Title: Skin Cancer Prevention

Student Module 

Title: Skin Cancer Prevention 

Eugene Oh 

Student Module: 

Skin Cancer Prevention 

by Eugene Oh, MS-3 

I. Introduction 

Skin cancer is the most commonly diagnosed type of cancer and the 

6th most common cause of cancer death in the United States. The 

American Cancer Society reports skin cancer as the most common 

cancer in the United States, with over 1 million new cases 

diagnosed per year and accounting for over 10,000 deaths in the 

United States alone (1). Though some factors are uncontrollable in 

the pathogenesis of skin cancer (gender and skin tone), risk can be 

substantially decreased by behavior modifications such as the use 

of sun screens and skin cancer screening examinations. This 

requires education for clinicians and patients and programs to 

encourage the implementation of preventative measures. 

This module will review important features of three clinically 

important types of skin cancer: basal cell carcinoma, cutaneous 

squamous cell carcinoma and melanoma. I will first discuss clinical 

features and epidemiology of these three types of skin cancer and 

then discuss current recommendations for prevention. 

Basal cell and squamous cell carcinomas are the two most common 

forms of skin cancer, but both are easily treated if detected 

early. In comparison, malignant melanoma is relatively uncommon, 

accounting for only 4-5% of all skin cancers. However, melanoma 

causes of the greatest number of skin cancer-related deaths 

worldwide and is a major reason why skin cancers are the sixth 

leading cause of cancer death in the United States (2). 

II. Overview of Basal Cell Carcinoma: 

A. Clinical Features 

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Basal cell carcinoma is a nonmelanocytic skin cancer (ie, an 

epithelial tumor) that arises from basal cells, small round 

cells found in the lower layer of the epidermis. Many believe 

that basal cell carcinomas (BCCs) arise from pluripotential 

https://casemed.case.edu/onlineprevmedadmin/grading/printModule.aspx?acyear=1011&e... 

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cells in the basal layer of the epidermis or follicular 

structures, which can form hair, sebaceous glands, and apocrine 

glands. Basal cell skin cancer tumors typically appear on sunexposed 

skin, are slow growing, and rarely metastasize (< 0.1%) 

(2). 

Basal cell carcinomas have a typical body distribution: 70% on 

head (most frequently on face); 25% on trunk; and 5% on penis, 

vulva, or perianal skin (3). Basal cell carcinoma has a high 

frequency in older men who have a long history of unprotected 

exposure to ultraviolet (UV) light. 

IMAGES: 

Palmar pits BCC nevus syndrome 

Nodular basal cell CA 

Rodent ulcer of basal cell CA 

Superficial basal cell CA 

Sclerosing basal cell CA 

B. Prevalence and Incidence (2) 

Determining the true incidence and prevalence of Basal cell 

carcinoma (BCC) is difficult because health registries exclude 

nonmelanoma skin cancer from their databases. 

Basal cell carcinoma (BCC) is the most common cancer, with more 

than 1 million cases each year in the United States. 

BCC represents about 80% of all skin cancer cases. 

The age-adjusted incidence per 100,000 white individuals is 475 

cases in men and 250 cases in women. 

The estimated lifetime risk of BCC in the white population is 

33-39% in men and 23-28% in women. 

C. Risk factors 


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Race - BCC is observed in people of all races and skin types, 

but it is most often found in light-skinned individuals (type 1 

or type 2 skin); dark-skinned individuals are rarely affected. 

Type 1 skin - Very fair skin, red or blond hair, freckles, 

always burn, never tan 

Type 2 skin - Fair skin, burn easily, tan minimally 

Sex - Current male-to-female ratio is approximately 2.1:1. The 

higher incidence in men is thought to be due to historically 

increased recreational and occupational exposure to the 

sun. These differences may becoming less significant with 

changes in lifestyle. 

Age - The likelihood of developing basal cell carcinoma 

increases with age. With the exception of basal cell nevus 

syndrome, basal cell carcinoma is rarely found in patients 

younger than 40 years. Patients 50-80 years old are affected 

most often (average 55 years old); data suggests that damaging 

effects of the sun begin at an early age and the results may 

not appear for 20-30 years. 

D. Causes 

UV radiation: This is the most important and common cause of 

basal cell carcinoma (BCC). Both short-wavelength UV radiation 

(290-320 nm, sunburn rays) and longer wavelength UVA radiation 

(320-400 nm, tanning rays) contribute to the formation of BCC. 

