Non-melanoma skin cancer: Symptoms, Causes & Treatments

What is Non-Melanoma Skin Cancer? | Symptoms | Causes and Risk Factors | Diagnosis & Staging | Treatment

Key Takeaways

• Early detection is crucial for effective treatment and management of NMSC.
• The two main types of NMSC are Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), with BCC being the more common form.
• Early signs often include new lumps or skin patches that persist for weeks, while varied symptoms may arise as the cancer progresses.
• Individuals with less melanin in their skin, often those with pale skin, are at a higher risk, especially in regions with high ultraviolet radiation exposure​.

 

What is Non-Melanoma Skin Cancer?

One of the most prevalent malignancies in the world is skin cancer. Skin tumors that don’t start as melanoma are referred to as non-melanoma skin cancer.

These more typical types of skin cancer are distinguished from the less frequent melanoma, which spreads more quickly in the body, by the name “non-melanoma.”

The emergence of a lump or patch of skin that doesn’t go away after a few weeks is typically the first indication of non-melanoma skin cancer. Many skin cancers, such as squamous cell carcinomas and pre-malignant conditions such as actinic keratoses, are most common on sites that receive the most exposure to UVR; for example, squamous cell carcinoma is most common on the heads of bald individuals, on the tops of the ears and the backs of the hands. Individuals who have pale skin, which contains less melanin, are at greatest risk of skin cancer. Melanin is a highly effective sunblock protecting normal skin from the mutagenic load of UVR. Skin cancer is most common in those areas that have the greatest ambient UVR (if other factors such as skin color are kept constant). Dramatically increased tumor rates are seen in those with pale skin who have migrated from areas of relatively low to relatively high UVR exposure.^[1]

 

Types of Non-Melanoma Skin Cancer

 

There are two types:

Basal cell carcinoma (BCC)

This is the most common human cancer. Rates are five times higher than for squamous cell carcinoma in European countries.

Squamous cell carcinoma (SCC)

SCC is the second most common skin cancer after BCC and, like other forms of skin cancer, is increasing in age-specific incidence.

 

Symptoms of Non-Melanoma Skin Cancer?

 

Early Signs

The onset of non-melanoma skin cancer is often signaled by the appearance of a lump or skin patch that doesn’t disappear after a few weeks.

 

Progression of Symptoms

As the cancer progresses, the symptoms might evolve over time, and different forms of non-melanoma skin cancer may present varied symptoms.

 

Basal Cell Carcinoma Symptoms

• In the modulo-ulcerative form, the earliest lesion appears as a small, glistening, skin-colored papule, often with fine telangiectatic vessels on the surface, which slowly enlarges.
• Central necrosis may occur, leaving an ulcer surrounded by a rolled pearly edge.
• The lesion may become cystic or pigmented over time.
• The morphotic variant appears as a slowly expanding, yellow, or grey waxy plaque with an ill-defined edge.
• The superficial (multifocal) variant is seen most often on the trunk; it appears as a slowly enlarging pink or brown scaly plaque with a fine ‘whipcord’ edge.^[2]

Identifying a New Mole in BCC

Basal cell carcinoma may also manifest as a change in the skin, such as a new growth or a sore that refuses to heal.

 

Changes in an Existing Mole in BCC

The skin alterations (lesions) typically exhibit traits like a glossy, skin-colored bump that may seem pink, pearly white, glossy black or brown depending on the skin tone, and may bleed and develop a scab.^[3]

 

Squamous Cell Carcinoma Symptoms

• SCC typically presents as proliferative tumors growing over a few months, and its clinical presentations vary including keratotic nodules, exophytic erythematous nodules, infiltrating firm tumors, and ulcers with an indurated edge.^[4]
• It may manifest as a hard lump on the skin, a flat sore covered in a crust of scales, an existing scar or sore with a fresh sore or elevated region, a hard, itchy lip patch that might erupt into an open sore, a painful or rough area inside the mouth, or a raised spot or wart-like sore on the genitalia, the anus, or both.^[5]

Identifying a New Mole in BCC

Basal cell carcinoma may also manifest as a change in the skin, such as a new growth or a sore that refuses to heal.

 

Changes in an Existing Mole in SCC

Changes in an existing mole, such as an increase in size, changes in color, or irregular borders, especially if accompanied by roughness or scaliness, may also be a symptom of SCC.

 

Consultation and Referral

Consult Your GP If

• There’s a growth on your skin that’s enlarging or has altered in color or texture.
• You notice a growth or skin patch that’s painful, itchy, bleeding, or has been crusted or scabbed for over a month.

Detecting non-melanoma skin cancer early enhances the effectiveness of treatment.

 

What happens at your GP appointment

Your doctor might:

• Inquire about your health, symptoms, and the amount of sun exposure you get.
• Ask if there’s been any recent change in the appearance of the growth or skin area in question.
• Discuss any personal or family history of skin cancer.
• Examine the affected skin area. They might consider taking a photograph to forward to a skin specialist (dermatologist) for further examination.

 

Specialist Referral

If your doctor suspects a more serious condition, they might refer you to a hospital specialist for additional tests.

• Non-urgent Referral: Typically, these take up to 18 weeks. Most skin cancers grow slowly and are less likely to spread, so immediate action might not be necessary.
• Urgent Referral: In cases where there’s a higher probability of a severe skin cancer type, you might get an appointment within two weeks.

