Diagnosis skin cancer—what now?

Update: 12 october 2024

If your doctor has diagnosed skin cancer, it can be a bit of a shock. The following conversation with the doctor is less well received or understood. After you leave the office hours, you may be wondering – now what? How can I prevent this in the future?

In the Netherlands, the number of people with skin cancer is increasing explosively. In the year 2023, approximately 77.000 Dutch people were diagnosed with a form of skin cancer. The KWF expects this trend to continue.

It is important to know which type of skin cancer you have. The 3 most common skin cancers are: basal cell carcinoma (BCC), squamous cell carcinoma (PCC) and melanoma.

Basal cell carcinoma

This is the most common type of skin cancer (71%) in white people. The BCC has several appearances, but most often we see a red, glassy spot or ulcer. Often there are dilated blood vessels and it has a shine. BCC can be divided into superficial, nodular and spiky type.

Treatment of BCC is in most cases surgical, sometimes with the superficial BCC type liquid nitrogen or topical with Efudix cream can be chosen and in special cases it is irradiated.

This form of skin cancer hardly metastasizes, the risk is 0.03%. The prognosis is good (up to 100% survival), but there is a 50% chance that a second BCC will develop somewhere else on the body within 5 years. It often occurs on the face.

Squamous cell carcinoma

It occurs in 16% of people with skin cancer. A squamous cell carcinoma often starts as a pale pink, rough raised spot. Sometimes with a scaly white bump in the center. The nodule grows slowly and is sometimes painful. A squamous cell carcinoma can also look like a small wound that slowly enlarges. Unlike a basal cell carcinoma, squamous cell carcinoma does not have the shine and dilated blood vessels. This form of skin cancer can sometimes spread to the lymph nodes and other organs. The chance of metastasis is 5%, but if it is on the lips or ears, the chance of metastasis is 16%.

High risk
There are low-risk versus high-risk squamous cell carcinomas. In a squamous cell carcinoma with a
high risk, there is a greater chance that the disease will come back and a greater chance of metastasis.
High-risk squamous cell carcinomas include:
• on the face (lips and ears)
• larger than 2 centimeters
• tumors that come back
• tumors that grow into the skin or, for example, into a nerve pathway or blood vessel (invasive tumors)

There are abnormalities of the skin that are not yet skin cancer, but can become squamous cell carcinoma. Premalignant also called precursor stage.
Pre-stages of squamous cell carcinoma are: actinic keratosis and Bowen’s disease. 60% of squamous cell carcinomas arise from actinic keratoses.

More about actinic keratosis – the dental plaque of the skin

As with a basal cell carcinoma, the treatment of squamous cell carcinoma is mainly surgical. Other options are irradiation, freezing with liquid nitrogen or burning away (coagulation). The disadvantage of the last three possibilities is that you do not know whether the tumor has completely gone, because it has not been sent for tissue testing. If there are metastases, the lymph nodes containing the metastases and lymph nodes around them are removed. This is called lymph node dissection. Metastases in organs then chemotherapy is sometimes chosen.

The chance of a second squamous cell carcinoma within 5 years is 30%.

Melanoma

A melanoma manifests itself as a dark-colored and irregularly shaped spot. Sometimes the melanoma may also bleed or ulcerate. In rare cases, a melanoma is not brown or black, but rather red or even somewhat skin-colored. Melanoma occurs in 12% of all skin cancers. It is the most life-threatening form of skin cancer because it can spread relatively quickly through the lymphatic and blood vessels. Important to know is the melanoma thickness, expressed in Breslow thickness. This thickness determines the prognosis, any additional lymph node examination and follow-up treatment.

Treatment almost always begins with minor surgery. First, a ‘suspicious’ birthmark is surgically removed, the area is circumcised more generously with a margin of 2-3 mm. If it is indeed a melanoma and the Breslow thickness is known, then a second operation takes place in which the scar and healthy skin around it is removed. So there is always a second operation. This second surgery makes it less likely that the melanoma will come back in the same place.

A Breslow thickness of 0.8 mm and higher follows a lymph node examination in addition to a re-excision. This is also referred to as a Sentinel Node procedure or sentinel gland examination. This is done by an oncological surgeon and performed under anesthesia. Metastatic melanoma requires follow-up treatment in the form of chemotherapy or immunotherapy. More about KWF melanoma

The chance of a second melanoma within 5 years is 5-8%.

More on melanomas and heredity

After treatment – ​​prevention skincancer

After the treatment is often a period of uncertainty. Every newly appearing spot, flake or bump gives the feeling of ‘is that another suspicious spot?’ This is a frequently expressed concern during the consult and a most common reason for an early patient skin check.