In particular, chronic sun exposure appears to be important in 

the development of BCC. A latency period of 20-50 years is 

typical between the time of UV damage and the clinical onset of 

BCC. 

Other radiation: X-ray and grenz-ray exposure are associated 

with BCC formation. 

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Arsenic exposure: Chronic exposure to arsenic is associated 

with BCC development. Exposure may be medicinal, occupational, 

or dietary, where contaminated water supply is most commonly 

implicated. 

Immunosuppression: Immunosuppression is associated with a 

modest increase in the risk of BCC but a much greater increase 

in squamous cell carcinoma (3). 


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Xeroderma pigmentosum: This autosomal recessive disease 

predisposes people to rapid aging of exposed skin, starting 

with pigmentary changes and progressing to BCC, squamous cell 

carcinoma, and malignant melanoma. The effects are due to an 

inability to repair UV-induced DNA damage. Other features 

include corneal opacities, eventual blindness, and neurologic 

deficits. 

E. Morbidity and Mortality 

Basal cell carcinoma (BCC) can cause clinically significant 

morbidity if allowed to progress. Cosmetic disfigurement can 

occur because BCC most commonly affects the head and neck. Loss 

of vision or the eye may occur with orbital 

involvement. Perineural spread can result in loss of nerve 

function and in deep and extensive invasion of the tumor 

(4). Lesions are often friable and prone to ulceration, thus, 

providing a site for infection. Death from BCC is extremely 

rare. 

F. Diagnosis 

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History - Patients often report a slowly enlarging lesion that 

does not heal and that bleeds when traumatized. Because BCC 

most commonly occurs on the face, patients often give a history 

of an acne bump that occasionally bleeds (3). People who 

sunburn are more likely to develop skin cancer than those who 

do not; however, sunlight damages the skin with or without 

sunburn (5). Patients will often have a history of chronic sun 

exposure: recreational (sunbathing, outdoor sports, fishing, 

boating) or occupational sun exposure (farming, construction). 

Physical - Basal cell carcinoma occurs mostly on the face, head 

(scalp included), neck, and hands and it rarely develops on the 

palms and soles. Basal cell carcinoma usually appears as a 

flat, firm, pale area that is small, raised, pink or red, 

translucent, shiny, and waxy, and the area may bleed following 

minor injury (4). Basal cell carcinomas may have one or more 

visible and irregular blood vessels, an ulcerative area in the 

center that often is pigmented, and black-blue or brown areas. 

Large basal cell carcinomas may have oozing or crusted areas. 

The lesion grows slowly, is not painful, and does not itch. 


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Procedures - Skin biopsy (usually shave biopsy) is often 

required to confirm the diagnosis and determine the histologic 

subtype (3). Skin biopsy is often curative. However, in the 

case of a pigmented lesion where there may be difficulty 

distinguishing between pigmented basal cell carcinoma and 

melanoma, an excisional or punch biopsy may be indicated. BCCs 

are rarely staged. 

III. Overview of Cutaneous Squamous Cell Carcinoma 

A. Pathogenesis and clinical features 

Squamous cell carcinoma (SCC) is a malignant tumor of epidermal 

keratinocytes. Some cases of squamous cell carcinoma occur de 

novo, while others arise from precancerous lesions induced by 

sun exposure called actinic keratosis. SCC is capable of 

locally infiltrative growth, spread to regional lymph nodes, 

and distant metastasis (most often to the lungs). 

SCC typically manifests as a new or enlarging lesion that 

concerns the patient. Squamous cell carcinoma usually is a slow 

-growing malignancy, but some lesions enlarge rapidly. Although 

most SCC patients are asymptomatic, symptoms such as bleeding, 

weeping, pain, or tenderness at the site may occur. Peri-neural 

spread may further cause numbness, tingling, or muscle 

weakness. 

IMAGES: 

Actinic keratosis 

Well differentiated SCC 

Well differentiated SCC 

B. Frequency 

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Determining the true incidence and prevalence of squamous cell 

carcinoma (SCC) is difficult because health registries exclude 

nonmelanoma skin cancer from their databases. This is primarly 

due to the high number of cases large regional variation in the 

rates of SCC. 


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In 1994, the annual incidence in the United States ranged from 

81-136 cases per 100,000 population for men and 26-59 cases per 

100,000 population for women (6). 

