(Written Fall, 2001)
“If you are going to get cancer, this is the kind to get,” Dr. Hamid Mahmud told me as we studied my biopsy report, which indicated “superficial basal cell carcinoma present at one lateral margin.”
Dr. Mahmud is a kindly man who has guided me safely through flu, sinus infections, tachycardia, high blood pressure, anemia, and injuries from a car accident. Since he could tell that the word “carcinoma” had shaken me, he wanted to reassure me.
However, when you have lost a father, a grandfather, and numerous aunts, uncles, and older cousins to various forms of cancer, you tend to become rather jangled by “carcinoma.”
The biopsy itself had been unsettling enough, coming as it had the day after Maureen Reagan died (8 Aug 2001) as the result of skin cancer that spread to her brain. As I sat waiting to be called for my pre-biopsy prepping, news of her death and Katie Couric’s interview with a skin cancer doctor emanated from a television in the waiting area at Salem Hospital. I couldn’t help wondering if God was preparing me for some bad news.
After seeing the biopsy results, Dr. Mahmud was quite insistent: I had to get a second opinion, and that second opinion had to come from a doctor at Barnes Hospital in St. Louis. Second opinion? Barnes? And almost immediately, too. Dr. Mahmud would make the appointment for me himself. Is this the bad news You were preparing me for, God?
Dr. Mahmud read the concern in my eyes.
“Remember,” he said, “if you have to get cancer, this is the kind to get.”
Okay. Reassurances from a doctor I trusted. Reassurances from my “bestest” friend Pammy, who, as always, would be right by my side every step of the journey and who knows what a world-class worrier I tend to be. Reassurances from a favorite cousin in Texas, Linda Gayle, who has had 52 of these skin cancer adventures.
“Nothing to worry about,” she told me. “Each one makes you ornerier is all.”
Reassurances from some quiet moments in my church and from the promised prayers of two special priests, Father Jon O’Guinn, who baptized me, and Father Vijay Prabhu, my e-mail buddy in India.
Then, a few days later, reassurances from a cancer doctor at Barnes-Jewish Hospital.
The fact that basal cell carcinoma (BCC) was present at a lateral margin of the biopsy specimen meant there was still malignancy present, Dr. Terry Larimore told me. However, BCC rarely spreads to other parts of the body. The surgery to remove the rest of the BCC would be quite minor outpatient surgery. His staff would call me to set up a surgery date sometime within the next two weeks.
Okay. I felt better, but this world-class worrier needed more reassurances in the meantime. Knowledge is power, so I searched for knowledge on the World Wide Web.
How could I, who had never been a sun worshipper, now be suffering the effects of obvious sun damage?
People with the highest risk of BCC are those with fair complexions (like me) and those with family histories of skin cancer. Besides Linda Gayle, my Aunt Doris has had her battles with BCC for several years.
Although it is occurring more frequently now in younger people because of increased recreational and occupational exposure to the sun, BCC usually happens in people age 50 or older. I had turned 50 in March.
A study in the June 2001 issue of Archives of Dermatology maintains that people with wrinkled facial skin are less likely to develop BCC. Experts think that BCC is linked to intense, intermittent sun exposure while wrinkling is the result of cumulative exposure to the sun. I don’t have so many wrinkles yet, a fact I attribute more to my fat, round face than to any inherent physiological tendency. However, here was another direct hit for me on the BCC checklist. (A note to any wrinkled readers: This Archives of Dermatology article cautions that even people with wrinkles should be careful about their exposure to the sun. Getting a sunburn is still a bad idea.)
Sun exposure from infancy to age 19 may increase the risk of BCC in adulthood. In the general population, the estimated lifetime risk of developing this malignancy is 28 to 33 percent.
Though I have never been the proverbial sun worshipper, in my younger years when my knees still worked, I spent a lot of daylight time on softball fields. At the beginning of each summer, too, I seemed to get one whomper-stomping sunburn, a sunburn that invariably peeled rather than turned to tan. I had to wonder about my EIU dorm sisters who had spent so many hours lying out in the sun after marinating their bodies with iodine-tinted baby oil. Some of them had even used homemade aluminum-foil reflectors to intensify their cooking time. Now young ladies, and even young men prefer to bake themselves within the confines of tanning beds, which create the same damaging effects on the skin.
