What changed: Skin cancer (all types)

When this page itself was last checked or edited.

Start with the reassurance, because it is true: the British Association of Dermatologists says basal cell carcinomas can almost always be cured and very rarely spread, and that most squamous cell carcinomas are low-risk skin cancers and can be cured. What frightens people is not the cancer, it is the operation, and almost nothing is written about it. There are four ways a wound on the face is closed and it is worth knowing which is yours before the day. Stitches, if the edges will meet. A skin graft, a thin sheet taken from a donor site (Cancer Research UK says usually somewhere not too obvious such as the inner thigh) and laid over the defect, which means a second wound where it came from; a shaved donor site heals by itself, a cut one is stitched. A skin flap, skin from immediately beside the wound moved across while still attached to its own blood supply, which is why the colour and texture usually match better; only specially trained dermatologists or plastic surgeons do them and more than one operation is sometimes needed. And fourth, the one people are least often warned about, leaving the wound open under a dressing to heal on its own over several weeks and up to two months, which is a recognised choice and not a failure. Near the eyelid, the nose, the ear and the lip the reconstruction is often handed to a different team, and the BAD names maxillofacial, oculoplastic and plastic surgeons as the ones who may repair a Mohs wound, so who removes the cancer and who closes the wound are two separate questions. Afterwards: Cancer Research UK says the scar is quite noticeable and red to start with and gets paler over time, that some are thick and raised, and that numbness, tingling and pain in the area are nerve injury and may improve with time. The NHS says most scars fade but that this can take up to two years or more, and that massage with a water-based cream, keeping the scar covered in the sun for at least a year and SPF 30 or more all help. One small thing nobody mentions: after a local anaesthetic to the middle or lower face you cannot feel anything until it wears off, so avoid hot food and drink because of the risk of burns.

Disease-free survival at 24 months 87.

Post hoc analyses in 17 participants suggested that patidegib topical gel reduced the number of new surgically eligible basal cell carcinomas and the level of hedgehog signalling, with minimal adverse effects; no pre-specified endpoint was met.

Objective response in 54.

Freedom from treatment failure at five years 77.

415 patients randomised after surgery and radiotherapy; 24-month disease-free survival 87.1 against 64.1 per cent with adjuvant cemiplimab.

If you take drugs that suppress your immune system, and above all if you have had an organ transplant, almost every sentence on this page is more serious for you and the leaflets addressed to you are rarely the ones you are handed. The scale, from the joint leaflet of the British Association of Dermatologists and the British Society for Skin Care in Immunosuppressed Individuals: squamous cell carcinoma is 150 times more common in transplant recipients than in the general population and is the commonest skin cancer in this group, basal cell carcinoma is up to 10 times more common, a UK study found one in three people transplanted for more than 10 years had developed a skin cancer, by about 20 years roughly half will have had one, and two in three of those who have had one go on to have several. The population studies agree: in 10,476 Swedish recipients the standardised incidence ratio for squamous cell carcinoma was 121 and 198 for heart and lung recipients, and in a prospective study of 615 squamous cell carcinomas immunosuppression was an independent predictor of metastasis with a hazard ratio of 4.32. Four things follow. What counts as suspicious is different: pain in a growing skin lump is specifically flagged, and any new, painful, bleeding or non-healing mark goes to a doctor rather than to a wait-and-see. Sun protection is stricter: SPF 50 with five UVA stars, daily, all year, to all exposed skin including a balding scalp and the ears, and it applies to people with brown and black skin on immunosuppressants where routine sun protection would otherwise rarely be needed in the UK. Surveillance is individual: ask your team for the frequency and setting of your in-clinic skin checks rather than assuming there is a standard. And the immunosuppression itself is on the table: where someone has multiple or more serious skin cancers, the dermatologist may discuss with the transplant physicians whether reducing or switching it would reduce future cancers, and preventive acitretin or nicotinamide may be added. None of that is a decision to make on your own, and none of it should be a surprise.

No kidney rejection or graft loss in 12 kidney transplant recipients given cemiplimab after cross-taper to a mammalian target of rapamycin inhibitor with pulsed corticosteroids, with responses in 5 of 11 evaluable patients (46 per cent, 90 per cent confidence interval 22 to 73).

