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Skin Cancer Prevention with North Shore LIJ Medical Center

Dr. Green discusses Skin Cancer Prevention with Medical Update

Hi. Welcome to Medical Update. I’m your host, Dr. Mike Rosen. In 2010, the National Cancer Institute announced that almost 70 thousand new melanoma cases were diagnosed in the US, and almost 9,000 people died from the disease. While melanoma is the least common form of skin cancer, it is considered the most serious and the most deadly. With us to discuss the ways to prevent skin cancer is Dr. Michele Green, a top dermatologist at Lenox Hill Hospital in Manhattan. Welcome to Medical Update.

Dr. Michele Green: Hi. Thank you for having me.

Dr. Mike Rosen: You know, this is a little depressing because I love the sun, and cases are on the rise, and is this sort of the message, that we should just be hiding from the sun completely?

Dr. Michele Green: Well, you don’t have to hide completely from the sun, but you should protect yourself during the key hours in the sun, meaning from 10:00 in the morning till 4:00 in the afternoon you should try your best.

Dr. Mike Rosen: Which is only like the whole day?

Dr. Michele Green: Well, you should try your best to wear a hat, and good UVA and UVB protection, and to really protect yourself well against the dangers of the sun.

Dr. Mike Rosen: So, it’s not just a matter of if you’re laying out, if you’re going out, if you’re going to work, if you are walking in the park?

Dr. Michele Green: That’s right.

Dr. Mike Rosen: You’re saying we should be really acting as if we’re at the beach?

Dr. Michele Green: That’s right. All day long you’re exposed to UVA and UVB rays, and they both can cause skin cancer.

Dr. Mike Rosen: I have to confess. I don’t carry around sunscreen in my briefcase, or in my pocket, and if I’m going out to the ballgame for the day, I don’t put sunscreen on. What percentage of people really do that?

Dr. Michele Green: I think a fair number now are starting to use sunscreen. I tell patients the way you brush your teeth in the morning, after you brush your teeth, put sunscreen on. It’s that simple. You know if you’re going to be out for extended period of time, you should be wearing a hat at the ball game, not just sunscreen.

Dr. Mike Rosen: Why do you wear a hat? Is to cover the face, or is it to cover the skin on the head, or both?

Dr. Michele Green: Both. The face and the areas that are really exposed most to the sun, meaning your face, your scalp, your arms, your hand, are the most common areas that people get skin cancer, so those are the key areas to protect. So, a hat will protect your face. The nose on your face is the most common area of the face to get a skin cancer because it’s sticking out, and it’s getting exposed most to the sun.

Dr. Mike Rosen: So, when you see all the people at the beach?

Dr. Michele Green: I cringe.

Dr. Mike Rosen: Do you?

Dr. Michele Green: I cringe when I see people laying out and frying. Some people probably aren’t even wearing any sun protection. If they put on an SPF 6, I consider that no sun protection, and they’re lying out and they’re baking. They’re frying, and I cringe because I know what lies in their future.

Dr. Mike Rosen: You really think that these people, as they move on in life, at very least, they’re going to get wrinkled, but you’re worried about their health?

Dr. Michele Green: Absolutely. The studies show that just one sunburn alone increases your risk for melanoma by 50%. That’s just one sunburn, so just do the math. If you’ve had 20 sunburns, you’re at a much higher risk, and now the statistics show that every 62 minutes, that’s almost once an hour, there’s a new patient dying of melanoma.

Dr. Mike Rosen: But in terms of prevention, and you’re talking about sunscreen, really what should we be doing? You talked about wearing a hat.

Dr. Michele Green: Right. Wearing a hat.

Dr. Mike Rosen: Covering yourself in armor. But if you don’t cover yourself in armor?

Dr. Michele Green: Staying out during those key hours of the day, and putting on at least one ounce of sunscreen 30 minutes before you go outside. What people don’t understand is they put a little bit of sunscreen on and they think that’s sufficient. You have to use one fluid ounce. That’s a lot of sunscreen.

Dr. Mike Rosen: It’s expensive stuff.

Dr. Michele Green: Well, it’s a lot less expensive than getting skin cancer.

Dr. Mike Rosen: Does it matter which brand? Does it matter? What should we be looking for on the labels?

Dr. Michele Green: Okay. I think that’s a great question. I don’t think the brand is as important as what the new labels. There are new FDA regulations coming down in the spring, and what will happen is there won’t be as much confusion as there is now. The labels will say … The maximum will be SPF 50 on any given label, and it will also say whether or not it protects against UVA and UVB. In order for a new sunscreen to say that it has broad spectrum protection, it has to have a higher number than SPF 15, and also be able to show that it protects against UVA and UVB radiation.

Dr. Mike Rosen: The American Academy of Dermatology formerly has recommended really SPF of 15 is the number. So, what you’re saying is 50 is?