Overexposure to powerful ultraviolet (UV) rays from either the sun or tanning beds ravages skin cells, which are made of two layers. The top layer, the epidermis, includes three types of cells: flat, scaly squamous cells; round basal cells; and melanocytes, cells that give skin its color. Too much sun prompts the visible damage we see in our sunburns and tanning. However, there is also invisible damage in the cellular level, damage that accumulates over the years. Depending on the individual, this damage will eventually prompt wrinkles, age spots, and often skin cancer.
According to estimates by the American Cancer Society (ACS), this year there will be more than one million cases of highly curable nonmelanoma skin cancers like BCC and squamous cell skin cancer. Of the 9,800 Americans expected to die of skin cancers this year, only 2,000 will die from the nonmelanoma skin cancers like BCC, which accounts for 75 percent of all skin cancers in the United States. The relative five-year survival rate for patients with BCC is greater than 99 percent. Although I am not a math whiz, the numbers were reassuring.
My BCC was but a freckle measuring 1.0 x 0.6 x 0.2 centimeters, a small spot just above the outer edge of my right eyebrow. I can’t even tell you why I asked Dr. Mahmud to check it out. Perhaps my guardian angel was whispering the suggestion to my subconscious. I had had a few concerns, however, because the freckle seemed to glow somewhat after I had been outside mowing on sunny summer days. Because of its location, I couldn’t see it well enough to determine whether it was changing shape or size. In any event, Dr. Mahmud didn’t want to waste any time. He scheduled the biopsy for two days after he checked out my freckle, and my surgery at Barnes was a month later.
There was some wiggle room because BCC generally does not spread quickly. Lesions may take months or years to reach a diameter of half an inch. However, if BCC is not treated, it can grow to several centimeters and invade bone or other tissues in the area or beneath the skin. Dr. Mahmud’s concern was that the location of my BCC was so close to my eye, my brain, and my temporal artery. Untreated BBC can cause loss of eyes, ears, and noses, and if it invades the brain, it may even be lethal.
If you are like me, you might wonder why anyone would let BCC progress to those degrees. Some of the BCC pictures I saw online were as gruesome as scenes from Halloween horror movies. (If you have a morbid curiosity to see what I mean, type “basal cell carcinoma photographs” into the Google search engine.) Faces were literally eaten away by oozy blobs: BCC that had been allowed to run amok.
Doctors recommend that people between the ages of 20 and 40 have cancer-related checkups and skin examinations every three years. People older than 40 should be checked every year.
Check your own skin about once a month in front of a full-length mirror. Use a hand-held mirror for areas that are difficult to see, or ask a partner for help. Up to 85 percent of BCC occurs in head and neck regions, but lesions occasionally crop up in unusual and routinely photo-protected locations. Ask your barber or hair stylist to tell you about any suspicious spots that may be hidden in your hair.
You should be particularly vigilant for spots that change in color or shape, new growths, spots or lumps that become larger, and sores that do not heal within three months. Make notes on the pattern of moles, freckles, and other marks on your skin so that you will more easily recognize any changes.
Since I have had BCC already, I can expect to have it again within the next five years, maybe even in the same location. Consequently, I will need to schedule follow-up examinations in three-month intervals for the first year. Thereafter, I will need a thorough skin examination each year, preferably by a qualified dermatologist.
This time around, my BCC was removed by simple excision: the lesion was cut out, along with some marginal skin, and then my skin was stitched back together. This procedure is most commonly used when the BCC is small and simple. Excision is quick and produces few post-operative complications. Cosmetic damage is minimal although I have been wondering why any woman would want a facelift. Just the pulling around my incision was been uncomfortable enough for me, thank you.
I experienced some swelling around my eye for a few days, and after a month, there is still some numbness in the area. I am also unable to raise my right eyebrow, a situation I am hoping is temporary so that I don’t have to manually maneuver my eyelid and the area above it when I am applying eye make-up.