Studies show an increase in the incidence of cutaneous squamous 

cell carcinoma over the past several decades. For instance, the 

annual age-adjusted incidence rates of squamous cell carcinoma 

per 100,000 women rose from 47 cases from 1984-1986 to 100 

cases in 1990-1992 in Rochester, MN (7). During the same time 

frame, SCC in men increased from 126 cases to 191 cases per 

100,000 population (7). 

The rising incidence of squamous cell carcinoma may be a result 

of an increase in sun exposure. This may be exacerbated by 

ozone depletion that intensifies UV exposure and the advancing 

age of the United States population. 

C. Risk factors (2,8,9) 

Race and skin tone - Squamous cell carcinoma (SCC) is the 

second leading cause of skin cancer in whites. While melanoma 

is uncommon in African Americans, Latinos, and Asians, it is 

frequently fatal for these populations. People with light skin; 

skin that sunburns easily; blonde or light brown hair; and/or 

green, blue, or gray eyes have the high risk for SCC. 

Sex - SCC occurs in men 2-3 times more frequently than it does 

in women presumably because of greater cumulative lifetime UV 

exposure. 

Age - The typical age at presentation for squamous cell 

carcinoma (SCC) is approximately 70 years. 

Geography - greater incedence of SCC in regions closer to the 

equator due to increased sun exposure 

History of prior nonmelanoma skin cancer 

Exposure to carcinogens - chemical (arsenic, tar) and ionizing 

radiation (medical treatments, occupational or accidental 

radiation exposure 

Chronic immunosuppression 

Chronic scarring condition 


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Human papilloma virus (HPV) infection (specific subtypes) 

D. Causes and precursor lesions 

Actinically-derived squamous cell carcinoma - The most common 

type of squamous cell carcinoma is the sun-induced 

type. Actinic SCC is correlated with multiple blistering 

sunburns during their lifetime, indoor tanning beds use, 

therapeutic UV light exposure such as the psoriasis treatment, 

psoralen with UVA (9). \ 

Actinic keratosis - Actinic keratosis (AK) is a UV light– 

induced lesion of the skin that may progress to invasive 

SCC. An AK will either regress, persist unchanged, progress to 

invasive squamous cell carcinoma. Progression to SCC has been 

estimated to be as high as 10%. Incidence of AK is clearly 

linked to sun exposure. For example, in Australia, the country 

with the highest skin cancer rate, the prevalence of AK among 

adults older than 40 years has been estimate to be 40-60% (10). 

Immune suppression - History chronic immune suppression 

predisposes to SCC. Examples include history of solid-organ 

transplantation, leukemia, HIV infection, or long-term use of 

immunosuppressive medications. 

Marjolin ulcer - SCC can arises from chronically scarred or 

inflamed skin. Malignant transformation of Marjolin ulcers to 

basal cell carcinoma, melanoma, or SCC may also occur with an 

average latency period of 35 years (11,12). Marjolin ulcers are 

associated with a high rate of metastasis and mortality, 

estimated at 30% and 33%., respectively. (12,13) 

HPV-associated squamous cell carcinoma (2) - SCC induced by 

viral infection commonly presents as a warty growth on the 

penis, vulva, perianal, or periungual areas. A history of 

previously documented genital HPV infection may be elicited. 


Most squamous cell carcinomas (SCCs) are readily treated and 

produce few lasting sequelae. 

Page 7 of 21 

A subset of high-risk lesions causes most of the morbidity and 

the mortality associated with squamous cell carcinoma. Such 


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lesions may cause extensive destruction of tissue, and may 

cause substantial cosmetic deformity. 

The overall risk of metastasis for squamous cell carcinoma is 

in the range of 2-6%; however, rates as high as 47% have been 

reported for cases with extensive perineural invasion (2). 

Lymph node metastasis is associated with significant morbidity; 

however, 5-year survival rates as high as 73% have been 

achieved with the combination of surgical lymphadenectomy and 

radiation therapy (14). 

Once lung metastasis occurs, the disease is incurable. 

F. Diagnosis 

Page 8 of 21 

Most squamous cell carcinomas are discovered by patients and 

are brought to a physician's attention by the patient or a 

relative. The diagnosis of SCC is often suggested based on 

clinical findings, but a skin biopsy is required for definitive 

diagnosis. A shave biopsy, punch biopsy, incisional biopsy, or 

excisional biopsy may be used. Depending on the clinical 

presentation, nodal staging may be considered. The 5-year 

survival rate of patients with nodal metastasis is as high as 

73% with aggressive treatment, while metastasis to distant 

organs remains incurable (14). Therefore, early detection of 

nodal metastasis may prove more beneficial in SCC. 