Dr. Michele Green: 50 is the maximum that will be allowed to be printed on any tube. 15 is probably the lowest number that’s considered acceptable. In other words, numbers like six, and seven, or eight, won’t be allowed to say that they protect you against skin cancer. Won’t be able to say that they protect you against wrinkles, or photo-aging because they don’t.

Dr. Mike Rosen: But there’s not really much of a difference between the 15 and 50, because there’s a curve, and you sort of get up to the top of the curve, and the amount that you get from a 15 to a 50 is …

Dr. Michele Green: Well you know, but they’ll show on the sunscreen and stuff how long your sunscreen is going to last for. I think that’s going to be the most important thing. They’re going to tell you on the actual tube if it will last for 20 minutes, an hour, and when you have to reapply it, and I think that’s really important information because people make the mistake commonly. They put on the sunscreen and they go out, and then they think they don’t have to reapply it, and it’s really important to reapply it. I think people are lulled into a false sense of security that they put on the sunscreen once during the day, or maybe even twice, and they think oh they’re all set. But now if the tube actually says you need to reapply it after 40 minutes, I think people’s understanding of how long the sunscreen really lasts will will be much clearer to people.

Dr. Mike Rosen: It actually gets broken down in the skin.

Dr. Michele Green: That’s right.

Dr. Mike Rosen: So it becomes less effective?

Dr. Michele Green: That’s right.

Dr. Mike Rosen: And if you get wet?

Dr. Michele Green: If you get wet, it comes off.

Dr. Mike Rosen: Isn’t it rubbed into the skin?

Dr. Michele Green: And rubbed right off in the water. What’s really a great thing that the FDA regulations are going to show is that the new sunscreens will say water resistant only. They’re not going to be able to say sweat-proof, waterproof, because there is no such thing as waterproof. There is no such thing as sweat-proof, and the new water resistant sunscreen will only have two times, 40 minutes and 80 minutes. That’s the maximum that a sunscreen will last on you.

Dr. Mike Rosen: What if you’re a person who does sweat? Especially if you’re laying in the hot sun, you’re sweating.

Dr. Michele Green: That’s right. You’re going to have to reapply it for it to be effective.

Dr. Mike Rosen: Can you reapply it on sweaty skin? I mean, I’m talking about-

Dr. Michele Green: Sure. Practically speaking, you probably have to-

Dr. Mike Rosen: … You towel off.

Dr. Michele Green: … You towel off and reapply the sunscreen.

Dr. Mike Rosen: But you shouldn’t be laying in the sun in the first place?

Dr. Michele Green: Yeah. That’s a lot of work, right?

Dr. Mike Rosen: It is a lot of work. Okay. Now that we’ve covered the sunscreen, in terms of preventative screening, in terms of going to the dermatologist, should we be going to a dermatologist? Can we go to a primary care doctor. Who should be looking at us once a year, once a lifetime? Never

Dr. Michele Green: That’s a great question. Internists are wonderful at referring to dermatologists, but they only get one week of dermatology training during the course of their entire residency. One week, so they’re really not skilled at being able to differentiate between a skin cancer and a benign lesion. A dermatologist goes for residency for three years, and they’re the ones who are trained in that field. You should be going to a dermatologist and it should be at least once a year, except if there’s a family history. If there’s a family history of skin cancer, if your mom, or your dad, or your brother or sister has had melanoma, you should be going twice a year to get screened for skin cancer.

Dr. Mike Rosen: What if you’ve had five, 10 burns? Is screening twice a year reasonable?

Dr. Michele Green: If you’ve had five or 10 burns, and you’ve never had any skin cancer, then probably once a year is sufficient, but once you get your first skin cancer, then you’re obligated to go at least twice a year.

Dr. Mike Rosen: Is that starting at age 18? What would you recommend to the average person out there?

Dr. Michele Green: I honestly, if I see a family history of melanoma, I have had children who have had melanoma, who have had skin cancer. There’s a family history of melanoma. I’ve had pediatricians send skin cancer patients to be examined. I would start as a child, because there are children, teenagers. The number one skin cancer, the number one cancer, in women ages 20 to 25 is actually melanoma. It’s a leading cause of death, actually, in that age group, except for accidents.

Dr. Mike Rosen: But can’t you look in the mirror and say, “Oh, that looks kind of new?” You really need a professional to do that?

Dr. Michele Green: Well, it’s good if you notice something new, but what happens is someone has a mole for a while and they don’t notice that it’s changing. They don’t really understand that it’s bad. Often people come in, I’ve had many young patients come in for acne, and I always make the patients do a skin check, a full body skin check on their first exam, and when I ask them about a mole that’s been there, they’d say, “Oh, I’m not worried. It’s been there forever. I’m not worried.” They’re shocked when I biopsy it and tell them it’s melanoma.

Dr. Mike Rosen: Wow.