One end of the approximately inch-and-a-half incision has been stubborn about healing, possibly because a couple of sutures were protruding there until I cut them off with manicure scissors. Though the stitches were supposed to dissolve a week or so after my surgery, for some reason they haven’t yet performed up to expectations. I am still going through a lot of hydrogen peroxide and Neosporin.
The scar remains rather ugly, but Dr. Larimore assures me that in about six weeks, it will be little more than a white line and the knots at either end of the incision will disappear.
Besides excision, other methods of treatment are electrodesiccation and curettage, Mohs Surgery, radiation therapy, laser surgery or topical chemotherapy, cryosurgery, and plastic surgery.
Electrodesiccation and curettage involves scraping off the tumor and cauterizing the base. The wound usually heals rapidly without stitches although for awhile there is a scab and scarring is marked, though minimal on certain areas of the face. Following this treatment, lesions smaller than five millimeters have a five percent recurrence probability. About half of the tumors larger than three centimeters will return within five years.
Mohs Surgery is a specialized, microscopically controlled surgical technique useful in treating tumors on or near the nose, eyes, ears, forehead, scalp, fingers, and genital area. The area of the lesion is mapped and excised, and the margins are checked immediately on frozen sections. If results are positive, affected areas are removed immediately. This process is continued until all specimens test clear. The cure rate when Mohs Surgery is used is about 96 percent, as compared to about 50 percent for other types of treatment.
Radiation therapy is a good option for older patients with large tumors, especially tumors involving skin areas that are difficult to treat surgically: eyelids, nose, or ears. Radiation is used only with complex tumors because it may be harmful to cartilaginous regions. Sometimes as many as 20 or 30 office visits may be required with this kind of therapy, which can also produce chronic inflammation, scarring, and further malignant degradation.
Laser surgery or topical chemotherapy is sometimes considered for very superficial lesions, those that have not extended too deeply under the skin’s surface. Thorough follow-up examinations are necessary because these treatments do not destroy any cancer cells that may lurk under the skin’s surface.
Cryosurgery, or freezing, involves the use of liquid nitrogen for small, superficial lesions. However, dermatologists generally do not recommend this kind of treatment, especially for larger tumors or those in certain parts of the nose, ears, eyelids, scalp, and legs. Although this procedure produces very little scarring, there can be post-therapy pain, swelling, tissue necrosis, and persistent oozing.
A patient with a larger lesion or a tumor in a difficult site may be referred to a dermatological surgeon or plastic surgeon, who may create a flap or graft to repair the defect after excision.
For recurrent tumors, surgical excision is the best therapy.
None of the treatments is pleasant, of course, but consider the alternatives. I have no desire for a face that looks like Hannibal Lector dined there. Besides the regular examinations, I will be following some good advice offered by the ACS.
Their slogan at ACS is “slip, slop, and slap.” In other words, anyone going outside should slip on a shirt, slop on the sunscreen, and slap on a hat (preferably one with a wide brim). Not that I am in the habit of leaving my house without a shirt, but you get the idea. You should use a sunscreen with a sun protection factor (SPF) of at least 15. Some dermatologists recommend an SPF as high as 30.
The simplest way to lower the risk of BCC is to reduce the amount of time you spend in the sun and in other sources of UV light. Stay in the shade whenever possible, especially in the middle of the day when sunlight is the most intense.
Other important details to remember:
* UV rays can get through clouds, fog, and haze.
* UV rays can pass through water, so you need protection when you are swimming.
* Water, sand, concrete, and especially snow can reflect and increase the sun’s burning rays.
* You need sun protection even in winter.
* Tanning booths and sun lamps use UV rays.
If you must use a tanning booth, be careful to follow the recommended tanning times. Otherwise you will reach a point where your skin stops tanning and starts cooking, literally.
Doctors report that the single greatest factor contributing to the most serious BCC cases is patient neglect. What I have just been through with my BCC is quite minor in terms of cancer. However, I plan to do my part to insure that I have to face nothing more serious in the future.
As Dr. Mahmud told me, “With cancer, you don’t always get a second chance.”
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