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Below, week by week, is what OnCo's record of Skin cancer (all types) says about the first two months: the order is typical, the timing is yours to ask about. Skin cancer covers the very common and rarely dangerous basal cell and squamous cell carcinomas, the less common but more serious melanoma, and rarer tumours such as Merkel cell carcinoma and Kaposi sarcoma. Almost all of it is caused by ultraviolet light and most of it is found and cured by simple surgery. Sections appear only where the record has something to say. Orientation, not medical advice.
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
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.
Ask which of these were tested and what the results were; see the report reader for what each value means.
Written by hand for this cancer from NHS, Macmillan, Cancer Research UK and charity pages, each item naming the page it came from. The days and weeks are the typical order those pages describe, not a schedule; tick what applies to you.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
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.
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.
The tumour is removed in thin layers, each mapped and checked under the microscope while the patient waits, until every edge is clear. Because the whole margin is examined rather than a few slices of it, it clears more tumour with less normal skin, which is why it is used on the face and on aggressive subtypes. The evidence is one randomised trial, in 612 high-risk facial basal cell carcinomas in the Netherlands. For tumours that had already recurred it is clearly better: ten-year recurrence 3.9 against 13.5 per cent (p=0.023). For tumours being treated for the first time the difference never reached significance, 4.4 against 12.2 per cent at ten years (p=0.100), and at five years it was 2.5 against 4.1 per cent. The finding that should change practice is that 56 per cent of the primary-tumour recurrences happened after year five, which is why the five-year papers in this disease understate the problem. Mohs surgery cost 1,248 euros against 990 for ordinary excision.
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.
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.
Excision with a measured margin of normal-looking skin, under local anaesthetic, in a few minutes. The standard margin is 4 mm, and it is not a convention: for basal cell carcinomas under 2 cm, marking the skin in 2 mm increments before Mohs surgery showed that 4 mm cleared more than 95 per cent of tumours, and the same method in cutaneous squamous cell carcinoma gave 4 mm for ordinary tumours and at least 6 mm for high-risk ones, meaning 2 cm or larger, grade 2 or higher, invading the fat, or in a high-risk site. Two practical corrections matter: a specimen shrinks between the skin and the pathologist's ruler, by 70 to 80 per cent of the measured width in one series, and dermoscopy moves the visible edge outwards in about one tumour in six. Cure is high and the cancer is almost always gone for good.
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.
Scraping the tumour out with a curette and burning the base, in minutes, with no specimen to check. For the right tumour it is reasonable and it is how a large share of low-risk basal cell carcinomas are treated worldwide. The Danish Skin Cancer Registry followed 47,358 tumours treated this way in office dermatology and found five-year recurrence of 9.9 per cent and eight-year recurrence of 13.3 per cent, dominated by selection: 25.1 per cent at eight years for head and neck tumours, 16.7 per cent for tumours over 10 mm and 8.4 per cent for superficial ones. Used on aggressive histological subtypes it fails, with 27 per cent recurrence at a median 6.5 years in one series of 37 tumours, which is an argument for a biopsy first in anything not obviously superficial.
Radiotherapy cures most skin cancers without an operation and is chosen for the person rather than the tumour: someone in whom surgery would cost an eyelid, a nostril or a lip, someone too frail or unwell for an operation, someone who refuses one, and after an incomplete excision that cannot be re-operated. It is second and not first because of the only randomised comparison ever run, in 347 patients with facial basal cell carcinoma, where the four-year failure rate was 0.7 per cent after surgery against 7.5 per cent after radiotherapy (p=0.003) and the cosmetic result was better after surgery on four of five independent judgements. Irradiated skin does not improve with time as a scar does. The techniques in that trial are not today's, so the gap is probably narrower now, but no one has repeated it.
Everything above is the treatment of the keratinocyte cancers, basal cell and squamous cell carcinoma, which is what most people who are told they have skin cancer have. Melanoma is treated by a different logic: the margin is set by the thickness of the tumour rather than by a fixed 4 mm, the lymph nodes are staged with a sentinel node biopsy, and advanced disease is treated with checkpoint immunotherapy or with BRAF and MEK inhibitors. Creams, curettage and photodynamic therapy have no role in invasive melanoma. The melanoma page carries all of it and this page does not repeat it.
Written by hand for this cancer. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
Every term links to the glossary.