar:

I am actually extraordinary optimistic about this landscape. When I started out as an oncologist, my big focus was in melanoma. I very quickly realized that most of the excitement was certainly, while in melanoma, was being generated, it was actually spilling over into non-melanoma skin cancer and the primary reason for that is the unique patient level challenges that make this disease a difficult disease to treat. The patient age, the comorbidities, the fact that a vast majority of our patients had gotten transplants, and that resulted in a relative contraindication of the administration of the effective agents that were developed that eradicated the majority of this disease.  

What oftentimes is a challenge, what is one man’s challenge is another man’s potential cure and it’s a potential benefit in an area in which it could be studied.  

What we realize about these challenges is they actually give us opportunities and avenues for research. As we think about non-melanoma skin cancer, we realize that this is an area in which there is tremendous potential where you can potentially give people immune therapy and improved outcomes, but not just improve patient outcomes in making people live longer, but also by reducing the burden of care by reducing the amount of surgery and radiation that people need that enables people to not just live longer, but live longer and maintain their quality of life as they age, and allows them to age with dignity. 

How Do Non-Melanoma Skin Cancers Impact Non-White Populations?

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How Do Non-Melanoma Skin Cancers Impact Non-White Populations? from Patient Empowerment Network on Vimeo.

Do non-melanoma skin cancers occur differently in non-white populations? Expert Dr. Silvina Pugliese explains how the appearance and location of squamous cell cancer and basal cell cancer can vary in non-white patients.

Silvina Pugliese, M.D., is a Clinical Assistant Professor of Dermatology and Attending Physician at the Stanford Medicine Outpatient Center and Stanford Cancer Institute. Learn more about Dr. Pugliese.

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“…recognize the disparate presentations of non-melanoma skin cancers in patients who are not white. So this includes pigmented basal cell cancers. So looking out not just for shiny red bumps, but also blue or purple bumps on the skin, making sure that patients know and also doctors know how to look within areas of wounds, chronic non-healing wounds and also scars and in different locations such as just…such as the genital skin and the perianal skin, as well as the lower legs where we might see squamous cell cancer in skin of color patients.”

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Transcript:

Mary Leer:

In more recent years, the incidence of cutaneous squamous cell carcinoma is increasing not only in non-Hispanic whites, but also in Hispanics and Asians. What are we learning about how non-melanoma skin cancers impact non-white populations?

Dr. Silvina Pugliese:

In dermatology, we’re certainly making a more concerted effort in recent years in studying squamous cell carcinoma in patients of all skin types. Most of our studies in the past were in white patients or lighter skin patients, but in recent years we’ve realized how important it’s to make sure that we know how non-melanoma skin cancers impact all patients, including our skin of color patients.

A few examples of how squamous cell cancer may impact non-white populations differently include where these skin cancers present. So, for example, squamous cell cancers may present in different locations on the body. So when we think about common squamous cell cancer locations, we think about areas exposed to a lot of UV, tops of the ears, the nose, et cetera.

We know that in skin of color patients we might see more of these skin cancers on the lower legs or on the feet or in genital or perianal skin. And that’s important, because we as dermatologists need to make sure that we’re examining all of these areas when we’re doing a full body skin exam.

In addition, about 20 to 40 percent of all squamous cell cancers diagnosed in Black patients are occurring within scars or areas of chronic inflammation such as wounds. It’s, therefore, really important for us to educate patients on the fact that these are areas that could be problematic in the future and need to be evaluated.

Other ways that squamous cell cancer impacts non-white populations is that patients may present…skin of color patients may present with more aggressive disease. There was one study looking at Mohs defect sizes, meaning when surgical procedures are done to remove a skin cancer, what’s left behind after skin cancer is moved is called the defect.

And because some of these skin cancers are more advanced, some of these squamous cell cancers, for example, are more advanced, they will have a larger area of skin removed, which as you can imagine really does impact how the skin heals the risk of scarring, the risk of having any longer term complications from that procedure.

There are a number of things that we can do better on the dermatology side in terms of educating patients about what to look for on their skin and also things that we can do about educating each other. And I’m talking about medical school and residency education in identifying skin cancer in skin of color patients.

