Skin cancer in Australia:
12 "what you should knows"
Who do I see if I'm worried about a spot?
Training in the recognition of skin cancers forms part of the requirement to become a GP in Australia. If you are worried about a particular spot then you should consult your GP. Your GP can refer you to a specialist if needed. A report will then be sent back to your GP.
If you seek the opinion of a non-specialist skin cancer doctor (i.e. a doctor at any clinic where referral is not required), you should ask that a full report be sent to your GP. This is particularly important before you consent to any form of surgical treatment. Unethical practices including unnecessary surgery, excessively complicated surgery & grandstanding have become rife throughout the skin cancer industry.
The issue of screening... "Skin cancer checks".
Despite recommendations from various self-interested groups, there is no official health policy pertaining to skin cancer screening in Australia. The main thing is that you know your skin and that you report any change that you're not sure about. All dangerous skin cancers will grow: if it's not growing, it is not dangerous. Here is a relevant article pertaining to "skin checks".
Are all skin cancers life threatening?
Malignant melanomas, which are cancers of melanocytes (pigment-producing cells) can spread if not detected early. The more common types skin cancer are cancers of keratinocytes (keratin-producing cells). These are far less dangerous and include basal cell cancers (BCC) and squamous cell cancers (SCC).
Of these, there are some advanced types of SCC that can be dangerous (see here for an example). The dangerous SCCs are large and easily recognised.
Do all skin cancers need to be cut out?
Melanomas should be cut out (excised) but the situation is different for BCCs and SCCs. There are excellent treatments that do not involve a scalpel and stitches. Cutting and stitching should not be considered as "gold standard" for all types of skin cancer. This is a myth.
Many BCCs and SCCs are suitable for less invasive treatment including curettage, photodynamic therapy*, chemotherapy creams, or cryotherapy. Infection is very uncommon with these treatments.
The cosmetic benefit of a non-surgical treatment (particularly photodynamic treatment) can be huge.
*see here for details.
I've been diagnosed with a skin cancer. How do I know if a non-surgical treatment is suitable?
Many basal cell cancers (BCCs) and superficial squamous cell cancers (SCCs) are suitable for non-surgical treatment. If the skin cancer is no thicker than a pea, or is larger but appears fairly flat then a non-surgical treatment may be all that is required. Many doctors will not offer non-surgical removals and so they won't be discussed with you. Some clinics will only offer scalpel removals and nothing else. We can assess suitability for non-invasive or less-invasive removal with a non-invasive scan that is performed at the first consultation and takes less than 30 seconds. Please phone us for advice. Ask to speak to Rosemary or to one of our nurses.
How do I know that a skin cancer has been removed following non-surgical treatment?
We offer "Optical Coherence Tomography" (OCT scanning) at our clinic (see here). A quick scan can verify that removal is complete. Scanning can be done on the day of treatment and/or once the treatment wound has healed. It can be used following any non-invasive treatment or following curettage. A scan is not always necessary but is available on request if just for reassurance. (See before and after scans of BCC removal in the image scroll here).
What is a BCC?
BCC stands for Basal Cell Cancer. Although labelled as a cancer, BCCs do not spread to other organs. They can fester like rot and break down your skin but they won't kill you. "Cancer" is perhaps not the best word to aptly describe this type of growth; "basal cell proliferation" or "basal cell growth" are more appropriate terms. The vast majority of these growths can be easily diagnosed at our clinic without the need for biopsy. Small BCCs and thin BCCs can be easily removed without the need for cutting and stitching.
What is Bowen's Disease (SCC-in-situ)?
Bowen's Disease is a bad name because it's not really a disease. It is better referred to as "Squamous cell carcinoma in situ (SCC-in-situ) or "non-invasive SCC".
SCC-in-situ usually presents as a flat red scaly patch in a sun-exposed site but is common on the lower legs of older people too. It's a type of growth where skin cancer cells (and they are not melanoma cells!) are forming sheets in the uppermost layer of skin. The bottom line is that SCC-in-situ will not kill you. SCC-in-situ has a very low chance of transforming to a potentially dangerous "invasive SCC" and this is fairly obvious if it happens - a lump develops.
The vast majority of SCCs-in-situ can be removed without the need for cutting and stitching.
What is SCC (invasive SCC)?
Invasive squamous cell cancer (SCC) of the skin is a very common type of skin cancer that is easily removed/cured in the vast majority of cases. Invasive means that cells have reached the 2nd layer of skin. Invasive SCC usually presents as a lump in a sun-exposed area with some scaliness at the top of the lump. If detected when they are small (<1cm diameter), they can be easily removed by scraping them off the skin and burning the base ("curettage and cautery"). They can also be cut out and stitched. There is a broad spectrum of types of SCC - the types that have potential to spread are larger and usually lack scaling.
What is a melanocytic naevus?
"Melanocytic naevus" is the technical term for a harmless mole. It is a collection of cells that produce pigment (melanin).
What is a dysplastic melanocytic naevus ("dysplastic mole")?
Not all moles look perfect. A dysplastic mole is a mole that isn't perfect either to the naked eye or when examined under the microscope. There are many features that can make a mole "dysplastic". Some people have dozens of dysplastic moles. They cause no harm but the problem with having many of them makes the job of detecting a melanoma more difficult! There is no evidence that dysplastic moles will turn into melanoma - this is a myth!
What is a "melanoma-in-situ"?
This diagnosis has become more common over the last few years and this is mainly because the histological criteria for "melanoma-in-situ" have changed and now includes lesions that were previously classified as an irregular type of mole. Here is an interesting read regarding the over-diagnosis of 'melanoma' in the USA but also applies to Australia.
Melanoma-in-situ (MIS) is the term used when a pathologist can identify abnormal cells (akin to melanoma cells) in a lesion but they are confined to the uppermost layer of skin. MIS has not had opportunity to spread and therefore is not regarded as a dangerous lesion in itself. There is no need to panic with this diagnosis - it is not invasive. It's just that the pathologist cannot tell whether it was heading towards invasive melanoma or not. Many MIS show no sign of change and these types are probably not "pre-invasive".
If MIS is diagnosed then it is best cut out with a clear margin. In Australia, the guidelines are that MIS be cut out with a 5mm margin from the visible edge of the lesion, nothing more. There are no guidelines as to what the minimum histologic margin should be. Excision of MIS generally means a simple, straight-line cut, not a complicated one.
Some doctors may simply refer to melanoma-in-situ as being "melanoma" without further clarification. If you have been diagnosed with "melanoma" it might just be a MIS. It is best to ask.
What is a malignant melanoma?
Malignant melanoma (MM) (invasive melanoma) is a cancerous growth of melanocytes (cells which produce pigment). Malignant does not mean that the tumour has spread, it means that cells have penetrated into the 2nd layer of skin. MMs have more potential to spread to other organs compared to other skin cancers. The risk of spread correlates with the depth of the tumour, not the size on the surface. The majority of MMs are curable and early detection is the key. Surgery is the standard treatment.
MMs are usually, but not always pigmented. MMs that lack pigment ("amelanotic melanoma") can be difficult to diagnose by doctors and almost impossible to diagnose for those relying on artificial intelligence (such as "MoleMax" or smartphone apps) or "mole-mapping". The best "software" for detecting all types of MM has been, and still is.. the trained human brain.