Nasty skin cancers

In my practice we treat multiple skin cancers daily.  One of the challenges is to determine the best technique for each individual patient.  The best cosmetic outcome is always a critical decision point as we contemplate treatment options.  The highest cure rate is even more important, of course.  A recent article in Lancet Oncology (2008 July 9) revisited the risk of recurrence in certain squamous cell carcinomas and found that the risk of local recurrence and distant metastasis was directly related to the cancers being large, poorly differentiated (meaning a loss of normal expression of skin cell characteristics), and forming scar tissue of its own (desmoplastic).  For example, local recurrences developed overall in 3% of patients but in 12% of tumors thicker then 6 mm; recurrences were all within 6 years of surgery.  No metastases developed in tumors less then 2 mm thick, but did develop in 4% of tumors 2.1 to 6 mm and in 16% of tumors thicker then 6 mm.  Patients who had a damaged immune system had significantly more problems.  None of this is surprising, and these same characteristics have long been known for basal cell carcinomas.  Another item we consider is tumor location; these cancers on the lip, temple and genitals are usually more aggressive.  

We use this information to decide on tumor margins (narrow versus wide), the need for adjuvant treatments (imiquimod immunostimulation, radiation therapy), the need for Moh’s surgery (frozen tissue processing with horizontal sectioning), and attention to lymph node enlargement and the need for chest x-rays.  

If you are unlucky enough to develop skin cancer, consider if your physician is thinking of the worst case scenario.  There is no need to overtreat, but it is important to know when more aggressive treatments are necessary.