How Skin Cancer Is Treated

Treatments for skin cancer depend on the type of cancer, the stage, the size and location of the tumor, and much more. For basal cell carcinomas and squamous cell carcinomas, surgery (excision) or electrodesiccation and cautery of the cancer is often all that is needed. Mohs surgery is an additional option to reduce scarring. The treatment of melanoma also includes surgery, but with a wider excision. Depending on the stage, additional treatments such as immunotherapy, targeted therapy, chemotherapy, and radiation therapy may be needed.

A team of doctors will work with you to determine the best skin cancer treatment plan. The team may include specialists such as a surgical oncologist, medical oncologist, radiation oncologist, dermatologist, plastic surgeon, and a pathologist.

Surgery

Both nonmelanoma (basal cell carcinoma and squamous cell carcinoma) and melanoma skin cancers can be successfully treated in almost all cases if they are diagnosed and treated when the tumor is relatively thin.

Surgery to remove the tumor is the standard treatment, but numerous other options are available as well.

The type of treatment method for nonmelanoma or melanoma cancers depends on how large the lesion is, where it is found on the body, and the specific type. Surgical options include:

Simple Excision

Simple excision is done by injecting a local anesthetic and then surgically removing (excising) the cancer and a small area of normal appearing tissue surrounding it. This is frequently done for smaller basal cell and squamous cell skin cancers.

Curettage and Electrodesiccation

Curettage and electrodesiccation is another option that may be used for very small basal cell and squamous cell carcinomas. In this procedure, the skin is numbed locally and a scalpel is used to shave off the lesion (curettage). Cautery (electrodesiccation) burns the surrounding tissue to stop bleeding and create a scab for when the area heals.

Mohs Surgery

Mohs surgery (microscopically controlled surgery) is a highly specialized surgical technique that may be used to excise melanoma-in-situ when the cancer involves an area where sparing tissue is important (e.g. the face).

The surgeon begins by excising visible cancer and sending the sample to the pathologist. The pathologist looks under the microscope to see if any tumor cells are near the margins (edges) of the sample removed. If so, further surgery is done, followed by pathological evaluation until all margins are clear. In some cases, many small excisions of tissue are done before clear margins are found.

The end result of this technique is less scarring than would occur if a surgeon simply took a wider margin of tissue to make sure that no cancer remained.

Surgery for Melanoma

Surgery for melanoma is more extensive, and many people are surprised at the amount of tissue that is usually removed. A wide excision is recommended whenever possible.

Depending on the location of the melanoma and the size, surgery may be done in the office or in an operating room. For small tumors, a local anesthetic may be injected, but other anesthesia techniques, such as a local nerve block or even general anesthesia may be needed.

A wide elliptical incision is done, paying attention to skin lines. With larger melanomas, or melanomas in challenging areas, a plastic surgeon usually performs the procedure rather than a dermatologist, or the two will work together. For melanoma in situ, a margin of 0.5 cm (about 1/4 of an inch) beyond the cancer is usually recommended. For other melanomas, a very wide margin (3 cm to 5 cm) was recommended in the past but was not found to increase survival. Today, a margin of 1 cm to 2 cm is usually recommended for tumors that are 1.01 mm to 2.0 mm thick, and a margin of 2 cm for those thicker than 2 mm. Some surgeons are now using Mohs surgery for melanomas as well.

If a sentinel node biopsy is needed, this is often done at the time of surgery.

For smaller melanomas, the incision may be closed after surgery, similar to an incision done for another type of surgery. If a large amount of tissue is removed, closing with skin grafts or skin flaps may be required.

You may be very concerned when your surgeon discusses the amount of tissue that must be removed, but reconstruction for skin cancer has improved dramatically in recent years.

That said, reconstruction may need to be done in stages as healing occurs.

Side Effects

Side effects of any type of surgery for skin cancer may include bleeding or infection, scarring, as well as disfigurement. Again, however, plastic surgery can do wonders in restoring appearance in even very extensive surgeries.