 

Main Causes and Risk Factors of Non-Melanoma Skin Cancer

Primary Cause

Ultraviolet (UV) Radiation: The leading cause of non-melanoma skin cancer is UV radiation, which originates from the sun and is also emitted by sunbeds.^[6]

 

Risk Factors

• Skin Type: Individuals with pale skin that is prone to burning upon sun exposure.^[7]
• Hair Color: Those with red or fair hair.^[9]
• Eye Color: Possessing blue or green eyes.^[9]
• Physical Characteristics: Having a large number of freckles or moles on the skin.^[7]
• Sun Exposure History: Experiencing frequent sun exposure and having been sunburned multiple times in the past, especially severe sunburns.^[7]
• Sunbed Usage: Regular and extensive use of sunbeds.^[8]
• Family and Personal Medical History: Having a familial history of skin cancer or having been diagnosed with skin cancer previously.^[7]
• Tanning Beds: Using indoor tanning beds increases SCC risk.^[10]
• Precancerous Lesions: Skin lesions like actinic keratosis and Bowen disease can progress into SCC.^[7]
• Weakened Immune System: Individuals with conditions like leukemia, lymphoma, or those on immunosuppressive medications are at higher risk.^[7]
• Genetic Disorders: Conditions like xeroderma pigmentosum increase sunlight sensitivity, posing a significant SCC risk.^[11]
• HPV Infection: The common sexually transmitted infection, human papillomavirus (HPV), amplifies the risk for SCC.^12]
• Chronic Skin Injuries: Long-standing scars, burns, or non-healing sores can be sites where SCC develops.^[7]

Reducing the Risk of Skin Cancer

Protecting yourself from excessive sun exposure is essential to reduce the risk of skin cancer.

Here are strategies to consider when spending time outdoors:

• Avoid direct sunlight during peak intensity hours, typically between 10 am and 4 pm in the U.S.
• Wear protective clothing like long sleeves, pants, and a wide-brimmed hat, along with sunglasses that offer UV protection.
• Choose a broad-spectrum sunscreen with an SPF of at least 30 and a rating for high UVA protection. Remember to reapply frequently, especially after swimming or sweating.
• Always ensure children are adequately protected when outdoors. Their skin is more delicate and susceptible to the sun’s harmful rays.

 

Diagnostic Procedures and Staging

 

Diagnosis

Both carcinomas are diagnosed by

1. History
2. Examination
3. Investigations-CBC
4. Biopsies-punch, Incisional, Excisional, and shave.
5. To investigate the metastasis-CT scan and MRI imaging.

 

Staging

 

Basal Cell Carcinoma (BCC) Staging:

1. Stage 0 (carcinoma in situ): Cancer is localized only in the epidermis or top skin layer. It hasn’t invaded deeper tissues or lymph nodes.
2. Stage 1: The tumor measures less than 2 cm and hasn’t spread to lymph nodes or other organs. However, there might be features increasing the likelihood of recurrence or spread, such as its location near the ear or its growth into small nerves.
3. Stage 2: The tumor is more than 2 cm in size. Though it hasn’t spread to nearby lymph nodes or other organs, it possesses multiple features that make recurrence or metastasis likely.
4. Stage 3: The cancer has invaded local lymph nodes or facial bones, but it hasn’t metastasized to other organs.
5. Stage 4: The cancer has metastasized to various lymph nodes, bones, or other organs, irrespective of its size.

 

Squamous Cell Carcinoma (SCC) Staging:

1. Stage 0: The cancer remains limited to the epidermis or topmost skin layer.
2. Stage 1: The cancer has penetrated deeper skin layers but hasn’t spread to nearby lymph nodes or other tissues.
3. Stage 2: The cancer has invaded deeper skin layers and exhibits high-risk attributes (like nerve invasion), but hasn’t metastasized to lymph nodes or other tissues.
4. Stage 3: The cancer has metastasized to lymph nodes but not to distant organs.
5. Stage 4: The cancer has spread to distant organs like the lungs, liver, brain, or to distant skin areas.

 

Prognosis

• The outcome largely depends on the stage at detection.
• Early diagnosis often allows for complete excision.
• SCC generally has a high survival rate, with a 99% five-year survival rate when detected early.
• BCC typically has an excellent prognosis.

 

Treatment for Non-Melanoma Skin Cancer

Non-melanoma skin cancer treatment efficacy usually remains high. The approach is tailored based on the cancer type, location, whether it has spread, and the patient’s overall health.

Surgery: Primary Treatment

• Mainstay for early-stage non-melanoma skin cancers.
• Methods include:
  • Excisional biopsy: Removes the tumor along with some surrounding healthy skin.
  • Cryosurgery: Freezes the affected skin, leading to scab formation that falls off within weeks.
• Advanced cases or recurrent tumors might require extensive surgery, sometimes necessitating a skin graft from another body part.

Radiotherapy: Radiation-Based Approach

• Used in cases with a large cancer area, challenging surgical locations, health concerns prohibiting surgery, or lymph node involvement.
• Can be adjunctive post-surgery to minimize recurrence risks.

Targeted Medicines & Immunotherapy

• These act specifically on cancer growth mechanisms or boost the immune system’s capability to fight cancer.
• Recommended in multifocal skin cancer, when cancer has penetrated deeper skin layers, or if other treatments aren’t feasible.

Photodynamic Therapy: Light-Driven Treatment

• Suitable for surface-level non-melanoma skin cancers that aren’t very thick.
• Administered in hospitals: a light-sensitive drug (via cream, tablet, or injection) is given, and post absorption by cancer cells, a light source is directed at the area, initiating a reaction that kills the cancer cells.

Chemotherapy: Medication-Based Approach

• Topical chemotherapy: Used for surface-layer-only cancers, typically applied for 3 to 4 weeks.
• Intravenous chemotherapy is sparingly used for skin cancer.

 

Follow-Up & Monitoring

Post-treatment, regular check-ups are crucial. Depending on the non-melanoma stage, certain tests or scans may be necessary. Patients are urged to promptly report any concerning symptoms or side effects without waiting for scheduled check-ups.