What’s New in Cutaneous Oncology

Presented by: Darrell S. Rigel, MD, MS, FAAD
Clinical Professor, New York University Medical Center, New York, NY, USA
  • Primary and secondary prevention remain essential elements of cutaneous oncology.
  • Developments in genomics are playing an increasingly prominent role in diagnosis, prognosis, and advanced disease response.

Seventy percent of skin cancer is caused by sun exposure, with preventive measures including sunscreen and protective clothing demonstrating established efficacy. Risk factors include genetic predisposition, environmental exposures, nutrition, advanced age, and radiation [1]. Examining non-melanoma skin cancer (NMSC) all-cause mortality, the relative risk for basal cell carcinoma (BCC) patients was 0.92% and for squamous cell carcinoma (SCC) patients was 1.25% compared with the general public.

  • The current US prevalence of NMSC (4,000,000 cases) is greater than melanoma (96,480 cases).
  • BCC is far more prevalent (3,200,00 cases) than SCC at 800,00 cases [1].
  • Cutaneous squamous cell carcinoma (cSCC) is an under recognized health issue with high mortality rates.
  • New medications, along with developments in technology and genetics provide more advanced approaches for the diagnosis, treatment, and management of cutaneous cancers.
  • The guidelines of care for the management of cSCC published in 2018 reflect changes in SCC management options [2].
  • This reflects:
    • recognition of a 10-year survival rate for advanced SCC (aSCC);
    • the fact that chemotherapy regimens are generally palliative rather than curative;
    • the potential efficacy of PD-1 inhibitors for head and neck SCC, nivolumab and pembrolizumab;
    • and the recognition that aSCC may be more particularly amenable to immunotherapy because they are more common in immunosuppression.
  • MOHS surgery. MOHS surgery alone provides excellent marginal control with low rates of local recurrence, nodal metastasis, and disease-specific death [3]. In high risk SCC, invasion beyond the subcutaneous fat and poor histologic differentiation may carry a greater risk of poor outcomes than other factors [3].
  • Medications. Medications include pembrolizumab for aSCC, nivolumab for recurrent aSCC, and cemiplimab for CSCC.
  • The prevalence of melanoma is increasing in the US, with a current prevalence of 3.7% among males and 2.7% among females [4].
  • Of 192,310 total cases in the US in 2018, 96,480 were invasive and 95,830 were in-situ [5].
  • Melanoma is the 5th most common cancer type for both males and females, resulting in 9,320 deaths in 2018, which accounts for 72% of skin cancer deaths [4].

A. Prevention

  • Seventy percent of skin cancer is caused by sun exposure.
  • Primary prevention consists of protective measures such as use of sunscreen and protective clothing, which reduces the incidence of melanoma.
  • Secondary prevention consists of early detection, which facilitates early treatment, thereby reducing mortality.
  • Melanoma trends indicate reduced rates of mortality, without similarly reduced incidence rates: this indicates that detection efforts have been effective, while primary prevention has been less effective.
  • Clinicians should therefore urge patients to engage in primary prevention measures such as sun protection.

Sunscreen: High Sun Protection Factor (SPF) Formulations

  • Sunscreens labelled with SPF >50 demonstrated greater efficacy in sunburn protection, with SPF 100+ demonstrating significantly greater efficacy than SPF 50 [6].

Sunscreen: Oxybenzone

  • Oxybenzone is a widely used sunscreen ingredient effective in protecting against skin cancer. Clinicians should advise patients regarding the low risks associated with its use and the advantages offered for skin cancer protection.
    • Marine harms: oxybenzone has been suspected as a cause of coral bleaching and other marine harms. Marine harms do not correspond to high oxybenzone concentration levels or locations with larger human populations; such harms may be attributable instead to the impact of climate change on water temperature [7].
    • Estrogenic effects in humans: while estrogenic effects were observed in rats exposed to oxybenzone, such effects were associated with very high levels. In humans, there have been no clinically significant negative effects associated with oxybenzone [7].

B. Risk Factors

  • IVF. Studies do not demonstrate a consistent association between in vitro fertilization (IVF) and melanoma among all infertile women, however, there is a possible increased risk associated with specific ovary-stimulating agents.
  • Cigarette smoking. Melanoma patients with a history of cigarette smoking are at higher risk of developing metastatic disease and have decreased survival rates [8].

A. Diagnostics

  • Clinical approaches are enhanced with applied technology and innovations.
  • Physical examination (by clinician or patient self-examination) plays an important role in early detection, with the visual appearance of melanoma exhibiting the following characteristics:
    • A – asymmetry;
    • B – border irregularity;
    • C – color change;
    • D – diameter bigger than ¼ inch;
    • E – evolving (color and size change) [9].

B. Technology

  • Computer Assisted Melanoma diagnostics are available, but their practical application for everyday clinical use has not yet been established.
  • Electrical Impedance Spectroscopy (EIS) Score. EIS score has been shown to result in a change in clinicians’ decision to biopsy in approximately 25% of cases, leading to improved diagnostic accuracy [10]. While the overall number of biopsies remained similar, a higher proportion of lesions biopsied were in fact melanoma rather than benign [10].

C. Genomics

  • Genomics is playing an increasingly essential role in diagnosis, prognosis, and advanced disease response.
  • For example, gene expression testing 2-GEP test is an accurate method for classifying melanoma and non-melanoma lesions and can reduce costs and improve outcomes by more efficiently detecting early melanoma and reducing the need for biopsy [11].

Key Messages/Clinical Perspectives

  • Clinical management of skin cancer emphasizes counselling patients regarding primary preventive strategies, implementing secondary preventive strategies such as screening, and decision-making regarding biopsy.
  • Personalized medicine approaches involving advances in genomics can assist in diagnosis, prognosis, and treatments.


Presenter disclosure(s): The presenter has reported relationships with the following companies: Aclaris Therapeutics, Inc.; Beiersdorf, Inc.; Castle Biosciences; Derm Tech International; Ferndale Laboratories, Inc.; Foamix; LEO Pharma, US; Myriad Genetics Inc; Novartis; Ortho Dermatologics; Pierre Fabre Dermo-Cosmétique US; SciBASE.

Written by: Daniel Bennett, MPH

Reviewed by: Martina Lambertini, MD


Welcome to the Highlights from AAD 2019

Prof. Nellie Konnikov, MD, FAAD

We are pleased to present highlights from the 2019 Annual Meeting of the American Academy of Dermatology (AAD). Our meeting was held from March 1 to March 5, 2019 in Washington, DC. The AAD conference … [ Read all ]

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