Specialist-Driven Procedures

There are a few procedures that are sometimes done or are being explored as alternatives to surgically removing a tumor. Some of these include:

  • Cryosurgery (freezing a skin cancer) is sometimes used to treat very small skin cancers, especially when a large number of precancerous and small cancerous lesions are present. As with surgery, cryosurgery can leave a scar. Cryosurgery may need to be repeated to eliminate any persistent lesions or to treat new precancerous ones.
  • Laser therapy (using a narrow beam of light to "cut out" a tumor) is being evaluated in the treatment of skin cancer. Since this treatment is relatively new, it's still not known how the effectiveness of laser therapy compares with surgery for skin cancer.
  • Dermabrasion (using rough particles to rub away a tumor) is being evaluated as a possible way to prevent the development of skin cancers, but research as to whether this procedure makes a significant difference is still in its early stages. It has reportedly been used for very small skin cancers.
  • Topical chemotherapy with Efudex (topical 5-fluorouracil) is sometimes used to treat small, superficial basal cell carcinomas and small, superficial squamous cell carcinomas. Imiquimod may also be used to treat superficial basal cell carcinoma and superficial squamous cell carcinoma. The treatment of superficial SCC with either Efudex or imiquimod is an off-label use, though these treatments have proven effective in numerous medical studies.
  • The topical cream Aldara (imiquimod) is a type of immunotherapy drug that stimulates a person's own immune system to fight off cancer. It is currently only approved for superficial spreading basal cell carcinoma. In general, surgery is preferred, though imiquimod may be recommended in certain cases. Due to its mechanism of action, it does not scar. The cream is usually applied daily for five to six weeks.

Adjuvant Therapy

There are a number of treatment options for skin cancers that spread to distant regions of the body. These therapies are also sometimes used if there is no evidence that a skin cancer has spread on exam or imaging studies. Since intermediate stage melanomas (such as stage II and stage III) frequently recur after surgery, it's assumed that some cancer cells are left behind. The chance that this is the case is greater the higher the stage of the tumor and if the tumor has spread to any lymph nodes.

With early-stage melanomas (stage 0 and stage I), only surgery may be needed. Stage II and stage III melanomas have a significant risk of recurrence, and additional treatment with immunotherapy, targeted therapy, and/or chemotherapy may be used to "clean up" any areas of cancer that remain in the body but are too small to be detected by imaging tests.

When treatments are used in this way, they are considered adjuvant therapies.

For stage IV melanomas, surgery alone is insufficient to treat cancer, and a combination of these therapies is needed. 

Immunotherapy

Immunotherapy (also called targeted or biologic therapy) helps the body's immune system find and attack cancer cells. It uses materials either made by the body or in a laboratory to boost, target, or restore immune function. 

There are several treatments that classify as immunotherapies. With melanoma, there are two major categories (as well as others being evaluated in clinical trials):

  • Immune checkpoint inhibitors: Our bodies actually know how to fight cancer, but cancer cells find a way to hide from or "turn down" the actions of the immune system. These drugs work by, essentially, taking the brakes off the immune system so that it can fight off cancer cells.
  • Cytokines (such as interferon alfa-2b and interleukin-2) work non-specifically to bolster the immune system to fight off any invader, including cancer cells.

Immunotherapy is the standard of care and can be used alone either as adjuvant treatment in localized or in metastatic melanomas. Immunotherapy may also be used in combination with surgery and/or chemotherapy, or as part of a clinical trial. Many other treatments are being tested, including therapeutic vaccines and oncolytic viruses.

Side effects of these treatments vary. They can include fatigue, fever, chills, headache, memory difficulties, muscle aches, and skin irritation. Occasionally, side effects from immunotherapy can include a change in blood pressure or increased fluid in the lungs. 

Chemotherapy

Chemotherapy is the use of drugs to kill any rapidly dividing cells in the body. This can, obviously, be quite helpful for cancer cells, but several normal cells divide rapidly as well—and they are targeted just the same. This gives rise to common chemotherapy side effects, such as low blood counts, hair loss, and nausea.

Chemotherapy may be given when there is a high risk of cancer recurring (as adjuvant therapy) or when cancer has metastasized. When given for metastatic disease, chemotherapy cannot cure cancer but can often prolong life and reduce symptoms.

