Skin Cancer (Face, Nose and Lip)

What is skin?

The skin is divided into two main layers:

• epidermis (outer layer)
• dermis (inner layer)

The epidermis contains three types of cells. On the surface are flat cells, known as squamous cells. Under these are round cells called basal cells. In between the basal cells are melanocytes.

The dermis contains nerve endings, blood vessels, and oil and sweat glands. It’s held together by a protein called collagen.

The hypodermis (subcutaneous fat and connective tissue) attaches the skin to bone and muscles, as well as supplying blood vessels and nerves.

What does the skin do?

The skin is the largest organ in the body with many purposes including:

• acting as a barrier to protect the body from injury and infection
• helping to maintain the body’s temperature
• protecting the body from the harmful effects of ultraviolet (UV) light
• keeping necessary fluids and proteins in the body
• ​detecting the sensations of touch, heat and cold

Diagram of the layers of the skin:

What Causes Skin Cancer?

In Australia, sun exposure is a major risk factor for Skin Cancer. UV exposure in childhood and built up over a lifetime increases the risk of Skin Cancer, especially NMSC.

Other factors that may increase the risk of Skin Cancer are:

• previous skin cancers
• fair complexion and inability to tan
• poor immune system
• family history of melanoma
• having moles on the skin
• genetic predisposition, e.g. basal cell naevus syndrome, dysplatic naevus syndrome, xeroderma pigmentosum

The signs and symptoms of Skin Cancer depend on where the cancer is, type of cancer, its size and how far it has spread in the body.

There are a number of symptoms that may indicate Skin Cancer. Common signs and symptoms may include:

• crusty, non-healing sores (or ulcers)
• small persistent lumps (these can be red, pale or pearly)
• new spots, freckles or lumps
• moles that change in thickness, colour or shape over a period of weeks to months.

Check the parts of your skin that get exposed to sunlight (e.g. face, back and neck) for any changes. If you notice any changes or have any of the symptoms speak to your doctor.

Tests for Skin Cancer

It is important that your doctor establishes the diagnosis and type of Skin Cancer, assesses the extent of the cancer and whether it has spread to the lymph nodes.

To answer these questions your doctor will need to do the following things:

• talk with you about changes to your skin/mole (if any) and discuss other health conditions and medications you are taking (called a medical history)
• use an instrument (dermatoscope) to view the mole clearly
• order some tests

The most common test for Skin Cancer is a biopsy.

Biopsy

​A biopsy involves removing a small piece (sample) from the cancer. The sample is then examined under a microscope to check for cancer cells. This is often the only sure way to tell if you have cancer.

Your doctor may recommend:

• Excision biopsy: to remove the cancer completely with a narrow margin; or if the cancer is large. This may be done in the clinic or in the operating room under general anaesthesia
• Incision biopsy: this is when a doctor removes a small amount of tissue from the affected area using a surgical knife. These are commonly done in the doctor’s office

​For both types of biopsy, your doctor will inject the area with an anaesthetic so that you don’t feel any pain. Depending on the size and location of the biopsy, you may need stitches. There may be some bleeding after the biopsy. If you take blood thinners you may need to stop these before the biopsy.

If the physical examination or other procedures suggest that the cancer has spread to the lymph nodes, your doctor may order a:

• Needle biopsy (also called Fine Needle Aspiration of FNA): This is used when there is a lump (enlarged lymph node) in your neck that could have cancer cells in it. This is done by a radiologist or pathologist using an ultrasound to see that the needle is in the right spot. You may feel a bit uncomfortable during the biopsy.
• Core biopsy: This is used to get more tissue in the biopsy. This is called a core biopsy. It can provide more information than needle biopsy but can be more uncomfortable. Your doctor will decide the type of biopsy that is most appropriate for you.

The most appropriate treatment of Skin Cancer depends on many factors. These include:

• type, size and location of the cancer and whether it has spread
• personal factors (e.g. age, general health and treatment history)
• types of treatment available
• your preferences for treatment

Most common Skin Cancers (e.g. non melanoma Skin Cancer) will be treated by a local excision only.

Skin Cancers become invasive when they breakthrough the bottom layer of the skin (dermis) and invade into the deeper tissues.

Ideally, Skin Cancers are treated when still within the skin - “in situ cancer”.

Treatment of in situ Skin Cancer can be with surgery (including excision or curettage also called scooping), radiation therapy or other treatments including liquid nitrogen therapy (freezing), cautery (using heat) or topical medications (e.g. creams or ointments).

How can I Prepare for the Surgery?

Your doctor will explain details of the surgery, general risks and side effects of surgery. Ask your doctor if you have questions. They may recommend:

• stopping blood thinners (e.g. aspirin) before surgery to reduce the risk of bleeding
• special stockings to reduce the risk of blood clots
• early mobilisation (i.e. not staying in bed) to reduce the risk of blood clots and chest infection
• antibiotics to lower the risk of wound infection.