Handles for early check-up are: rapid growth, complaints (pain or sudden itching), bleeding, color change, does not heal within 2-3 weeks and in case of doubt or concern.

Skin self examination

Needed: a standing mirror, a hand mirror. Write down the places that catch your eye or take a photo with your smartphone.

Step 1 – the faceChoose a fixed order: first the forehead, temples, nose, lips, cheek and neck. Check the ears, both the front and the back. Use the hand mirror for this. Also look at the inside of the lips and the buccal mucosa

Step 2 – arms and hands
First check the left and then the right arm. Check the fingers, the back of the hand and the palm of the hand carefully. Then the forearm and the upper arm. First the stretch side and then the bending side.

Step 3 – shoulders, chest, and belly

Women should also remember to check the underside of the breasts and the crease under the breasts.

Step 4 – armpits and flanks
Step 5 – neck and back
Step 6 – butt and backside legs

Step 7 – the genital area
Inspect the skin and mucous membranes of the genitals and the area around them. Also use the hand mirror.

Step 8 – lower legs and feet
For this examination, sit on a chair and place your left foot on a raised surface. Check the front of the lower leg and the back of the foot. Look at the nails, between the toes and inspect the sole of the foot. Do the same with the right leg.

Step 9 – scalp
Check the scalp by feeling for bumps with your fingers. Look in the hairs and if necessary use the hair dryer to blow the hairs to the side so that all areas of the scalp can be inspected. The hand mirror will be needed to check part of the hairy head.

And what are other preventive measures?

Sun protection is always useful—you prevent the chance of a second or further sun-damaged skin. It is important to know that sunlight emits three different types of ultraviolet radiation. You have UVA, UVA and UVC radiation. UVC plays no role for us because it does not reach the earth’s surface and is stopped by the ozone layer.

UVA radiation, also used in tanning beds, penetrates deep into the dermis. It has an effect on your collagen and elastin skin fibers. The elastin and collagen fibers provide the elasticity of the skin. In the long term, UVA rays can lead to skin aging such as wrinkles, fine lines, skin discolorations and even skin cancer. What many people don’t realize is that UVA rays contribute to sun-damaged skin. UVA rays are ALWAYS present and Asymptomatic, you do not feel the radiation. So no redness, burning or blistering unlike UVB sunburn.

UVB radiation does not penetrate the skin beyond the superficial epidermis and is responsible for our vitamin D production. Too much UV-B causes redness, sunburn and eventually skin aging and skin cancer. Unlike UVA, UVB does not penetrate glass or cloud cover.

Most common misconceptions about UV radiation in practice!

• It’s cloudy and raining, I don’t have to apply sunscreen! UVA radiation is always present, regardless of the weather or season. UVA radiation passes through the window and penetrates the clouds.
• Sun Protection Factor SPF protection is sufficient. SPF says about the degree of UVB protection and does NOT provide UVA protection.
• I use a day cream with an SPF, that’s enough! Check the packaging or jar to see if it also contains a UVA filter. If not, then you are half protected. Do realize that the sun’s power is less strong in autumn and winter, so UVB radiation is lower, while UVA radiation is still just as strong.
• A tanning bed treatment before spring starts provides extra protection. Tanning bed lamps are mainly UVA radiation and indeed it gives a tan But this sunbed brown tint gives a protection factor of 4 (about 75% UVB protection). UVB radiation ensures a more effective skin thickening.
• SPF30 vs SPF50. Difference is not big, SPF30 provides 97% UVB protection and SPF50 covers 98% UVB radiation.
• Applying once is sufficient. The advice is to reapply every 2-3 hours AND 2 fingers (index and middle finger) covered with sunscreen.

Sunscreen filters

In 2019, the US Food and Drug Administration, FDA, scrutinized sunscreen filters. There are currently 16 commercially available filters, divided into: 2 groups: Minerale filters: zinc oxide and titanium dioxide, act mainly as small mirrors to reflect light and a smaller portion of ultraviolet light is absorbed. Chemical filters, completely absorb the ultraviolet light. Based on advancing insight over the past twenty years, the FDA has created the acronym GRASE for sunscreen filters. GRASE stands for: Generally Recognized As Safe and Effective This is a step in the right direction and a start has also been made in Europe to properly investigate sunscreen filters.

What came out of GRASE? Only two of the sixteen filters are GRASE, namely Zinc Oxide and Titanium Dioxide. Two filters are not GRASE: PABA and trolamine salicylate and the others have insufficient safety data to make a good sun protection claim.

