Nonmelanoma Skin Cancer

skin anatomy

Skin cancer is a disease in which malignant (cancer) cells form in the tissues of the skin. The skin is the body’s largest organ. It protects against heat, sunlight, injury, and infection. Skin also helps control body temperature and stores water, fat, and vitamin D. The skin has several layers, but the two main layers are the epidermis (upper or outer layer) and the dermis (lower or inner layer). Skin cancer begins in the epidermis, which is made up of three kinds of cells:

  • Squamous cells: Thin, flat cells that form the top layer of the epidermis.
  • Basal cells: Round cells under the squamous cells.
  • Melanocytes: Cells that make melanin and are found in the lower part of the epidermis. Melanin is the pigment that gives skin its natural color. When skin is exposed to the sun, melanocytes make more pigment and cause the skin to darken.

Skin cancer can occur anywhere on the body, but it is most common in skin that is often exposed to sunlight, such as the face, neck, hands, and arms.

There are different types of cancer that start in the skin. The most common types are basal cell carcinoma and squamous cell carcinoma, which are nonmelanoma skin cancers. Nonmelanoma skin cancers rarely spread to other parts of the body. Melanoma is the rarest form of skin cancer. It is more likely to invade nearby tissues and spread to other parts of the body. Actinic keratosis is a skin condition that sometimes becomes squamous cell carcinoma.

This page is about nonmelanoma skin cancer and actinic keratosis. Find information about melanoma here.

Risk Factors
Symptoms
Screening and Diagnosis
Staging
Treatment
Support

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Risk Factors

Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. Talk with your doctor if you think you may be at risk. Risk factors for basal cell carcinoma and squamous cell carcinoma include the following:

  • Being exposed to natural sunlight or artificial sunlight (such as from tanning beds) over long periods of time.
  • Having a fair complexion, which includes the following:
    • Fair skin that freckles and burns easily, does not tan, or tans poorly.
    • Blue or green or other light-colored eyes.
    • Red or blond hair.
  • Having actinic keratosis.
  • Past treatment with radiation.
  • Having a weakened immune system.
  • Having certain changes in the genes that are linked to skin cancer.
  • Being exposed to arsenic.

Risk factors for actinic keratosis include the following:

  • Being exposed to natural sunlight or artificial sunlight (such as from tanning beds) over long periods of time.
  • Having a fair complexion, which includes the following:
    • Fair skin that freckles and burns easily, does not tan, or tans poorly.
    • Blue or green or other light-colored eyes.
    • Red or blond hair.

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Symptoms

Not all changes in the skin are a sign of nonmelanoma skin cancer or actinic keratosis. Check with your doctor if you notice any changes in your skin.

Possible signs of nonmelanoma skin cancer include the following:

  • A sore that does not heal.
  • Areas of the skin that are:
    • Raised, smooth, shiny, and look pearly.
    • Firm and look like a scar, and may be white, yellow, or waxy.
    • Raised, and red or reddish-brown.
    • Scaly, bleeding or crusty.
Possible signs of actinic keratosis include the following:
  • A rough, red, pink, or brown, raised, scaly patch on the skin that may be flat or raised.
  • Cracking or peeling of the lower lip that is not helped by lip balm or petroleum jelly.

Huntsman Cancer Institute recommends that people examine their skin monthly to get familiar with individual patterns of moles and freckles, and to look for symptoms of cancerous skin changes. If you abnormal changes are found, visit a dermatologist as soon as possible.

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Screening and Diagnosis

Current screening recommendations for skin cancer include the following:

  • A monthly skin self-exam to look for symptoms of cancerous skin changes.
    1. Examine the body from all sides in front of a mirror. Bend the elbows and look carefully at the forearms, upper arms, and palms.
    2. Look at the backs of the legs and feet, the soles, and spaces between the toes.
    3. Examine the back of the neck and scalp with a hand mirror, parting and lifting the hair. Also, check the back, buttocks, and genital area.
  • A yearly skin exam by a dermatologist. Learn about HCI's annual free skin cancer screening by calling the G. Mitchell Morris Cancer Learning Center at 1-888-424-2100.