Three things happen at once and only one of them is ever discussed. The first is the face. The BAD says larger basal cell carcinomas may leave larger scars after surgery which may cause concern, especially on prominent areas such as the face, and that is as close as most patient material comes to naming it. The practical answers exist and are underused: the NHS says a GP can refer you for skin camouflage or you can refer yourself online, that a trained professional colour-matches creams and powders to your skin, that they can be prescribed, and that a GP can refer you for talking therapy if a scar is affecting your mental health. Changing Faces is the UK charity for visible difference. The second is watchfulness. Once you have had one of these cancers, you are being asked to examine your own skin monthly, which means every new mark is now a question rather than a mark; in a study of 160 people after surgery for facial non-melanoma skin cancer, those with recurrent disease had a higher adjusted symptom severity score and poorer psychological quality of life than those treated once. The third is the one people find hardest to say out loud, that everyone around them has decided this does not count. It is not baseless: Cancer Research UK's own coping page says nearly everyone diagnosed with skin cancer can have a simple treatment that will cure the cancer, and that is true and is also the sentence people hear instead of sympathy. In the study of 400 patients scored on the disease-specific BaSQoL questionnaire, the mean subscores were 1.20 for the 'other people' domain, 1.01 for diagnosis and treatment, 0.90 for worries, 0.78 for behaviour and 0.40 for appearance; the overall impact was low to moderate and the highest-scoring domain was not the one about how you look. Both things can be true. It is the cancer most likely to be cured, and it is still a cancer, and being told how lucky you are is not the same as being listened to.

Disease-free survival 85 per cent at 12 months and 84 per cent at 24 months with adjuvant nivolumab against 77 and 73 per cent with observation (hazard ratio 0.

Objective response 47% (37 of 78) in metastatic disease by independent central review at the primary report, median duration of response not reached; the current label reports 50% (39 of 78) metastatic and 55% (17 of 31) locally advanced.

Pathological complete response in 40 of 79 patients (51 per cent, 95 per cent confidence interval 39 to 62) and pathological major response in a further 13 per cent, with grade 3 or higher adverse events in 18 per cent.

Objective response by independent central review in 26 of 84 patients (31 per cent, 95 per cent confidence interval 21 to 42) with five complete responses; grade 3 or 4 treatment-emergent adverse events in 48 per cent.

Surgical downstaging in 44 of 55 patients (80 per cent, 95 per cent confidence interval 67 to 90) with 27 complete responses, an objective response rate of 71 per cent, and recurrence in 16 of the 44 downstaged patients (36 per cent) by three years.

Neoadjuvant nivolumab produced pathological complete responses in a substantial share of resectable Merkel cell carcinomas, with durable responses; nivolumab also showed activity in recurrent cervical cancer.

Objective response 34% in recurrent or metastatic disease and 50% in locally advanced disease.

Objective response 47% in the metastatic group; 46% in the pooled analysis of 193 patients with 16% complete responses.

Tumour-free survival at five years 80.

Freedom from locoregional relapse at five years 87 per cent with chemoradiotherapy against 83 per cent with radiotherapy alone (hazard ratio 0.

Five-year results of the 601-patient Dutch trial: tumour-free survival 80.5 per cent with imiquimod, 70.0 with fluorouracil and 62.7 with methyl aminolevulinate photodynamic therapy.

Clinical success at three years 84 per cent with imiquimod against 98 per cent with surgery (relative risk 0.

Investigator-assessed response 68.

Written as a list a real person can follow rather than as a warning. Cancer Research UK's version for someone who has had one of these cancers is: close-weave cotton clothing, long sleeves and trousers; a wide-brimmed hat that shades the face and neck; sunglasses with 100 percent UV protection; shade between 11am and 3pm in the UK; never a sunbed; and sunscreen of at least SPF 30 with four or five UVA stars, used generously, reapplied regularly, alongside the shade and the clothing rather than instead of them, even on a cloudy day. A specialist may suggest SPF 50 on exposed skin. The BAD adds the timing that makes the difference: apply plenty 15 to 30 minutes before going out and reapply every two hours and straight after swimming and towel-drying. NICE NG34 (1.1.1) names the groups public health activity should focus on and a reader of this page is in at least one of them: a personal or family history of skin cancer, immunosuppression, a tendency to burn rather than tan, outdoor work or outdoor hobbies. Two things are usually left out. The first is vitamin D: Cancer Research UK says covering up reduces it, and that the Scientific Advisory Committee on Nutrition recommends a 10 microgram daily supplement between October and March, and all year for people who are mostly indoors or who cover up outdoors, so ask rather than guess. The second is that none of this is retrospective. The damage that caused this cancer was done years ago and cannot be undone by anything you do now; what sun protection changes is the chance of the next one, which in a meta-analysis of 17 studies ran at 44 percent within three years of a first basal cell carcinoma. That is a figure for a group of people, not a prediction for you.

