Dr. David Leffell, Detection and Prevention of
Melanoma
September 7, 2008
Welcome to Yale Cancer Center Answers with Dr. Ed Chu and Dr. Ken Miller. I am Bruce Barber. Dr. Chu is Deputy Director and Chief of Medical Oncology at Yale Cancer Center and Dr. Miller is a medical oncologist specializing in pain and palliative care and he also serves as Director of the Connecticut Challenge Survivorship Clinic. If you would like to join the discussion, you can contact the doctors directly. The address is canceranswers@yale.edu and the phone number is 1-888-234-4YCC. This evening, Ken Miller is joined by Dr. David Leffell, Professor of Dermatology and Surgery and Deputy Dean of Yale School of Medicine, he is also the CEO of Yale Medical Group and the author of "Total Skin." Dr. Leffell is here to talk about the latest information on skin cancer prevention and melanoma.
Miller
Let us talk a little bit about the progress, or lack of progress,
in the last decade in getting people to use sun protection.
Leffell
I think there has been progress. In a moment I will talk
about some brand new data that suggests we are not making as much
progress as we would like, but I think overall in the last decade
we have had a chance to convince people of one important fact;
generally speaking the sun causes skin cancer. The scientific
evidence that supports that has mushroomed, and that has given
physicians and other health care providers a hook to be able to
educate listeners about the importance of protecting their skin
against the harmful effects of the sun.
Miller
Along those lines, tanning has become popular. Is it safe?
Leffell
Tanning has been popular ever since it was popularized by Coco
Chanel. It is a durable social statement and fashion
statement and it is especially concerning because it has captured
the imagination of our youth. The reality is that a tan is
the body's response to injury caused by ultraviolet
radiation. In addition to that fact there are now many mixed
messages out there by different groups who have vested interest in
convincing people that tanning is actually healthy. We are
dealing with a younger population, particularly women who go out of
their way to get a tan using tanning parlors. Tanning parlors
are so dangerous from a dermatologist's point of view that in many
states they have been tightly regulated. Just this summer new
evidence was published showing that the rates of malignant
melanoma, the most serious form of skin cancer, are increasing in
women born after 1990. A report came out showing an increase
in melanoma in young women compared with young men, and this is
consistent with what we as practicing dermatologists have been
saying. Although the reason for the increase in melanoma in
young women is not known, I believe an important role has to be
assigned to the use of tanning parlors and aggressive tanning in
general. The fact that young people are spending more time in
the sun has been demonstrated in several other
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studies published over the past couple of years. On the one
hand, people are getting the message that the sun can cause skin
cancer and therefore proper sun protection is important. On
the other hand, we are dealing with the age old phenomenon seen in
young people that they believe they are immortal. Because of that,
they feel they do not have to take the precautions that older or
more mature people among us recognize as a good idea.
Miller
It is frightening that it is people that young, and I did not know
that so it is an important piece of information to get out
there. Looking at the flip side of it, is there one? Is
there is any amount of sun exposure that is healthy?
Leffell
Of course there are many good things about the sun. It has
crept into our language, our music and our poetry, and there is a
reason for it. We know that the sun makes us feel good and we
know conversely, that in the absence of sun, there is a phenomenon
called seasonal affective disorder, which some of us in the
Northeast may be at risk for. Having said that, everything in
nature has its pluses and minuses, so while a big plus of the sun
is that we cannot have life on earth without it because it is a
source of photosynthesis, the bad side is that when we are
immoderate with respect to our exposure to the sun, we set up a
cascade of events in our skin that can lead to skin cancer.
While the majority of skin cancers are easily treated, we worry the
most about the development of malignant melanoma, which does have a
potential to not only spread throughout the body once it develops
in the skin, but leads to death as a result.
Miller
There has been a lot in the media recently about vitamin D.
We need vitamin D and it may reduce the amount of breast cancer and
reduce the risk of recurrence of breast cancer. What are your
thoughts about that? Is that a reason people should get more
sun?
Leffell
The vitamin D story is actually one of the issues that I was
referring to earlier when I commented on vested interests.