Tests or procedures that examine the skin are used to detect (find) and diagnose nonmelanoma skin cancer and actinic keratosis. The following procedures may be used:

  • Skin exam: A doctor or nurse checks the skin for bumps or spots that look abnormal in color, size, shape, or texture.
  • Skin biopsy: All or part of the abnormal-looking growth is cut from the skin and viewed under a microscope by a pathologist to check for signs of cancer. There are four main types of skin biopsies:
    • Shave biopsy: A sterile razor blade is used to “shave-off” the abnormal-looking growth.
    • Punch biopsy: A special instrument called a punch or a trephine is used to remove a circle of tissue from the abnormal-looking growth.
    • Incisional biopsy: A scalpel is used to remove part of a growth.
    • Excisional biopsy: A scalpel is used to remove the entire growth.

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Staging

After nonmelanoma skin cancer has been diagnosed, tests are done to find out if cancer cells have spread within the skin or to other parts of the body. The process used to find out if cancer has spread within the skin or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.

The following tests and procedures may be used in the staging process:

  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
  • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • Lymph node biopsy: For squamous cell carcinoma, the lymph nodes may be removed and checked to see if cancer has spread to them.

There are three ways that cancer spreads in the body:

  • Through tissue. Cancer invades the surrounding normal tissue.
  • Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
  • Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

  • Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
  • Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if skin cancer spreads to the lung, the cancer cells in the lung are actually skin cancer cells. The disease is metastatic skin cancer, not lung cancer.

Staging of nonmelanoma skin cancer depends on whether the tumor has certain "high-risk" features and if the tumor is on the eyelid. Staging for nonmelanoma skin cancer that is on the eyelid is different from staging for nonmelanoma skin cancer that affects other parts of the body.

The following are high-risk features for nonmelanoma skin cancer that is not on the eyelid:

  • The tumor is thicker than 2 millimeters.
  • The tumor is described as Clark level IV (has spread into the lower layer of the dermis) or Clark level V (has spread into the layer of fat below the skin).
  • The tumor has grown and spread along nerve pathways.
  • The tumor began on an ear or on a lip that has hair on it.
  • The tumor has cells that look very different from normal cells under a microscope.

The following stages are used for nonmelanoma skin cancer that is not on the eyelid:

Stage 0 (Carcinoma in Situ)

In stage 0, abnormal cells are found in the squamous cell or basal cell layer of the epidermis (topmost layer of the skin). These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Stage I

In stage I, cancer has formed. The tumor is not larger than 2 centimeters at its widest point and may have one high-risk feature.

Stage II

In stage II, the tumor is either:

  • larger than 2 centimeters at its widest point; or
  • any size and has two or more high-risk features.

Stage III

In stage III:

  • The tumor has spread to the jaw, eye socket, or side of the skull. Cancer may have spread to one lymph node on the same side of the body as the tumor. The lymph node is not larger than 3 centimeters.
    or
  • Cancer has spread to one lymph node on the same side of the body as the tumor. The lymph node is not larger than 3 centimeters and one of the following is true:
    • the tumor is not larger than 2 centimeters at its widest point and may have one high-risk feature; or
    • the tumor is larger than 2 centimeters at its widest point; or
    • the tumor is any size and has two or more high-risk features.

Stage IV

In stage IV, one of the following is true:

  • The tumor is any size and may have spread to the jaw, eye socket, or side of the skull. Cancer has spread to one lymph node on the same side of the body as the tumor and the affected node is larger than 3 centimeters but not larger than 6 centimeters, or cancer has spread to more than one lymph node on one or both sides of the body and the affected nodes are not larger than 6 centimeters; or
  • The tumor is any size and may have spread to the jaw, eye socket, skull, spine, or ribs. Cancer has spread to one lymph node that is larger than 6 centimeters; or
  • The tumor is any size and has spread to the base of the skull, spine, or ribs. Cancer may have spread to the lymph nodes; or
  • Cancer has spread to other parts of the body, such as the lung.

The following stages are used for nonmelanoma skin cancer on the eyelid:

Stage 0 (Carcinoma in Situ)

In stage 0, abnormal cells are found in the epidermis (topmost layer of the skin). These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Stage I

Stage I is divided into stages IA, IB, and IC.

  • Stage IA: The tumor is 5 millimeters or smaller and has not spread to the connective tissue of the eyelid or to the edge of the eyelid where the lashes are.
  • Stage IB: The tumor is larger than 5 millimeters but not larger than 10 millimeters or has spread to the connective tissue of the eyelid or to the edge of the eyelid where the lashes are.
  • Stage IC: The tumor is larger than 10 millimeters but not larger than 20 millimeters or has spread through the full thickness of the eyelid.