Another thing I did want to mention is that basal cell cancer, which is our most common type of skin cancer, has a very different look in patients with skin of color. So it might have more of a purple or blue appearance than the classic pink shiny bump that we talk about. And then finally there is a rare tumor that we call DFSP that is actually more likely to occur in Black patients and can often have a scar-like appearance. This is a rare soft tissue tumor that can involve the deeper skin sometimes into the fat and even muscle.

And patients with skin of color are more likely to present with larger tumors.  So my activation tip for this question is to recognize the disparate presentations of non-melanoma skin cancers in patients who are not white. So this includes pigmented basal cell cancers.

So looking out not just for shiny red bumps, but also blue or purple bumps on the skin, making sure that patients know and also doctors know how to look within areas of wounds, chronic non-healing wounds and also scars and in different locations such as just…such as the genital skin and the perianal skin, as well as the lower legs where we might see squamous cell cancer in skin of color patients. So overall I think education all around for our doctors and our patients will help our skin of color patients have their skin cancers, their non-melanoma skin cancers diagnosed more properly. 

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Non-Melanoma Skin Cancer Subtypes | Are Some Populations More At-Risk?

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Non-Melanoma Skin Cancer Subtypes: Are Some Populations More At-Risk? from Patient Empowerment Network on Vimeo. 

Are some populations more at-risk for non-melanoma skin cancer subtypes? Expert Dr. Silvina Pugliese explains common subtypes, incidence rates, and risk factors linked with the subtypes.

Silvina Pugliese, M.D., is a Clinical Assistant Professor of Dermatology and Attending Physician at the Stanford Medicine Outpatient Center and Stanford Cancer Institute. Learn more about Dr. Pugliese.

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“Patients who have any of the risk factors discussed, so, for example, lighter-skinned, chronic sun exposure, and immunosuppressed for any reason, whether due to an underlying medical condition or a medication, or who have genetic mutations or history of radiation or any environmental factors that put them at risk, should be aware that looking at their skin for skin cancers is very important, and that they should see a doctor, a dermatologist, if they notice anything that looks suspicious on their skin, that warrants for their evaluation.”

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Transcript:

Mary Leer:

All right. Dr. Pugliese, what are the various subtypes of non-melanoma skin cancers, and are certain populations more susceptible to getting non-melanoma skin cancers than others?

Dr. Silvina Pugliese:

So there are a number of subtypes of non-melanoma skin cancers. The most common one is called a basal cell cancer, that occurs in about 4 million, there are about 4 million cases of basal cell cancer in the United States every year, and it’s considered a skin cancer related to keratinocytes, the most common type of skin cell. The second most common type of non-melanoma skin cancer, is called a squamous cell cancer, also arising from keratinocytes with about 2 million cases diagnosed each year in the United States. There are also less common types of non-melanoma skin cancers, including Merkel cell carcinoma, which arises from Merkel cells and sebaceous carcinoma. 

When we think about risk factors, there are a number of risk factors that put certain populations at a higher risk of developing non-melanoma skin cancers. So, for example, one thing that we think about often is lighter skin. So patients who have blonde hair, red hair, freckles, who are more likely to sunburn, who have lighter skin, are going to be more prone to the UV damage that can cause some of these skin cancers to develop. Chronic sun exposure is closely interplayed with that concept, so patients that live in a warm climate, are closer to the equator, live at higher altitude, have outdoor hobbies or outdoor jobs. There are certain medications that can also confer a greater risk of developing non-melanoma skin cancers.

So medications that suppress your immune system or that making more sensitive to light or getting sunburns from UV. And any condition that suppresses the immune system. So, for example, patients that have undergone a solid organ transplant, like a heart transplant or a lung transplant, or patients that have a diagnosis such as chronic lymphocytic leukemia. We know that those patient populations are at much higher risk of developing non-melanoma cancers.

There are other factors that are environmental. So, for example, if there is arsenic in well water that is being bathed in, then that could also lead to development of squamous cell cancer, smoking, chronic wounds or scars can put certain patients at increased risk of squamous cell cancer, certain genetic mutations, and then a history of any radiation, for example, for the treatment of other types of cancer.