Physical examination of lymph nodes - Draining lymph node 

basins should be palpated. If nodes are palpable, a biopsy 

should be performed using fine-needle aspiration (FNA) or 

excision. Subsequently, management currently varies with regard 

to further staging (15). 

Radiologic staging - Imaging should be performed in patients 

with regional lymphadenopathy and/or neurologic symptoms; for 

nodal staging; and for preoperative planning when deep or 

extensive tissue involvement is suspected. Currently, the 

utility of radiologic imaging has not been proven for staging 

cutaneous squamous cell carcinoma with the exception of MRI and 

CT scanning in patients with peri-neurally invasive SCC (16). 

Sentinel lymph node biopsy - Sentinel lymph node biopsy (SLNB) 

can detect many cases of subclinical nodal metastasis. However, 

the sensitivity of SLNB in comparison to other diagnositc 

modalities is unknown (17). 


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High-risk squamous cell carcinoma 

A subset of SCC is considered high risk because they are 

associated with higher rates of recurrence, metastasis, and 

death. Squamous cell carcinoma can be characterized as highrisk 

by virtue of tumor-related factors (intrinsic factors), 

patient-related factors (extrinsic factors), or a combination 

of both (9). 

Tumor-related factors in high-risk squamous cell carcinoma 

a) location (lips, ears, anogenital, within a scar or 

chronic wound) 

b) size greater than 2 cm (or 1.5 cm on ear or lip) 

c) invasion to subcutaneous fat (or deeper) 

d) poorly differentiated tumor cells 

e) recurrent tumor 

f) perineural involvement 

Patient-related factors in high-risk squamous cell 

carcinoma 

a) organ transplant recipient 

b) hematologic malignancy (chronic lymphocytic leukemia) 

c) long-term immunosuppressive therapy 

d) HIV infection or AIDS. 

G. Prognosis 

Most squamous cell carcinomas (SCCs) are readily treated with 

an expectation of cure. The rate of metastases to lymph node 

and beyond for primary tumors is 2-6% (8). To date, there are 

no prognostic models for SCC. High risk squamous cell 

carcinomas carry an elevated risk of local recurrence, nodal or 

distant metastasis (usually to the lungs), and death. 

Overall 3-year survival rate for SCC is estimated to be 85%. 

Page 9 of 21 

Survival rates approach 100% for lesions with no high-risk 

factors, but decreases to 30% for patients with at least 1 high 

-risk factor (8). 

Once nodal metastasis of cutaneous squamous cell carcinoma has 

occurred, the overall 5-year survival rate has historically 

been in the range of 25-35%. 


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Combined use of surgery and adjuvant radiotherapy for patients 

with nodal metastasis increased the 5-year disease-specific 

survival rate to 73% (14). 

Metastasis to distant organs remains incurable. 

IV. Overview of Malignant Melanoma 

A. Pathophysiology and Clinical Features 

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Molecular events underlying the process in which normal 

melanocytes transform into melanoma cells is poorly understood. 

It probably involves progressive genetic mutations that alter 

cell proliferation, differentiation, and death and impact 

susceptibility to the carcinogenic effects of ultraviolet 

radiation. (18) 

The most common warning signs for melanoma are new or changing 

mole or blemish. Variation in color and/or an increase in 

diameter, height, or asymmetry of borders of a pigmented lesion 

are noted by more than 80% of patients with melanoma at the 

time of diagnosis. These other symptoms are less common: 

bleeding, itching, ulceration, and pain in a pigmented lesion 

but warrant an evaluation (19). 

There may be divergent pathways of melanoma pathogenesis 

evident by distinct clinical presentations. Melanomas in sunprotected 

skin (trunk) more often develop in association with a 

high nevus count and intermittent ultraviolet radiation in 

contrast to low nevus counts and chronic sun exposure in 

patients developing melanoma on sun-exposed skin (20,21). 

The ABCDEs criteria have the greatest diagnostic accuracy when 

used in combination. They are (22,23): 

1. Asymmetry: Half the lesion does not match the other half. 

2. Border irregularity: The edges are ragged, notched, or 

blurred. 