Chemotherapy may be given in a number of different ways:

  • Topically: Topical 5-fluorouracil for is used for extensive basal cell carcinoma.
  • Intravenously: Chemotherapy can be delivered through the bloodstream targets cancer cells wherever they happen to be and is a mainstay for cancers that have metastasized to a number of different areas.
  • Intrathecally: For skin cancer metastases to the brain or spinal cord, chemotherapy may be injected directly into the cerebrospinal fluid. (Due to the presence of a network of tight capillaries known as the blood-brain barrier, intravenous chemotherapy does not often penetrate into the brain).
  • Intraperitoneal: For melanomas that have spread within the abdomen, chemotherapy may be given directly into the peritoneal cavity.
  • Into a limb: For cancers present in an arm or leg, a tourniquet may be applied and a higher dose of chemotherapy injected into the arm or leg that would otherwise be possible if given through a vein (isolated limb perfusion, ILP and isolated limb infusion, ILI).​

Targeted Therapy

Targeted therapies are drugs that zero in on specific molecular pathways involved in the growth of cancer cells. In this way, they do not "cure" cancer, but may halt its progression for some people. Since these treatments have specific cancer (or cancer-related) targets, they often—but not always—have fewer side effects than traditional chemotherapy.

There are two primary categories of drugs now used (with others in clinical trials) including:

  • Signal transduction inhibitor therapy: These drugs target cellular communication pathways between cancer cells that are needed for the growth of some melanomas. Zelboraf (vemurafenib) and Taflinar (dabrafenib) may be effective for people who have tumors that test positive for changes in BRAF. The targeted drugs Mekinist (trametinib) and Cotellic (cobimetinib) may also be used.
  • Angiogenesis inhibitors: In order for tumors to grow and spread, new blood vessels must be formed (a process referred to angiogenesis). Angiogenesis inhibitors work by preventing the formation of new blood vessels, essentially starving a tumor so it cannot grow. Side effects can sometimes be serious and include problems such as high blood pressure, bleeding, and rarely, bowel perforation.

Radiation Therapy

Radiation therapy is the use of high-energy X-rays or other particles to kill cancer cells. The most common type of radiation treatment is external-beam radiation therapy, which is radiation given from a machine outside the body. Radiation may also be given internally via seeds that are implanted in the body (brachytherapy).

With melanoma, radiation may be given when cancer has spread to lymph nodes, after a lymph node dissection (with or without chemotherapy or immunotherapy). It is used most commonly as a palliative therapy to reduce pain or prevent fractures due to bone metastases, rather than to treat skin cancer directly.

Clinical Trials

There are many clinical trials in progress that are looking for newer and better treatments for skin cancer, and the National Cancer Institute currently recommends that everyone diagnosed with melanoma consider the possibility of joining one. 

The treatment of cancer is changing very rapidly. The immunotherapy and targeted therapies currently used for melanoma were unheard of a decade ago, and even a few short years ago were only available in clinical trials. Some people have had what oncologists call a "durable response" to treatment with these drugs, essentially—and cautiously—suggesting their effectiveness as a cure. This is true even for people with very advanced stage metastatic melanomas. Though these individuals remain the exceptions and not the norm, this is promising.

Oftentimes, the only way a person can receive a newer treatment is by being enrolled in a clinical trial. There are many myths about clinical trials, and many people are nervous about taking part in one. It may be helpful to understand that, unlike clinical trials of the past, many of these treatments are designed very precisely to target abnormalities in melanoma cells. Because of this, they are much more likely to be of benefit to a person receiving them as part of a research study than in the past.

Complementary Medicine (CAM)

We do not currently have any alternative cancer treatments that work to treat skin cancer, but some of these integrative therapies for cancer may be helpful in reducing the symptoms of cancer and cancer treatments. Options such as meditation, yoga, prayer, massage therapy, acupuncture, and more are now offered at many of the larger cancer centers.

It's important to note that some dietary supplements, as well as vitamin and mineral preparations, could interfere with cancer treatment. Some of the supplements may also increase the risk of bleeding after surgery. It's important to talk to your oncologist before taking any over-the-counter or nutritional supplements.

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Additional Reading

  • Bast, R., Croce, C., Hait, W. et al. Holland-Frei Cancer Medicine. Wiley Blackwell, 2017.
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