So my activation tip for this question is, there are a number of non-melanoma skin cancers that can present, the most common ones being basal cell cancer and squamous cell cancer. Patients who have any of the risk factors discussed, so, for example, lighter-skinned, chronic sun exposure, and immunosuppressed for any reason, whether due to an underlying medical condition or a medication, or who have genetic mutations or history of radiation or any environmental factors that put them at risk, should be aware that looking at their skin for skin cancers is very important, and that they should see a doctor, a dermatologist, if they notice anything that looks suspicious on their skin, that warrants for their evaluation.

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Do Non-Melanoma Skin Cancers Differ in Diverse Patient Populations?

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Do Non-Melanoma Skin Cancers Differ in Diverse Patient Populations? from Patient Empowerment Network on Vimeo.

Can non-melanoma skin cancers vary in diverse patient populations? Expert Dr. Silvina Pugliese explains how the occurrence and treatment of squamous cell cancer and basal cell cancer can differ in diverse population groups and advice for patients to help ensure their best care.

Silvina Pugliese, M.D., is a Clinical Assistant Professor of Dermatology and Attending Physician at the Stanford Medicine Outpatient Center and Stanford Cancer Institute. Learn more about Dr. Pugliese.

[ACT]IVATION TIP

“…be aware that some common skin cancers can present looking very different in skin of color patients. To know that skin of color patients can develop these skin cancers so that you feel empowered to ask your doctor to take a look at something and to really feel like you can advocate for yourself if you are worried about something, to ask for biopsy or just monitoring or whatever you feel most comfortable with so that we don’t allow some of these skin cancers to go undiagnosed for a longer period of time, unnecessarily.”

Download Guide  |  Download Guide en español

See More from [ACT]IVATED Non-Melanoma Skin Cancer

Related Resources:

Melanoma vs. Non-Melanoma Skin Cancer | What’s the Difference?

Melanoma vs. Non-Melanoma Skin Cancer | What’s the Difference?

 Explaining Skin Cancer to Newly Diagnosed Patients | An Oncodermatologist Weighs In

Explaining Skin Cancer to Newly Diagnosed Patients | An Oncodermatologist Weighs In

 Non-Melanoma Skin Cancer Subtypes | Are Some Populations More At-Risk?

Non-Melanoma Skin Cancer Subtypes | Are Some Populations More At-Risk?

Transcript:

Mary Leer:

Do non-melanoma skin cancers differ in a diverse patient population, and how does that difference if there is one, impact treatment?

Dr. Silvina Pugliese:

So there is a lot to talk about with this question. I think that one aspect of this question is the clinical appearance difference. And the answer is sometimes yes. So in certain patient populations, I’m talking primarily about skin of color currently, certain skin cancers like basal cell cancer can look different. They can have a more purple or blue appearance as opposed to the classic shiny pink red bump that you might hear about or be educated about. Another skin cancer presents a little bit differently in certain patients and specifically in a skin of color patients is squamous cell cancer. So there’s a higher likelihood of having a squamous cell cancer and in a chronic wound or on a scar in patients who are Black as opposed to lighter skin patients. And also, squamous cell cancer can present in different locations, like the genitals, perianal skin, or the lower legs. This is really important in terms of impacting treatment because you can imagine that if a lesion is not picked up early, the way something may be when it has a classic presentation, by the time that it’s diagnosed, it can be much larger or much more advanced. And this impacts treatment because that could mean a larger surgery, it could mean in certain cases needing to do treatments beyond surgery to completely get rid of the skin cancer.

But even just with surgery alone, having a larger surgery can cause a larger scar. It can cause some functional impairment after surgery, or it can even cause some other problems like impaired nerve sensation, for example. So it’s really important that we think about the different presentations of skin cancer across all skin types, and be mindful of both looking for those different kinds of skin cancers when we’re doing our skin checks as doctors, but also be really mindful of how can we educate all of our patients for what to look out for, because often our education is be mindful of sun-exposed areas, wear sunscreen, make sure that you’re looking at your ears and your nose and your face, but we’re not really educating about examining the genital area for skin cancer or being mindful of burns or being mindful of scars.

So my activation tip for this question is to be aware that some common skin cancers can present looking very different in skin of color patients. To know that skin of color patients can develop these skin cancers so that you feel empowered to ask your doctor to take a look at something and to really feel like you can advocate for yourself if you are worried about something, to ask for biopsy or just monitoring or whatever you feel most comfortable with so that we don’t allow some of these skin cancers to go undiagnosed for a longer period of time, unnecessarily.

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