For some reason the tanning industry, in another words the
people that market tanning booths, had been very aggressive about
claiming that ultraviolet radiation does not cause skin cancer,
which by the way is scientifically incorrect. Moreover, they
are making the claim that people that use sunscreen, for example,
are diminishing the amount of sun exposure they need to develop
vitamin D. Now it is quite true that vitamin D is a hormone
and it is manufactured by the body when ultraviolet light hits the
skin and converts cholesterol molecules that normally sit in your
skin into precursor molecules that then turn into vitamin D.
We have known for a long time that vitamin D is essential for bone
health and many other aspects of metabolism, and recently, there
has been epidemiologic, though not laboratory data, to
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suggest that vitamin D levels may correlate with some of the
things that you have mentioned relating to cancer. I caution
listeners that that information is far from validated and that the
risk of developing skin cancer from excess of exposure to the sun
far out weighs any theoretical risk related to vitamin D levels.
Besides, you can boost vitamin D levels with oral supplementation.
We have supplemented milk for many-many years, in fact, going back
to the early to mid part of the last century when school children
were developing rickets, it became obvious that they were suffering
from a vitamin D deficiency and that is what led to milk
supplementation. Sun does stimulate vitamin D production in
the skin. You really need about 2, 15 minutes sessions of sun
exposure, exposing your arms, face or some relatively small part of
your body to noonday sun. One interesting observation is that
an excess of sun exposure will actually breakdown vitamin D
precursors in the skin. Like everything else in nature, there
is a balance, and the trick for individuals thinking about how they
are going to develop a personal sun strategy is to figure out what
their personal risk is for skin cancer and how they are going to
protect themselves on a day-to-day basis.
Miller
How does a person assess what their risk is as opposed to their
neighbor?
Leffell
First and foremost you have to take a look in the mirror and see
what kind of skin, hair, and eye color you have. The people that
are most at risk for developing melanoma are those with fair skin,
blonde or red hair, and light colored eyes; green/gray eyes.
These individuals know who they are because when they go out in the
sun they either burn, or they burn and then tan, and this is an
indication that your body lacks the pigmentation necessary to
protect you from the harmful effects of the sun. After you
look in the mirror and figure out what your so called phenotype is,
that is the word that we use to describe what you look like, then
turn around and look at the family pictures on the wall and see if
you can identify through your family history whether there is a
history of melanoma. If you do have a family history of melanoma
that is another risk factor that you should pay attention to.
If you had a blistering sunburn in childhood, that increases your
risk of melanoma. If you fall into any of these categories,
you need to be especially vigilant about protecting yourself from
the harmful effects of the sun.
Miller
Along those lines, if someone looks at themselves in the mirror
and goes through their family history, if they identify themselves
in two groups considered high risk, what would you recommend as a
strategy? And if they identify themselves at low risk, what would
you recommend as a strategy?
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Leffell
If an individual is identified as high risk for skin cancer,
melanoma, they should make sure that they follow the following sun
protection strategies:
Miller
Let me ask you about clothing because my own sort of belief would
be that if I have my shirt and pants on I am not getting sun
exposure. Is that true or false?
Leffell
Well it depends upon the fabric. A white T-shirt, for
example, which many may choose to run around in during the summer
months or fall months, provides sun protection of 4. The sun
protective factor, or component of fabric, depends on the tightness
of the weave and the color of the fabric. A dark T-shirt
actually provides more protection and it is especially attractive
for children because remember, we believe that 85% of lifetime sun
exposures is acquired by age 18. If you can protect your
children from the harmful effects of the sun and buy sun protective
clothing for them, even if you think you yourself are a lost cause,
which I hope you are not, you can help them minimize those initial
genetic injuries caused by the sun that set them up later in life
for getting skin cancer.
Miller
That reminds me, years ago, in my lifetime, people used to put oil
on to get a sunburn or a sun tan, and now, thankfully, most of us
are using the sun block.
Leffell
You are absolutely right. There is still a lot of confusion
among my
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patients and others about what kind of sunscreen to buy.
