Treatment for skin cancer

More than 9 out of 10 people (90%) with basal cell and squamous cell cancers are completely cured by the original treatment. A list of treatments is below:

Types of treatment

Surgery is an important treatment for many skin cancers. Surgery can be done in a variety of ways. Small cancers can usually be removed under local anaesthetic.

When larger tumours are removed, skin grafts or flaps are sometimes needed to replace the removed skin. A skin graft is a thin layer of healthy skin taken from another part of the body. This is done under either a local or general anaesthetic. In many cases, surgery is the only treatment needed. Rarely, patients with squamous cell skin cancers will also have surgery to remove nearby lymph nodes .

Radiotherapy may be used instead of surgery. It can be a very effective alternative for basal and squamous cell cancers. Radiotherapy is often used in areas of the face where surgery might be difficult or cause unacceptable scarring. However, its use is not recommended in young people as it causes skin damage which becomes more visible over the years.

Radiotherapy may be given after surgery if there is a risk that some cancer cells may still be present. Sometimes it is used for tumours that have grown into the deeper layers of the skin.

Cryotherapy destroys cancer cells by using liquid nitrogen to freeze them. It is a very quick way of treating small, low-risk skin cancers.

Photodynamic therapy (PDT) is a newer treatment for skin cancer. It uses light sources, combined with a light-sensitive drug (sometimes called a photosensitising agent) to destroy cancer cells.

Topical chemotherapy Some early squamous cell carcinomas (SCCs) and superficial BCCs can be treated using a chemotherapy cream, containing a drug called 5FU (Efudix®). The cream is applied directly to the skin cancer and it works by destroying the cancer cells.

Topical immunotherapy Another cream that is used to treat some BCCs and SCCs uses the immune system to attack the cancer cells. The cream is also applied directly to the skin cancer and is known as imiquimod (Aldara®).

Planning treatment

Your doctor will plan your treatment taking into account a number of factors including:

• your age
• your general health
• the type of skin cancer
• the size of the cancer
• where it is on your body
• what the cells look like under the microscope.

You may be asked to take part in a clinical trial of a new treatment. A team of doctors and other staff will work together to decide the best treatment for you. They will follow national cancer treatment guidelines.

Discussing your treatment

Don't be afraid to ask your doctor or nurse if you have any questions about your treatment. It often helps to make a list of questions. You may want to take a close friend or relative with you to appointments. They can remind you of questions you want to ask, and afterwards help you remember what was said.

Giving your consent

Before you have any treatment, your doctor will explain its aims. You will usually be asked to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent. Before you are asked to sign the form you should be given full information about:

• the type and extent of the treatment you are advised to have
• the advantages and disadvantages of the treatment
• any other treatments that may be available
• any significant risks or side effects of the treatment.

If you don't understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it's not unusual for people to need repeated explanations.

It's often a good idea to have a friend or relative with you when the treatment is explained. This can help you remember the discussion more fully.

People often feel that hospital staff are too busy to answer their questions, but it's important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions. You can talk to the specialist nurse in dermatology at the hospital or our cancer support specialists on 0808 808 00 00.

Second opinion

Usually a number of cancer specialists work together as a team and they use national treatment guidelines to decide on the most suitable treatment for a person. Even so, you may want to have another medical opinion. Either your specialist, or your GP, should be willing to refer you to another specialist for a second opinion, if you feel it will be helpful.

Getting a second opinion may delay the start of your treatment, so you and your doctor need to be confident that it will give you useful information.

If you do go for a second opinion, it may be a good idea to take a friend or relative with you and have a list of questions ready, so that you can make sure your concerns are covered during the discussion.

Surgery for skin cancer

Surgery is the most common treatment for skin cancer. How it is done depends mostly on the size of the cancer.

Small cancers can often be removed by cutting them out (excision), or by a technique known as curettage and electrocautery .

Larger tumours are more likely to be cut out (excised) and the skin replaced with a skin graft or a skin flap if necessary.

A type of surgery called Mohs micrographic surgery (or margin-controlled excision) is used in some hospitals in the UK.

Excision

Many small skin cancers are removed by simple surgery. The surgeon or dermatologist will remove the lump and also some normal-looking skin around it to try to make sure that the cancer has completely gone.

You will have stitches that may need to be removed 5-14 days after your operation.

Sometimes surgeons use stitches that dissolve and don't need to be removed.

Most operations will be done under local anaesthetic and you'll probably be able to go home the same day. The wound will be covered by a dressing. The staff at the hospital will explain how to take care of the area and the dressing. If necessary, they can arrange for your district nurse to change your dressings at home.