Before starting treatment, it is important that you consider stopping smoking to reduce the risk of infection and help you fully recovery after your treatment.

Radiation Therapy for Skin Cancer

Radiation therapy can be used to treat both melanoma and NMSC.

Most people with melanoma will have surgery but some people with widespread in situ melanoma, or with metastatic lymph nodes after surgery may be referred to a radiation oncologist to consider having radiation therapy.

The common type of radiation therapy for Skin Cancer is called external beam radiation therapy. This type of radiation therapy is applied from outside of the body. The machines used to deliver radiation therapy for Skin Cancer give less penetrating radiation that is because these Skin Cancers are on the skin surface. Some people will need deeper treatment with deeply penetrating x-rays called megavoltage photons.

Radiation therapy can be used in the following ways:

Definitive

Definitive radiotherapy can be used on its own (without surgery) to cure Skin Cancer.

It may be recommended if surgery is not appropriate because of the size and location of the Skin Cancer or an operation is not safe for the person involved. This therapy is more common for people with a NMSC.

Adjuvant
Done after surgery. It is used as an additional treatment to kill any cancer cells that may not have been removed during surgery.

Palliative
Used to relieve symptoms of advanced Skin Cancer, such as pain and bleeding or if the cancer has spread to other parts of the body such as the bones.

How do I Prepare for Radiation Therapy?

You will meet with many members of the cancer care team, who will help you learn how to look after yourself through radiation therapy, recovery and long term follow-up. They will also talk to you about side effects and how to manage them. It may be helpful to write down questions as they come up, so you can ask anyone in your cancer care team when you see them.

Radiation Therapy Mask-Making and Simulation

Radiation therapy is a precise treatment. In order to make sure, that the cancer is covered by the treatment, you will need to be very still during the treatment, usually for about five minutes. A radiation therapy mask that is made to fit perfectly to your shape, will be put on you during each treatment to help the machine target where the cancer is.

You will have a planning CT scan (and sometimes other scans) with the mask on. Your radiation oncologist and radiation therapists will use these scans with all your other clinical information to develop a radiation therapy plan just for you (a personalised plan). Your plan will be checked by the radiation therapy and radiation oncology physics team before it is ready to be used for your treatment. This whole process can take approximately 2-3 weeks.

Teeth and Mouth Care

You might need to have some of your teeth taken out, this will depend on the area being treated and the dose of radiation therapy. It is important to take out any broken or infected teeth before radiation therapy. Taking out unhealthy teeth after radiation therapy can cause problems with the jaw bone. Further information about removing teeth and what to expect during and after the operation is available here.

Diet, Nutrition and the role of your Dietitian

Your cancer and its treatment can make it hard to eat and drink. Your doctor will recommend you see a dietitian to maximise your nutrition during treatment as well as while you are recovering. Sometime feeding tubes may be recommended depending on the area being treated and the dose of radiation therapy.

There are two common types of feeding tubes:

• Gastrostomy tube (sometimes called a PEG tube): this type of tube is inserted through your abdominal wall into your stomach, with part of the tube staying outside the stomach. A syringe can be attached to the tube to give you food this way if needed. The tube is inserted using a camera through the mouth into the stomach (gastroscopy) or using a CT scanner to guide insertion directly through the skin. If a PEG tube is needed, your doctor will organise this before starting your radiation therapy
  
  
• Nasogastric tube: this type of tube goes through the nose down into the stomach and is usually used for short periods (days or weeks). A nasogastric tube can be inserted at any time (before, during or after treatment).

There are many other aspects of supportive care that will available to you, ask your doctor if you have any specific needs

Side Effects

The side effects of radiation therapy can start during treatment and progress through treatment to peak at the end of treatment and the week after treatment. They begin to improve 2-3 weeks after the end of treatment.

Side effects associated with radiation therapy depend on:

• the dose of radiation therapy
• the area being treated
• whether or not chemotherapy is added to the radiation therapy
• how quickly the treatment is delivered.

Common early side effects of radiation therapy may include:

• tiredness
• skin irritation in the area treated- redness, dryness and itching, weeping skin, scaling or even skin breakdown by the end of treatment
• local loss of beard (in men) or hair if the scalp are treated
• nasal cavity crusting, congestion and bleeding of nose is treated.

Most side effects are short lived and may go away shortly after you finish radiation therapy. Some side effects may last for some time after you finish radiation therapy and some may be permanent.

Once your radiation therapy ends, you will have regular have follow-up appointments, so that your doctor can check your recovery and monitor any side effects that you may have.

Your doctor may recommend specific supportive care options to help you during your treatment and recovery.

Chemotherapy for Skin Cancer

Chemotherapy for non-melanoma Skin Cancers is rarely used but is usually given into a vein through a needle with a cannula (tube) attached. Chemotherapy works by attacking rapidly dividing cells, such as cancer.

People with melanoma may be recommended types of systemic treatment called immunotherapy. Many people with melanoma may also be asked to take part in a clinical trial of different types of these drugs.