Needless to say, like everything else in the marketplace, there is
a lot of advertising and a lot of claims and that is why I would
like to keep it simple. Any sunscreen that feels good on your
skin with a sun protection factor of 30, which also provides UVA
protection, is good. The continuous spray products made by many
different companies now are very effective, especially with kids
who are not especially eager to sit still while you smear them with
cream. You can actually spray the sunscreen on as they run by.
Miller
We would like to remind you, you can email questions to us at canceranswers@yale.edu.
We are going to take a short break for medical minute. Please stay
tuned to learn more information about melanoma and sun exposure
with Dr. David Leffell.
Miller
Welcome back to Yale Cancer Center Answers. This is Dr. Ken
Miller and I am joined today by Dr. David Leffell who is the author
of the book Total Skin. He is also a dermatologist here at
Yale Cancer Center and he is discussing the latest information on
melanoma detection and treatment. We are also talking about
the sun and sun exposure. David, I want to ask you a little
bit more about the sun and then about skin cancer. Can you
tell us a little bit about the different types of UV, ultraviolet
rays?
Leffell
There are three types of ultraviolet radiation that come from the
sun that we typically think about. There are only two that we
are concerned about; ultraviolet B rays and ultraviolet A
rays. Ultraviolet B rays are those that cause sunburn, and a
good way to remember it using a mnemonic device is to say,
ultraviolet B, B for burning. Ultraviolet A rays penetrate
more deeply into the skin and are thought to be responsible in
large part for the ageing of the skin, premature wrinkling,
pigmentation, spots and that sort
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of thing. It is true though that ultraviolet A rays do play a role
in causing cancer, though they are probably not as problematic from
that point of view as the ultraviolet B rays.
Miller
Let's talk about melanoma, how common is it? How many
patients each year develop melanoma?
Leffell
Melanoma is increasingly common. Fortunately, the death rate
from melanoma is going down. What that suggests is that we
are diagnosing it earlier. Typically about 8000 people a year
die from melanoma so it certainly is not one of the more common
causes of death. The important point is that unlike other
cancers, which may be hard to diagnose, melanoma for the most part
originates on the skin where it can be identified early at its most
curable stage.
Miller
What should lead a person to go the doctor? What kinds of things
might they see on skin that should be of concern?
Leffell
I think that individuals should, #1, have a full body skin
examination with a dermatologist, or other individual properly
trained in doing a skin exam, once a year. But you yourself should
learn how to examine your body and be alert to any moles that come
up or any spots. The typical things we advise is any sore that
bleeds and does not go away or heals up and then comes back; that
could be any form of skin cancer, but when it comes to melanoma we
are specifically concerned about moles or spots that grow in size
that are asymmetrical, in other words, if you folded them over in
your mind's eyes, the size would not match, or if they have
irregular pigmentation. Most moles are an even tan or brown color,
but melanomas tend to have a variety of colors in them because they
actually reflect the biological processes going on as the body is
trying to fend off that cancer from developing, and also moles that
have irregular edges or sharp angles. Basically, any mole
that looks odd or funky, and I have just described the classic
signs of melanoma. You typically do not want to wait until your
lesion or your spot is ulcerated or bleeding because that is a more
advanced stage of melanoma. You want to get it at the first
sign that it is abnormal. I have been impressed over the past 20
years how well patients can identify lesions themselves, it is
really quite remarkable. People with no special knowledge or
background in medicine will come in for a full body skin
examination and I will go through it and not identify anything that
is of concern to me, but the patient will ask, "What about this
thing here?" And I will look at it again and it is not especially
concerning but I will say, what do you not like about it?
They will say, "I do not know, I just do not like it." We
train our residents at Yale that if this happens, that lesion comes
off. If the patient does not like a spot, even though the
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majority of the time it is benign, it comes off because there have
been enough occasions in my experience where patients identify
lesions that otherwise reflect nothing, but prove to be
problematic. It emphasizes the point that the doctor needs to
listen to the patient, but that can only happen if the patient
speaks up.
Miller
It is a good lesson for all parts of medicine, if people feel
something is not right with their body, it is important to tell the
doctor and to ask that it be looked into further, but especially in
the case of skin cancer. There was an article in the paper
several years ago about dogs that were trained to identify skin
cancer, is that truth or myth?
