Treatment Options for Skin Cancer

Surgery is the primary treatment for skin cancer. Sometimes, however, it may need to be followed up with other types of therapy.

There are several different ways to treat skin cancer surgically. The method your doctor recommends depends on the size and place of the growth and other factors. 

• Simple Excision is surgery to remove the tumor and some of the normal tissue around it. Depending on where the skin cancer is located, a local anesthesia may be all that’s needed. This is the most common way of treating nonmelanoma skin cancers. 
• Wide-local excision (WLE) or excisional skin surgery is the most common and typically the first treatment to remove melanoma. It can also be used for non-melanoma removal if your doctor feels it’s necessary. After numbing the area, the surgeon removes the growth with a scalpel. The surgeon also removes a border of skin around the growth; this skin is the margin. The margin is examined under a microscope to be certain that all the cancer cells have been removed. The size of the margin depends on the size of the growth. Some of the lymph nodes may also be removed.

There are additional surgical procedures that may be done to determine if melanoma has spread to the lymph nodes.

• Lymphadenectomy may be used for treatment of melanoma. A surgical procedure in which the lymph nodes are removed and a sample of tissue is checked under a microscope for signs of cancer.
• Sentinel lymph node biopsy is the removal of the sentinel lymph node (the first lymph node the cancer is likely to spread to from the tumor) during surgery. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes. This is most commonly needed for melanoma patients.

Repair of the skin to be sure the wound heals from the removal of the cancer may require additional surgeries, depending on how large of an area was affected.

• Grafts are sometimes needed to close an opening in the skin left by surgery. The surgeon first numbs and then removes a patch of healthy skin from another part of the body, such as the upper thigh. The patch is then used to cover the area where skin cancer was removed. If you have a skin graft, you may have to take special care of the area until it heals.

Other skin cancer surgeries primarily used for non-melanoma patients include:

• Shave excision is used when there is an area that does not appear to be melanoma but could be skin cancer. A small blade is used to shave off the surface of the skin so that it can be tested for cancer cells. 
• Curettage and electrodesiccation, also known as electrosurgery, is often used to remove small basal cell skin cancers. The doctor numbs the area to be treated and then the cancer is removed with a curette— a sharp tool shaped like a spoon. Next, an electric current is sent into the treated area to control bleeding and kill any cancer cells that may be left. Electrodesiccation and curettage is usually a fast and simple procedure.
• Mohs surgery (also called Mohs micrographic surgery) is often used for skin cancer. A specially-trained surgeon shaves away thin layers of the growth after the area of is numbed. Each layer is immediately examined under a microscope. The surgeon continues to shave away tissue until no cancer cells can be seen under the microscope. In this way, the surgeon can remove all the cancer and only a small bit of healthy tissue.
• Cryosurgery is often used for people who are unable to have other types of surgery. It uses extreme cold, created by liquid nitrogen, to treat early stage or very thin skin cancer. The doctor applies liquid nitrogen directly to the skin growth. Sometimes, this treatment may cause swelling. It also may damage nerves, which can cause a loss of feeling in the damaged area. The NCI fact sheet “Cryosurgery in Cancer Treatment: Questions and Answers” has more information.
• Laser surgery uses a narrow beam of light to remove or destroy cancer cells. It is most often used for growths that are on the outer layer of skin only and rarely used for basal cell skin cancers. The NCI fact sheet “Lasers in Cancer Treatment: Questions and Answers” has more information.

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.

Topical Chemotherapy for Non-melanomas

When a drug is put directly on the skin, the treatment is topical chemotherapy. This method is most often used for non-melanomas. It can be helpful when the skin cancer is too large for surgery, or when the doctor keeps finding new skin cancers. Most often, the drug comes in a cream or lotion and is usually applied to the skin one or two times a day for several weeks. 

A drug called fluorouracil (5-FU) is a common topical chemo used to treat basal cell cancers that are in the top layer of the skin only. Other topical chemotherapy drugs are available and the right one for you will be determined by your skin cancer specialist.