3. Color variegation: Pigmentation is not uniform and may 

display shades of tan, brown, or black; white, reddish, or blue 

discoloration is of particular concern. 

4. Diameter: A diameter greater than 6 mm is characteristic, 

although any growth in a nevus warrants an evaluation. 

5. Evolving: Changes in the lesion over time 


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IMAGES: 

Superficial spreading melanoma 

Lentigo maligna melanoma 

Acral lentiginous melanoma 

Nodular melanoma 

B. Prevalence and Incidence 

The incidence of melanoma has more than tripled in the white 

population during the last 20 years, and melanoma currently is 

the sixth most common cancer in the United States. 

Approximately 68,720 Americans (39,080 men and 29,640 women) 

developed invasive cutaneous melanoma in 2009, with an 

estimated additional 53,120 or more cases of melanoma in situ. 

(24) 

The current lifetime risk for developing invasive melanoma is 1 

case per 60 Americans, a twenty-fold increase since 1930. This 

risk rises to 1 case per 32 Americans if noninvasive melanoma 

in situ is included. 

The incidence of melanoma increases by 5-7% yearly, an annual 

increase second only to lung cancer in women. While the 

lifetime risk of developing melanoma in 1935 was only 1 per 

1500, the lifetime risk in 2000 was estimated at 1 per 75. 

American Cancer Society - Cancer Facts & Figures 

C. Risk factors 

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Race - Melanoma is primarily a malignancy of white individuals. 

African American persons develop melanoma approximately one 

twentieth as frequently as white persons, and the prevalence in 

Hispanic persons is approximately one sixth of that in white 

persons. However, mortality rates are higher in African 

Americans and Hispanics, who are more likely to have acral 

melanoma and advanced disease at presentation (25). 

Sex - In the United States, invasive melanoma has a higher 

female predilection from birth to age 39 years (1 in 370 women 

compared with 1 in 645 men). However, from age 40 years and 


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older, melanoma in men predominates, occurring in 1 in 39 men 

compared with 1 in 58 women over a lifetime (24). 

Age - The median age at melanoma diagnosis is 53 

years. However, melanoma is the most common cancer in women 25- 

29 years of age and is second only to breast cancer in women 

aged 30-34 years (25). Older individuals are more likely to 

acquire and to die from melanoma. Therefore, elderly persons 

should be a primary target for secondary melanoma prevention, 

including early detection and screening (19). 

D. Precursor lesions (8,19,22) 

Forty percent of primary cutaneous melanoma may develop in 

precursor melanocytic nevi (moles) 

1. common 

2. congenital 

3. atypical/dysplastic types (highest risk) 

The remaining 60% of cases are believed to arise de novo 

(not from a preexisting pigmented lesion). 


While melanoma accounts for roughly 4% of all skin cancers, it 

is responsible for more than 74% of skin cancer deaths. In the 

United States, one person each hour dies from metastatic 

melanoma. Treatment of melanoma in its early stages provides 

the best opportunity for cure. 

In the United States, an estimated 8650 deaths occurred in 2009 

(5550 men and 3100 women) (24). 

Analysis of US Surveillance, Epidemiology, and End Results 

(SEER) data from 1969-1999 has demonstrated a disproportionate 

burden of melanoma deaths among middle-aged and older white men 

(25). 

Incidence data generally parallel mortality data and have shown 

a 3-fold increase in middle-aged men and a 5-fold increase in 

older men over a similar period. 

F. Diagnosis 


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Clinicians should have a high suspicion for melanoma because of 

poor outcomes related to incorrect or delayed diagnosis. The 

most important aspects of the initial workup are a careful 

history, review of systems, and physical examination. National 

Comprehensive Cancer Network (NCCN) support the concept that 

most melanoma recurrences are diagnosed clinically. The current 

guidelines state that no further workup (ie, baseline 

laboratory tests and imaging studies) is required in stage 0 

(melanoma in situ) and for asymptomatic patients with stage IA, 

IB, or IIA melanoma. However, for more advanced lesions, 

imaging techniques to assess metastasis and lymph node 

involvement can be used. Histopathologic examination remains 

the criterion standard for diagnosis of clinically suggestive 

lesions. 

Biopsy - Complete excisional biopsy of the lesion is preferred 

and should include a 1-2 mm margin of healthy skin. If the 

suggestive lesion is large or present in a cosmetically 

sensitive area, an incisional or punch biopsy may be 

appropriate. 

