June 20, 2017

Skin cancer rates, and treatment options, grow

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Skin cancer diagnosis and treatment options are growing in Central Massachusetts.
The number of U.S. melanoma diagnoses have more than tripled since the mid-1970s, but deaths have stayed roughly flat as detection and treatment have improved.

Here's the bad news: skin cancer diagnoses are on the rise. In particular, new cases of melanoma of the skin—the most dangerous sort of skin cancer—more than tripled between 1975 and 2014, according to the National Cancer Institute.

"Unfortunately, (rates are) still increasing in spite of the fact that we do more screening and we always talk about sun protection and really work on that," said Dr. Mary Maloney, director of dermatologic surgery and professor of dermatology at UMass Medical School in Worcester.

Maloney said there are a number of reasons that's true. First, baby boomers are getting older, which means a larger part of the population is at greater risk for all sorts of cancers every year. Also, increased leisure time and damage to the ozone layer means many of us have spent more time hanging out in the sun while sunlight has gotten more dangerous. And rising rates of skin cancer among young people—particularly women—suggest tanning beds have also contributed significantly to the problem.

Now, here's the good news. Doctors are finding cancers earlier, and developing increasingly effective ways to treat them.

There are a number of different skin cancers, but the most important distinction is between melanoma and everything else. The non-melanoma diseases—including basal cell and squamous cell cancers—are by far the most common and much less dangerous. They only rarely spread to other parts of the body, and doctors can usually remove them safely.

But that doesn't mean it's a pleasant process. Even if the tumor is small, cutting it away can leave painful scars. To make this easier on patients, some hospitals use a process known as Mohs surgery. Last year, HealthAlliance Hospital in Leominster built a new clinic so that patients from North Central Massachusetts, who would otherwise have to travel to UMass Memorial Medical Center in Worcester to get Mohs surgery, could be seen locally.

"The Worcester campus was seeing a high volume trend of patients that would have to wait to be seen because of the long waitlist," said Geri Tusalem, senior director of perioperative services at HealthAlliance, who oversees the Mohs surgery clinic.

Tusalem said some older patients in particular didn't like traveling, and many people prefer to stay in the hospital where they see their dermatologist and primary care physician.

Mohs surgery involves slicing one tiny layer at a time from a tumor. After each slice, the surgeon examines the tissue under a microscope to see if it contains cancer cells. Then, they can stop as soon as they get to healthy skin rather than risk cutting too deep. That's especially important when a tumor is on a visible spot where patients want to avoid scarring, or in areas like the tip of the nose or ear where there's not much extra skin to close up the wound, Tusalem said.

Because of the need to look at each slice of tissue, the surgery can take one to five hours, depending on how deep the tumor goes. Fortunately, rather than having to stay in a standard operating room, the clinic lets patients spend that time in a Tempur-Pedic chair, with a television available.

Amid new treatments, advanced melanoma declines

Melanoma is a more serious matter than other skin cancers, but there's good news there as well. Dr. Kala Seetharaman, medical director for hematology and oncology at MetroWest Medical Center in Framingham, said that in most cases a biopsy is able to remove the entire tumor. After that, patients need to be extra careful to keep an eye on their skin.

"If they have one legion, they're at risk for another one," Seetharaman said.

She said that if there's even a small chance the cancer could have spread to a patient's lymph nodes, doctors will sample them too. In cases where the skin tumor is particularly thick or where the cancer has spread, Seetharaman said doctors will recommend further treatment.

It's only when a cancer has spread, making it a stage 4 disease, that medical oncologists like Seetharaman need to get involved. And she said that today fewer people end up in that position now than 10 years ago, thanks to increased public awareness. She now sees only five to 10 patients a year, she said.

"People are more aware of the skin lesions," she said. "More tools are available to identify the lesions."

And even for those who do end up with a melanoma that has spread, there are new options that weren't available just a few years ago. Seetharaman explained that melanoma can hijack the immune system's "checkpoints," which tell the body whether or not to attack a disease.

"That's how the cells keep growing and spread to the brain or liver," she said.

But immunotherapy drugs developed in recent years can retrain the immune system to recognize and attack melanoma.

David Shepro, medical director of the cancer program at Saint Vincent Hospital in Worcester, said trials have shown these drugs can have a big impact. In one case, 50 percent of patients who received immunotherapy treatment were alive after five years, compared with 30 percent of those who got a placebo.

"That's really quite a big difference in the world we live in," he said. "That's 20 [additional] people out of 100 that are alive at five years."

But Shepro said the drugs aren't right for everyone. Messing with the immune system can have serious side-effects, like causing the body to attack its own liver or lung. Drug trials generally enroll patients who are otherwise healthy, but, in the real world, people with additional health problems may not be able to tolerate the new drugs.

Financial concerns

For all the good news about skin cancer, there's still plenty of progress to make.

One important issue with the new drugs is their cost. A single therapy may run up to $120,000 a year, Shepro said, and some patients need to use two drugs at once. Some patients with high-deductible insurance plans, or plans that require them to pay a percentage of their total cost of treatment, simply don't have the money. A social worker and financial counselor try to help patients get support from private foundations or funds created by the pharmaceutical industry, but it's not easy.

"This is an everyday occurrence, struggling with these kinds of things," he said.

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