Leffell
Well, I have not seen followup scientific studies. My guess
is that because dogs have such a strong sense of smell, they may
have been keying into the smell of blood. Tumors have an
increased blood flow if they are ulcerating and bleeding, and that
becomes a unique spot on the person's body that the dog might horn
into, but I probably would not rely on the canine approach to
diagnosis. It is much better for you to learn your own body and if
you see a mole that bothers you, that is new, that you have not
seen before, or has changed, that is in anyway worrisome, pick up
the phone, call your dermatologist, and if they cannot get you in
soon enough ask for a reference to another one so you at least have
that spot evaluated.
Miller
If we put the canine approach to the side, which is probably a
good idea, how do you make the diagnosis of melanoma?
Leffell
Well it starts with the examination that I have described, and if I
see a mole that is of concern, that just does not fit into the
right pattern for a normal mole, then I discuss with the patient
what my concern is and recommend a biopsy. A biopsy, at least the
way we do at Yale Cancer Center, is a very simple procedure.
We simply numb up the area with a little injection of anesthetic
that takes literally just a few seconds, and then with a blade we
simply shave across the undersurface of the lesion to ensure that
we got it all and send it off to the pathologist. The whole
procedure takes just a couple of minutes and it allows us to
evaluate the lesion. In cases where there is a very large
spot that cannot be biopsied in that fashion we might take a little
punch biopsy that's like a little cookie cutter and take a small
sample of a larger area. Many years ago, there was concern,
as there was for many types of cancers, that if you cut into it you
could spread it, but there is not evidence that that is the case.
Most of the time when you "biopsy a melanoma" in the approach that
we do, and the approach we train our residents and fellows, the
biopsy itself removes a lesion and if it is a melanoma, an early
stage melanoma, we have to go back and perform some definitive skin
surgery.
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Miller
When the pathologist looks at that sample, what are some
other features that they are looking for that can help guide them,
what happens next with the patient?
Leffell
They are looking first to make the diagnosis of melanoma and to see
the abnormal pigment cells. Melanoma is a cancer of the pigment
cells, but the single most important thing that pathologist look to
identify is the depth or the thickness of the melanoma because
there is a huge amount of data which suggests that the thickness of
the melanoma is directly related to the prognosis. The vast
majority of early melanomas are up to 1 mm in depth and they have
better than 96% cure rate with simple office surgery. The
melanomas that go deeper than that, of course, can be more
problematic. By and large, patients do well with proper
treatment. The fact that there is a relationship between the
depth of the melanoma, how long it has been there in many cases and
the prognosis for the patient, highlights the importance of early
diagnosis and treatment.
Miller
After the patients have a biopsy and you have established the
diagnosis, what happens next?
Leffell
Well if it is a early stage melanoma, then an individual simply has
to have a re-excision with typically 1 cm margins, or third of an
inch, all around the growth, however, if it is a more advanced
melanoma, there is a procedure that is commonly done now by
surgical oncologists specially trained in the procedure. It is
called, sentinel lymph node mapping. With this procedure it allows
the surgeon to evaluate the lymph node chain to which the
particular melanoma might be draining. When that is done, you
can sample the lead lymph node, or the sentinel lymph node, and if
there is no cancer in it you know you do not have to take any more
lymph nodes and you also have some additional information about
prognosis. If there is already melanoma in that sentinel
lymph node then there is a decision made to remove the lymph nodes
and consider what kind of chemotherapy or other treatment might be
indicated.
Miller
You are very, very well known for Mohs surgery. One of the
e-mail questions we received was about that and the woman was
asking if it is something that would be useful for her husband who
was just diagnosed with melanoma?