Objective response 31.

Objective response 56%, durable in most responders; similar in virus-positive and virus-negative tumours.

Tumour at the inked edge means the operation did not clear it. It happens in roughly 3 to 15 per cent of excisions depending on the site and the series, most often on the nose, in infiltrative, morphoeic, micronodular and superficial multifocal subtypes, and where invasion goes below the dermis. What follows is a judgement: re-excision or Mohs surgery for aggressive subtypes, central facial sites and any squamous cell carcinoma, radiotherapy where further surgery is not possible, and observation where a frail person has a low-risk basal cell carcinoma at a low-risk site. In one series of 23 incompletely excised facial basal cell carcinomas, six recurred and all six were superficial multifocal, infiltrative or micronodular.

Objective response at 200 mg: 43% in locally advanced and 15% in metastatic basal cell carcinoma (central review).

Ten-year cumulative recurrence 4.

Pembrolizumab and nivolumab approved for advanced melanoma, later moving to adjuvant and neoadjuvant use.

501 people randomised in the United Kingdom; clinical success at three years 84 against 98 per cent and at five years 82.5 against 97.7 per cent.

Mohs is described everywhere as a technique and almost nowhere as a day, which is the thing you have to get through. The British Association of Dermatologists leaflet describes it honestly. You arrive as for any appointment and are taken to a surgical suite. The surgeon marks and photographs the lesion, injects local anaesthetic (it stings for less than 30 seconds), removes the tumour with a rim of normal-looking skin, dresses the wound and sends you to a recovery bay. Your sample goes to the laboratory and is read under a microscope while you wait; the leaflet says it can take up to three hours to get the result. If any cancer remains, more anaesthetic is injected and another layer is taken, and the clock restarts. In 90 percent of cases the cancer has gone after one or two stages, but you could be in hospital for up to a day, and the leaflet says in its own words that more than one set of injections is often needed and that it can be a long and tiring day. You do not know at the start how much will come out or how big the wound will be, which is the part people find hardest, and the wound is only closed once the surgeon is satisfied. The drawbacks the BAD names itself are worth hearing: waiting lists are usually longer than for standard excision because fewer cases fit in a day, so the cancer could grow while you wait; it takes half a day on average against minutes for a standard excision; and not all skin cancers should be removed this way. What it buys: in the Dutch randomised trial of high-risk facial basal cell carcinoma, ten-year recurrence was 4.4 percent after Mohs against 12.2 percent after excision for primary tumours (not statistically significant) and 3.9 percent against 13.5 percent for recurrent ones (significant). Practical matters the leaflet is specific about: someone must drive you there and back, public transport is not advised afterwards, you can eat and drink, and bring something to do.

Objective response 43% in locally advanced and 30% in metastatic basal cell carcinoma (independent review).

No difference in the appropriateness of referral (56.

New cutaneous squamous cell carcinoma in 22 per cent of patients switched to sirolimus against 39 per cent continuing calcineurin inhibitors (relative risk 0.

First hedgehog pathway inhibitor.

The first checkpoint inhibitor and the first BRAF inhibitor, the two routes that transformed melanoma.

Five-year recurrence 20 per cent after cryotherapy against 22 per cent after methyl aminolevulinate photodynamic therapy (p=0.

Mohs surgery better for recurrent facial basal cell carcinoma (2.4 against 12.1 per cent) and not significantly better for primary tumours; the ten-year report in 2014 found 4.4 against 12.2 per cent for primary tumours with 56 per cent of recurrences after year five.

Five-year recurrence 14 per cent after methyl aminolevulinate photodynamic therapy against 4 per cent after excision (sustained complete response 76 against 96 per cent, p=0.

Four-year failure rate 0.

347 patients randomised at the Institut Gustave Roussy: four-year failure 0.7 against 7.5 per cent and a better cosmetic result after surgery on four of five independent judgements. The comparison has never been repeated.

117 basal cell carcinomas marked in 2 mm increments before Mohs surgery showed that 4 mm clears more than 95 per cent of tumours under 2 cm; the 1992 companion study did the same for squamous cell carcinoma and gave 4 mm, or at least 6 mm for high-risk tumours.