Chemotherapy for Melanomas

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. This is called systemic chemotherapy. It’s used primarily if the lymph nodes showed signs of cancer cells being present.

The type and stage of the cancer being treated will determine the way in which chemotherapy is given. One unique way of administering chemo for melanoma patients is with regional chemotherapy.

The chemotherapy is placed directly into the patient’s limb where cancer is present such as an arm or leg. The flow of blood to and from the limb is temporarily stopped with a tourniquet, allowing a high dose of drugs to affect primarily the area where the cancer was found.

Radiation therapy (also called radiotherapy) is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. The rays come from a large machine outside the body (external radiation) which are aimed at only the area where the skin cancer is present. Minnesota Oncology offers outpatient radiation therapy at our offices in the Minneapolis-St. Paul area.

Radiation therapy is used for a few different reasons:

• To kill any left over cancer cells around the area where the surgery was done.
• When surgery would be difficult or leave a bad scar such as on the eyelid, ear, or nose. 
• If the cancer comes back after surgery.

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

PDT is used to treat cancer on or very near the surface of the skin. It’s not typically recommended for treatment of melanoma.

While there can be side effects of PDT, they usually aren’t serious. PDT may cause burning or stinging pain. It also may cause burns, swelling, or redness. It may scar healthy tissue near the growth. If you have PDT, you will need to avoid direct sunlight and bright indoor light for at least 6 weeks after your skin cancer treatment.

Immunotherapy, sometimes referred to as 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.

It may be used as an additional treatment, after skin cancer surgery, especially for patients who have a higher likelihood of recurrence. 

Interferon and imiquimod are immunotherapy drugs used to treat nonmelanoma skin cancers:

• Interferon (by injection) may be used to treat squamous cell carcinoma of the skin.
• Topical imiquimod (a cream applied to the skin) may be used to treat some basal cell carcinomas.

Melanoma can be treated with several different immunotherapies, some of which are recently introduced as a result of cancer research trials.

• Checkpoint inhibitor therapy helps the immune system to recognize melanoma is present and stimulates the immune cells — specifically T cells — to kill the cancer cells. Checkpoint inhibitors may be used alone or in combination with other cancer treatments to achieve more successful outcomes. 
• Interferon: Interferon affects the division of cancer cells and can slow tumor growth.
• Interleukin-2 (IL-2): IL-2 boosts the growth and activity of many immune cells, especially lymphocytes (a type of white blood cell). Lymphocytes can attack and kill cancer cells.
• Tumor necrosis factor (TNF) therapy: TNF is a protein made by white blood cells in response to an antigen or infection. TNF is made in the laboratory and used as a treatment to kill cancer cells. It is being studied in the treatment of melanoma.

Targeted therapy is a type of treatment that uses drugs or other substances to attack cancer cells. Targeted therapies usually cause less harm to normal cells than chemotherapy or radiation therapy do. 

The following types of targeted therapy are being used in the treatment of skin cancers:

Targeted therapy for nonmelanoma skin cancer - basal cell carcinoma

• Signal transduction inhibitors: A substance that blocks signals that are passed from one molecule to another inside a cell. Blocking these signals may kill cancer cells. 

Targeted therapies for melanoma

• Angiogenesis inhibitors: Angiogenesis inhibitors block the growth of new blood vessels. In cancer treatment, they may be given to prevent the growth of new blood vessels that tumors need to grow.
• Oncolytic virus therapy: Oncolytic virus therapy uses a virus that infects and breaks down cancer cells but not normal cells. Radiation therapy or chemotherapy may be given after oncolytic virus therapy to kill more cancer cells.
• Monoclonal antibody therapy: A cancer treatment that uses antibodies made in the laboratory, from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells. Monoclonal antibodies may be used with chemotherapy as adjuvant therapy. Ipilimumab is a monoclonal antibody used to treat melanoma.