Dr. Michele Green: I think people don’t really understand. And also, there are places that people don’t see. I’ve had many patients who have melanoma on their backs, or their buttocks, or you know. Men have them on the top of their scalp.

Dr. Mike Rosen: Does it go where the sun don’t shine?

Dr. Michele Green: It goes where the sun don’t shine because it’s genetic. Obviously there’s sun relation to it, so the skin cancer is exacerbated by the sun, and melanoma is exacerbated by burns, but it is genetic. Melanoma is clearly a genetic disease, so absolutely it goes where the sun don’t shine.

Dr. Mike Rosen: Can dark-skinned individuals like African Americans get it?

Dr. Michele Green: Absolutely. Dark-skinned individuals get it. It’s more prevalent in white or Caucasian. The lighter the skin type, it goes by eye color and skin color, so the lighter the eye color, blue and green eyes, and the lighter the skin color, the more susceptible you are to burning, and the more susceptible you are to getting skin cancer. But sure, there are darker patients from Brazil, and Argentina, and South America, and Hispanic patients who get skin cancer.

Dr. Mike Rosen: We’ve got three minutes. Let’s take a look at some pictures and scare the audience a little into wearing their sunscreen.

Dr. Michele Green: Okay. This is a common skin lesion that comes up very quickly, but it is a form of a squamous cell carcinoma. Patients come in, they complain that they have a new growth. They don’t know what it is. It grows very, very quickly. This needs to be surgically removed in order to cure.

Dr. Mike Rosen: Okay. Next thing I think we have is a dysplastic nevus.

Dr. Michele Green: A dysplastic nevus is a very, very common mole. I think it’s an important mole to speak about because it looks very similar to a melanoma. A dysplastic nevus is really a marker to someone being more predisposed to getting a melanoma. Itself is not considered a malignant mole, but it’s really just a sign that you’re more predisposed than the regular person to having a malignant melanoma. And the more dysplastic nevi you have, as in this case where that someone actually has something called the familial dysplastic nevi syndrome, where they have multiple dysplastic nevi, the more dysplastic nevi I have, the more the increased risk you have of getting a malignant melanoma during your lifetime.

Dr. Mike Rosen: Let’s move to the next picture, which is?

Dr. Michele Green: Which is a malignant melanoma. This was an early lesion, and it shows the variegation of color, the asymmetry, the irregular border, and the diameter of greater than six millimeters. There’s the ABCDs of melanoma. That’s what this slide shows. The only thing I don’t like about this slide is that the D, the diameter greater than six millimeters, because a lot of melanomas start smaller. The melanomas that we’re finding nowadays are smaller than six millimeters.

Dr. Mike Rosen: But that’s good news.

Dr. Michele Green: That’s great news, because the cure rate is much higher, because a thin melanoma is a 99% cure rate. A thicker melanoma that’s been there for a long time is only a 15% cure rate, so really, truly people are dying from these skin cancers when they’re not detected early.

Dr. Mike Rosen: Now we’re moving into a different kind of skin cancer, which is basal cell carcinoma.

Dr. Michele Green: Right. This is a picture of a nodular basal cell carcinoma. You can see the pearly papule with these red little telangiectasures that run through it, and this is the most common form of skin cancer that people present with. I think there are something like 3 million cases diagnosed each year of basal cell carcinoma.

Dr. Mike Rosen: They’re not as deadly. They’re easier to pick up.

Dr. Michele Green: That’s right.

Dr. Mike Rosen: But you do want to remove them>

Dr. Michele Green: That’s right. And here’s one on the nose. They don’t generally don’t metastasize. That’s right. They’re not deadly, but they can be very cosmetically disfiguring when you get them, especially on the nose and the face, which are the primary areas, because again, it’s in sun exposed areas.

Dr. Mike Rosen: Here’s an actinic keratosis.

Dr. Michele Green: Right. This actinic keratosis is a precancer, and 10% of these precancerous go on to become squamous cell carcinomas, which do metastasize, can metastasize, and are potentially deadly.

Dr. Mike Rosen: Which is the next image on the screen, if we can quickly show a squamous cell carcinoma.

Dr. Michele Green: Squamous cell carcinoma in this man’s forehead shows that that’s been there for many years. It’s very deep, probably because it’s been there for so long, and again, between two and 10% of these metastasize, which are potentially fatal.

Dr. Mike Rosen: Protect your skin.

Dr. Michele Green: That’s right.

Dr. Mike Rosen: Stay out of the sun.

Dr. Michele Green: Enjoy The sun, but be sun safe.

Dr. Mike Rosen: And use sunscreen.

Dr. Michele Green: That’s right. And a lot of it.

Dr. Mike Rosen: And a lot of it. Dr. Green, thanks so much for joining us .

Dr. Michele Green: Thank you very much.

Dr. Mike Rosen: We’ll be right back after this.

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