Staging - Melanoma staging is critical for diagnosis, 

determining prognosis and selecting appropriate treatment 

option. Cancer staging is based on the TNM criteria (tumor 

characteristics, nodal involvement and metastasis) (23). 

For more details on the staging system see: 

AJCC Collaborative Melanoma Staging System 

G. Prognosis 

Prognosis of a melanoma lesion can be predicted based on the 

following: the depth of invasion, presence or absence of 

ulceration and to nodal status at diagnosis. Survival varies 

widely based on stage of diagnosis and treatment: 

1. Patents with stage I disease have a 5-year survival rate 

greater than 90%. 

Page 13 of 21 

2. Patients with stage II disease have a 5-year survival rate 

ranging from 45-77%. 

3. Patients with stage III disease have a 5-year survival rate 

ranging from 27-70%. 


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4. Patients with metastatic disease have a grim prognosis, with 

a 5-year survival rate of less than 20%. 

V. Cost Burden of Skin Cancers 

A. In 2004, the economic burden for excess UV exposure in the 

United States was estimated at $6-7 billion (26). 

B. In 2004, the total direct cost associated with the treatment for 

non-melanoma skin cancer was $1.5 billion (27). 

C. The estimated annual charge of treating melanoma in the 

population 65 years or older is $390 million with a per-patient 

lifetime costs of $28,210 from the time of diagnosis to the time of 

death (28). 

D. In 1997, The annual direct cost of treating newly diagnosed 

melanoma in 1997 was estimated to be $563 million (29). 

VI. Skin Cancer Prevention Programs Available 

National Council on Skin Cancer Prevention 

Skin Cancer Foundation 

American Cancer Society 

American Academy of Dermatology 

Environmental Protection Agency 

National Cancer Institute 

VII. Primary Prevention 

Many of the more than 1 million cases of skin cancer estimated to 

be diagnoses in 2010 could have been prevented by limiting sun 

exposure and use of tanning beds. Two-thirds of all melanomas may 

be attributable to excessive UV exposure (2). 

A. Limit sun exposure 


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Avoid direct exposure to the sun between the hours of 10 A.M. 

to 4 P.M. when UV rays are the most intense. 

Avoid sun burns. One blistering sunburn in childhood or 

adolescence more than doubles the chances of developing 

melanoma later in life, and melanoma risk doubles with five or 

more sunburns at any age (30). 

B. Use sun screens 

American Academy of Dermatology recommends year-round 

application of broad spectrum sunscreen with SPF 30 or higher 

to all areas of the body exposed to the sun. Daily sunscreen 

use has been shown to reduce the incidence of squamous cell 

carcinoma (31). Although sunscreen lotions may inhibit the 

synthesis of vitamin D, their use still allows adequate vitamin 

D levels to be achieved since they block most, but not all 

sunlight (32). Furthermore, increased oral intake has been 

proposed, decreasing the overall risk of vitamin D deficiency 

(5). Current recommendations regarding sun screens are: 

1. Wear hats with a wide brim enough to shade face, ears and 

neck 

2. Wear clothing that adequately covers the arms, legs and 

torso 

3. Cover exposed skin with sunscreen lotion with SPF of 30 or 

higher 

C. Avoidance of other sources of UV radiations (tanning beds) 

1. For melanoma sharp increase in incidence were noted in 

Iceland that appeared to lag a few years behind the increased 

prevalence of sunbeds (33,34). 

2. The U.S. Department of Health and Human Services has 

categorized Ultraviolet radiation (UVR) is a proven human 

carcinogen. 

Page 15 of 21 

3. Frequent tanners using new high-pressure sunlamps may 

receive as much as 12 times the annual UVA dose compared to the 

dose they receive from sun exposure (35). 

4. Nearly 30 million people tan indoors in the U.S. every year; 

2.3 million of them are teens (36,37). 


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5. On an average day, more than one million Americans use 

tanning salons. 

6. Seventy one percent of tanning salon patrons are girls and 

women aged 16-29 (38). 

7. First exposure to tanning beds in youth increases melanoma 

risk by 75 percent. 

8. People who use tanning beds are 2.5 times more likely to 

develop squamous cell carcinoma and 1.5 times more likely to 

develop basal cell carcinoma. 

9. The indoor tanning industry has an annual estimated revenue 

of $5 billion (37). 