More about FDA news from 21st february 2019.

Advice: Mineral sunscreen with both Titanium Dioxide and Zinc Oxide, SPF30. More about Titanium Dioxide in skin care

And how do you apply sunscreen, how often and how much? As a rule every 2-3 hours and per location (face or arm left or arm right, leg left, right etc) – 2 fingers (index and middle finger) full of sunscreen! It’s much more than you think. The SPF values ​​are based on this amount.

More about how to apply sunscreen?

Cosmetic ingredients against sun-damaged skin

Vitamin A:

Vitamin A products such as tretinoid are a powerful and effective option to reduce sun-damaged skin. The over-the-counter option is retinol, which is available in different concentrations and formulations. The efficacy of retinol is already at 0.3%. A higher concentration is not always better, it can cause skin irritation. In people with Asian skin, a high concentration can cause burning, redness. More about the Asian skin

Vitamine B3 (Niacinamide):

Niacinamide, one of the eight B vitamins, is the so-called essential vitamins. This means that only a small part can be stored in our body.

Niacinamide can reduce the risk of skin cancer! An Australian study has shown that the use of niacinamide can have a reduction in actinic keratosis (precursor of skin cancer, squamous cell carcinoma). A 1% niacinamide lotion was used in the test. Even low doses of UV radiation can cause measurable DNA damage in the skin. Niacinamide is able to improve this recovery and reduces the suppression of the skin’s immune reactions caused by UV radiation.

Iconic Elements Spotreducer and Targeted Pigment serum contain >1% niacinamide.

Research into photo-protective effect of natural ingredients from herbs, fruits, also called phytochemicals are starting to get more attention. Substances such as curcuma, resveratrol from grapes, tea polyphenols, silymarin and quercetin in onions, apples, green tea, berries, olive oil can be used in cosmetics, with the use of sunscreens would also be an effective approach for reducing UV-generated sun damage and skin cancer

Diet

Lycopene, in tomato paste

It has been shown that a diet rich in fruits and vegetables can provide overall protection against these skin cancers. Some studies showed that certain nutrients reduced some of the effects of photocarcinogenesis (transformation of normal cells into cancer cells by UV radiation). In a randomized study, the intake of tomato paste, which is rich in lycopene, was shown to protect the skin against the effects of UV radiation such as redness and DNA damage.

Blue berries

More studies (in vitro) showing that blueberries prevent carcinogenesis include inhibition of the production of pro-inflammatory molecules, oxidative stress (free radicals), and consequences of oxidative stress such as DNA damage, inhibition of cancer cell proliferation, and increased apoptosis. This causes tumor cells to reduce Blueberries also have a protective effect against skin cancer

The rol of vitamines

Vitamin C: Shows toxic and anti-growth effects against melanoma cells in vitro, but increased citrus intake is associated with higher melanoma risk. This may be related to other photoactive substances in citrus fruits, such as psoralens. Psoralens are natural substances that, when exposed to ultraviolet (UV) light, become photoactive and cause a reaction in the skin. They can therefore also make the skin more sensitive to sunlight, which can lead to an increased risk of skin damage or melanoma.

Vitamin D: Has a protective effect against cancer by inhibiting cell growth and promoting apoptosis (programmed cell death). Apoptosis is a natural process in which damaged or unwanted cells die in a controlled manner. This is essential for maintaining healthy cells in the body and preventing the uncontrolled growth of cancer cells. High levels of vitamin D are associated with thinner tumors and better survival in melanoma patients.

Vitamin A (retinoïden): High intake of retinol can reduce the risk of melanoma by 20%, although there are inconclusive results for other forms of vitamin A, such as beta-carotene.

Vitamin E: Although known for its antioxidant properties, there is no clear association between vitamin E intake and melanoma risk. Some studies show a modest protective effect, but results remain mixed.

Vitamin B-complex: The effect of B vitamins on melanoma is controversial. Some studies suggest a protective effect, especially for folic acid and pyridoxine (vitamin B6), while other studies find no link.

While you are here

A self-tanner as an alternative to sunscreen or a ‘healthy’ tan. One of the best known agents is dihydroxyacetone (DHA). DHA is a sugar form that has been used in the cosmetic industry for over 50 years. It can be obtained from natural sources such as beets and sugar cane as well as synthetically. It is very popular because the tan obtained with it is very similar to that achieved by sunlight or tanning beds. More about what many people don’t know about a cosmetic self-tanner