Leffell
That is a great question. Mohs surgery is an office-based technique
for removing non-melanoma skin cancer, basal cell cancer, and
squamous cell cancer. The reason it works so well there is because
success in removing those cancers depends on removing all the
cancer cells and as little normal tissue as possible. The
procedure is done in the office by a specially
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trained dermatologist, and one is able to go ahead and do plastic
reconstruction if necessary at the same time, however, treatment
and cure of melanoma depends on taking that margin of safety I
talked about, so there is really no advantage to doing the Mohs
procedure. There is a form of melanoma that is increasing
that we did not mention, and that is called melanoma in situ. This
is actually the least serious form of melanoma because it is
non-invasive, it remains confined to the epidermis or the top layer
of the skin, and this is also removed surgically in the office, but
sometimes the edges are hard to see and you have to go back a
second time. Even for that we do not use the Mohs technique
because, in my opinion, looking at the tissue right away after it
has been frozen and stained is not as reliable as the permanent
section method where we actually embed the tissue in paraffin.
Miller
This question is based on things that I have heard people ask, are
melanomas always black?
Leffell
That is a myth. Melanomas can sometimes be variegated.
Horticulturalists among the listeners would know that word for
sure. They can have varying coloration. In addition,
there is an especially challenging type of melanoma called
amelanotic melanoma. In very fair individuals, melanoma can
develop that has no pigmentation and does not look like anything
special at all and dermatologists are always on the look out for
that and I find the patient's own sense of whether there is
something wrong can often be a good cue in that situation.
Miller
All right truth or myth, melanoma only develops in sun-exposed
areas.
Leffell
Myth. The reason for doing a full body skin examination is
because melanoma can occur where the sun does not shine, and I
think all dermatologists have seen melanomas in the groin area and
other sun protected areas such as the palms and soles. The
fact is that a certain percentage of melanomas are not related to
the sun. The result of genetic or familial tendency will
develop whether or not there is sun exposure.
Miller
Another question I've heard, can African Americans develop
melanoma?
Leffell
Absolutely, people with dark skin tend to develop melanoma on the
palms, soles or in the nails, and that is why careful examination
of those areas is so critical.
Miller
Let me ask you a little bit about multidisciplinary care for
people who have had melanoma. If someone had lets say, initial
surgery, they have had a wider excision and you do find a lymph
node involved, what
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progress has been made in that situation?
Leffell
There has been a great deal of progress, but it all begins with the
multidisciplinary approach that you are referring to. For the
earliest stage melanoma that is easily treated in the doctor's
office, it is important to have regular followup and regular exams,
but for the more advanced melanomas, presentation to a
multidisciplinary melanoma panel is important. At Yale Cancer
Center, we have had a melanoma panel shared by Dr. Stephen Ariyan
that goes back many, many years. It is an opportunity to bring
together a variety of specialists who can review the patient's case
and make recommendations about further treatment, studies that
might be helpful and how to best manage that particular case.
Miller
It sounds like a number of efforts are being made at Yale and
elsewhere to really harness the power of the immune system.
Leffell
It is interesting, melanoma is one of the few cancers that is
directly impacted by the immune system. I could go on for
hours talking about it, but all I will tell you is that when I
talked before about irregular pigmentation, one of those
colorations you see in melanoma is white, sometimes even red, and
that is a sign of regression of the melanoma being auto-digested by
the body's immune system. For some reason, melanoma is very
susceptible to immune function and immuno-biologists at Yale, and
elsewhere, are trying to figure out what the best approach is. It
is not uncommon to read about a new vaccine for melanoma in which
individuals are trying to harness the body's native, or actual
immune system, to fight off melanoma either by developing a vaccine
to a protein of the melanoma or the patient's own melanoma
cells.
Miller
Which is exciting. We learned a lot today about diagnosis
and about risk factors. I want to encourage people, even
though we are starting the fall season, it is still important to
wear sun block. David is that true?
Leffell
It is true. The sun continues to shine and the best approach
to sun protection is to make a daily habit of it. In that
way, you do not even have to think about it.
Miller
I want to thank Dr. David Leffell for joining us on Yale Cancer
Center Answers. Until next week, this is Dr. Ken Miller from the
Yale Cancer Center wishing you a safe and healthy week.
If you have questions, comments, or would like to subscribe to our podcast, go to www.yalecancercenter.org where you will also find transcripts of past broadcast in written form. Next week, we will examine the latest information on ovarian cancer. I am Bruce Barber and you are listening to the WNPR health forum from Connecticut Public Radio.
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