D. Chemoprevention (18,19) 

In immunosuppressed patients or immunocompetent patients with 

history of squamous cell carcinoma (high risk group), 

administration of systemic retinoids reduces the number of new 

SCC. Low doses are often sufficient for prophylaxis. However, 

treatment must be continued indefinitely because a relapse in 

tumor development occurs following discontinuation of oral 

retinoids. Adverse effects of systemic retinoids include 

mucocutaneous xerosis, dyslipidemia, liver function 

abnormalities, and teratogenicity. 

E. Smoking cessation 

F. Limit exposure of other carcinogens associated with skin 

cancer 

VIII. Secondary Prevention 

Skin cancers are especially amenable to screening examinations 

since the lesions are externally visible. 

A. Risk assessment (39) 

1. Family history of skin cancer 


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2. Considerable history of sun exposure and sun burn 

B. Identifying groups at increased risk for melanoma 

1. Fair-skinned mean and women older than 65 

2. patients with atypical nevi (moles) 

3. patients with more than 50 moles 

C. Self-examination (40) 

1. American Cancer Society recommends monthly head-to-toe self 

examinations of the skin. 

2. Most patients do not follow all recommendations for self 

screening. 

3. Patients should get to know their moles and track changes 

over time. 

4. Particular attention should be paid to the skin on the back 

D. Clinical detection 

The American Cancer Society recommends that adults old get at 

least a baseline total body skin examination. It also endorses 

skin cancer-related checkups and counseling about sun exposure 

as part of any periodic health examination for men and women 

beginning at age 20. Clinicians should pay close attention to 

the A, B, C, D, Es of melanoma recognition (22): 

1. Assymmetry 

2. Border irregularities 

3. Color variegation (i.e. different colors within a same 

region) 

4. Diameter > 6 mm 

5. Enlargement or evolution of color change, shape, symptoms 

E. Genetic screening 

Genetic mutations in the genes CDKN2A and CDK4 have been 

identified in melanoma-prone families (41). However, screening 

for these mutations in the general population is not 

recommended. 

F. Removal of precursor lesions 


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Removal of actinic keratoses and in situ squamous cell 

carcinoma may prevent the future development of invasive 

squamous cell carcinoma, and removal of suspicious or 

dysplastic nevi may prevent progression to malignant melanoma 

(9,15). 

IX. Tertiary prevention 

A. Appropriate Diagnosis and Treatment of initial lesion(s) 

1. Importance of determining lesion type and grade 

2. Appropriate choice of treatment based on grade of tumor 

(particularly important for malignant melanoma) 

B. Patient education about continued avoidance of UV exposure: 

1. Sun-protective measures (including sun-protective clothing 

and sunscreens) 

2. Skin self-examinations for new primary melanoma 

C. Skin self-examinations for new primary melanoma 

1. Warn about possible recurrence within the melanoma scar. 

D. Regular total body skin clinical examinations 

1. All cancer organizations endorse skin cancer-related 

checkups in patients with history of melanoma. 

E. Genetic screening (21,41) 

1. Indicated if multiple family members are affected or if 

clinical presentation is suggestive of heritable cancer 

syndrome 

2. Screening of first-degree relatives, particularly if they 

have a history of atypical moles 

X. Key Findings 


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A. Skin cancer is the most common type of cancer in the United 

states and the sixth overall cause of cancer death. Current 

estimates are that one in five Americans will develop skin cancer. 

B. Basal cell carcinoma is the most common skin cancer 

C. Squamous cell carcinoma is a slow growing cancer with a low rate 

of metastasis, except in a subset of high-risk SCC. 

D. Melanoma accounts for 4-5% of all skin cancers, but 75% of all 

skin cancer deaths. 

E. In general, the ABCDEs are important tool for identification of 

cancerous lesions. 

F. Virtually all skin cancers are exacerbated and in part caused by 

exposure to UV radiation. 

G. Excessive sun exposure and indoor tanning are preventable 

sources of carcinogenic risk. 

XI. References 

Page 19 of 21 

1. Jemal, A., Siegel, R., Xu, J., and Ward, E. (2010) CA Cancer 

J Clin 60, 277-300 

2. Geller, A. C., and Annas, G. D. (2003) Semin Oncol Nurs 19, 2 

-11 

3. Akinci, M., Aslan, S., Markoc, F., Cetin, B., and Cetin, A. 

(2008) Acta Chir Belg 108, 269-272 

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