Stage II

In stage II, one of the following is true:

  • The tumor is larger than 20 millimeters.
  • The tumor has spread to nearby parts of the eye or eye socket.
  • The tumor has spread to spaces around the nerves in the eyelid.

Stage III

Stage III is divided into stages IIIA, IIIB, and IIIC.

  • Stage IIIA: To remove all of the tumor, the whole eye and part of the optic nerve must be removed. The bone, muscles, fat, and connective tissue around the eye may also be removed.
  • Stage IIIB: The tumor may be anywhere in or near the eye and has spread to nearby lymph nodes.
  • Stage IIIC: The tumor has spread to structures around the eye or in the face, or to the brain, and cannot be removed in surgery.

Stage IV

The tumor has spread to distant parts of the body.

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Treatment

Treatment is based on the type of nonmelanoma skin cancer or other skin condition diagnosed:

  • Basal cell carcinoma is the most common type of skin cancer. It usually occurs on areas of the skin that have been in the sun, most often the nose. Often this cancerappears as a raised bump that looks smooth and pearly. Another type looks like a scar and is flat and firm and may be white, yellow, or waxy. Basal cell carcinoma my spread to tissues around the cancer, but it usually does not spread to other parts of the body.
  • Sqamous cell carcinoma occurs on areas of the skin that have been in the sun, such as the ears, lower lip, and the back of the hands. Squamous cell carcinoma may also appear on areas of the skin that have been burned or exposed to chemicals or radiation. Often this cancer appears as a firm red bump. The tumor may feel scaly, bleed, or form a crust. Squamous cell tumors may spread to nearby lymph nodes. Squamous cell carcinoma that has not spread can usually be cured.
  • Actinic keratosis is a skin condition that is not cancer, but sometimes changes into squamous cell carcinoma. It usually occurs in areas that have been exposed to the sun, such as the face, the back of the hands, and the lower lip. It looks like rough, red, pink, or brown scaly patches on the skin that may be flat or raised, or the lower lip cracks and peels and is not helped by lip balm or petroleum jelly.

At Huntsman Cancer Institute, skin cancer is treated by a team of specialists, including dermatologists (doctors who specialize in diseases of the skin), medical oncologists, radiation oncologists, nurses, social workers, dietitians, and other professionals.

Different types of treatment are available for patients with nonmelanoma skin cancer and actinic keratosis. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Five types of standard treatment are used:

New treatments are being tested in clinical trials.

Surgery

One or more of the following surgical procedures may be used to treat nonmelanoma skin cancer or actinic keratosis:

  • Mohs micrographic surgery: The tumor is cut from the skin in thin layers. During surgery, the edges of the tumor and each layer of tumor removed are viewed through a microscope to check for cancer cells. Layers continue to be removed until no more cancer cells are seen. This type of surgery removes as little normal tissue as possible and is often used to remove skin cancer on the face. Watch our video about Mohs urgery to learn more:

 

  • Simple excision: The tumor is cut from the skin along with some of the normal skin around it.
  • Shave excision: The abnormal area is shaved off the surface of the skin with a small blade.
  • Electrodesiccation and curettage: The tumor is cut from the skin with a curette (a sharp, spoon-shaped tool). A needle-shaped electrode is then used to treat the area with an electric current that stops the bleeding and destroys cancer cells that remain around the edge of the wound. The process may be repeated one to three times during the surgery to remove all of the cancer.
  • Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormal tissue, such as carcinoma in situ. This type of treatment is also called cryotherapy.
  • Laser surgery: A surgical procedure that uses a laser beam (a narrow beam of intense light) as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.
  • Dermabrasion: Removal of the top layer of skin using a rotating wheel or small particles to rub away skin cells.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Chemotherapy for nonmelanoma skin cancer and actinic keratosis is usually topical (applied to the skin in a cream or lotion). The way the chemotherapy is given depends on the condition being treated.

Retinoids (drugs related to vitamin A) are sometimes used to treat squamous cell carcinoma of the skin.

Photodynamic therapy

Photodynamic therapy (PDT) is a cancer treatment that uses a drug and a certain type of laser light to kill cancer cells. A drug that is not active until it is exposed to light is injected into a vein. The drug collects more in cancer cells than in normal cells. For skin cancer, laser light is shined onto the skin and the drug becomes active and kills the cancer cells. Photodynamic therapy causes little damage to healthy tissue.

Biologic therapy

Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

Interferon and imiquimod are biologic agents used to treat skin cancer. Interferon (by injection) may be used to treat squamous cell carcinoma of the skin. Topical imiquimod therapy (a cream applied to the skin) may be used to treat some small basal cell carcinomas.

Clinical trials

These studies discover and evaluate new and improved cancer treatments. Patients are encouraged to talk with their doctors about participating in a clinical trial or any questions regarding research studies. For more information, visit HCI's clinical trials website.

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Support

When you or someone you love is diagnosed with cancer, concerns about treatments and managing side effects, hospital stays, and medical bills are common. You may also worry about caring for your family, employment, or how to continue normal daily activities.

There are several places you can go for support:

  • Your health care team can answer your questions and talk to you about your concerns. They can help you with any side effects and keep you informed of all your treatments, test results, and future doctor visits.
  • The G. Mitchell Morris Cancer Learning Center has hundreds of free brochures and more than 3,000 books, DVDs, and CDs available for checkout. You can browse the library, perform Internet research, or talk with a cancer information specialist.
  • Our Patient and Family Support Services offer emotional support and resources for coping with cancer and its impact on daily life to HCI patients and their families.
  • The Linda B. and Robert B. Wiggins Wellness-Survivorship Center offers many programs to increase the quality of life and well-being of HCI patients and their families.

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Adapted from the National Cancer Institute's Physician Data Query (PDQ®) Cancer Information Summaries
This information last updated on HCI website April 2014

*If you are interested in a trial that is currently marked *Not Open, please contact the Patient Education team at 1-888-424-2100 or patient.education@hci.utah.edu for other trial options. Enrollment is updated daily.

Forte Research Systems in partnership with Huntsman Cancer Institute

Robert Hans Ingemar Andtbacka, M.D., C.M.

Locations
Huntsman Cancer Institute (801) 587-8808

Specialties: Gastrointestinal Stromal Tumors, Melanoma Surgery, Melanoma and Cutaneous Oncology, Oncology, Oncology Surgery, Sarcoma, Soft Tissue Sarcoma Surgery, Soft Tissue Sarcomas, Surgery, General

Glen M. Bowen, M.D.

Locations
Huntsman Cancer Institute (801) 581-2955

Specialties: Cutaneous Lymphoma, Dermatology, Melanoma Surgery, Melanoma and Cutaneous Oncology, Mohs Surgery

Keith Duffy, M.D.

Locations
Dermatology & Laser Center (801) 581-2955
Huntsman Cancer Institute (801) 581-2955
Redstone Health Center (435) 658-9262
South Jordan Health Center (801) 581-2955
University Hospital (801) 581-2955

Specialties: Cutaneous Lymphoma, Dermatology, Dermatopathology, General Dermatology, Melanoma Surgery, Melanoma and Cutaneous Oncology, Mohs Surgery

Mark J. Eliason, M.D.

Locations
Dermatology Murray Clinic (801) 581-2955
University Hospital (801) 581-2955

Specialties: Allergic Skin Diseases, Dermatology, General Dermatology, Melanoma and Cutaneous Oncology

Douglas Grossman, M.D., Ph.D.

Locations
Huntsman Cancer Hospital (801) 581-2955

Specialties: Dermatology, Melanoma Surgery, Melanoma and Cutaneous Oncology

Payam Tristani-Firouzi, M.D.

Locations
Dermatology & Laser Center (801) 581-2955
Dermatology Murray Clinic (801) 581-2955
University Hospital (801) 581-2955

Specialties: Dermatology, Laser and Cosmetic Dermatology, Melanoma and Cutaneous Oncology, Mohs Surgery

David A. Wada, M.D.

Locations
Huntsman Cancer Hospital (801) 581-2955
University Hospital (801) 581-2955

Specialties: Cutaneous Lymphoma, Dermatology, Dermatopathology, Melanoma and Cutaneous Oncology

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travis hakala skin cancer Melanoma and Cutaneous Oncology Program
Care coordinator: Travis Hakala
Phone: 801-585-0209
E-mail:travis.hakala@hci.utah.edu

Did You Know?

  • A person will sunburn 30% faster in Salt Lake City than in Los Angeles. This is because the UV intensity is much greater at Salt Lake City's high altitude.
  • For best skin protection, look for a broad-spectrum sunblock that contains zinc oxide or titanium dioxide with an SPF 30 or higher.
  • Huntsman Cancer Institute offers an annual free skin cancer screening. Call the Cancer Learning Center at 1-888-424-2100 for more information.
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