Skin grafts and skin flaps

If the tumour is large or spreading, a larger area of skin may have to be removed. You may then need a skin graft skin graft or, less commonly, a skin flap to cover the wound. Skin grafts and flaps are layers of skin taken from another part of the body and placed over the area from which the skin cancer has been removed.

A skin graft is a very thin layer of skin. The surgeon (often a plastic surgeon) will take a layer of skin from another part of the body (known as the donor site). The inner thigh is a common place from which to take the skin. It is then put over the area where the cancer has been removed.

A skin flap is a slightly thicker layer of skin which is taken from an area very close to the wound where the cancer has been removed. The flap is cut away but left partly connected so it still has a blood supply. It is moved over the wound and stitched in place. This is a very specialised type of surgery and you may have to travel to a different hospital to have it.

If you have a skin graft you can probably go home the same day. But if the graft is large, or if you have a skin flap, you may have to stay in hospital for up to four days. You may also have to stay in hospital if you have other health problems. With a skin graft you will normally have a dressing over the area to press the graft down. This helps it to create a good blood supply from the blood vessels underneath.

A skin graft for the face will usually be taken from behind the ear or the neck area to try to get a good match for the skin colour. The area where the graft has been placed will look very noticeable to begin with, but will heal within about two weeks or so. It will then fade so that it is less obvious.

Sometimes a graft is taken from the thigh area: this takes about two weeks or more to heal and may be a bit sore. The area from which the graft was taken will also become less noticeable when it has healed.

Mohs' micrographic surgery

This is very specialist surgery and is only available at a few hospitals in the UK. Your specialist may refer you to one of these centres if they think that this technique may be necessary for you.

In Mohs surgery, the tumour is removed piece by piece. As each piece is removed, it is examined under a microscope straight away. Skin tissue is gradually removed until there are no signs of any cancer cells. This technique aims to remove as little healthy skin as possible, while making sure that all the cancer has been taken away.

Mohs surgery is particularly useful for basal cell cancers that have come back in the same place, or where the doctor thinks that the cancer has begun to spread into the surrounding area. It is also sometimes used for skin cancers on the face (to minimise the effects of surgery) or for large skin cancers. The procedure is often done under local anaesthetic and you are usually allowed to go home the same day.

If you are having a large tumour removed, you may also need to have a skin graft or flap to cover the wound.

Curettage and electrocautery

This means scraping away the cancer and using heat or electricity to stop any bleeding. First you will be given a local anaesthetic. When the area is numb, the doctor will scrape away the cancer using a spoon-shaped instrument called a curette. An electrically heated loop or needle is then applied to cauterise the wound (stop any bleeding) and destroy any remaining cancer cells. Usually this treatment gives good cosmetic results. A few people may develop some scarring which may be more noticeable if you have fair skin.

Removing lymph glands

If there is evidence that squamous cell cancer has spread, you may need to have some lymph glands removed. This operation, called a lymphadenectomy, is done to see whether there are any cancer cells in the lymph glands. If cancer cells are present, removing the lymph glands can also help to prevent further spread. This is quite a large operation and is done under a general anaesthetic.

It is only necessary for a very small number of people who have squamous cell cancer and is not done for patients with basal cell cancer as these types of skin cancer almost never spread to the lymph nodes.

After a lymphadenectomy, you will have tubes (drains) in place to allow fluid to drain from the wound. These will be removed a few days after the operation.

Occasionally this operation may cause swelling of the affected area. The swelling is called lymphoedema and happens because lymph fluid cannot drain properly from the area after the lymph nodes have been removed.

Skin grafts for skin cancer

This information is about skin grafts for skin cancer . A skin graft is where skin is taken from one area of the body to cover a wound in another area.

Skin grafts

Surgery for all types of skin cancer involves removing the affected area and some of the surrounding, healthy-looking, skin.

If the area is fairly small, it will be possible to close the wound by bringing the edges of skin together. Larger wounds may need a skin graft to cover the area. Skin grafts are layers of skin taken from another part of the body (the donor site) and placed over the area where the cancer has been removed.

A partial thickness (or split thickness) skin graft is where the epidermis and a part of the dermis layer is used. The skin is usually taken from the thigh, buttock or upper arm. Skin will grow back in this area.

A full thickness skin graft is where the epidermis and the full dermis layers are used. In this case, only a small area is taken from the donor site and the skin edges of the donor site are then stitched together to heal. Skin may be taken from the neck, the area behind the ears and the inner side of the upper arm.

How a skin graft is done

You may have either a general or a local anaesthetic depending on the area being grafted. Your doctors will advise you which is best for you.

The grafted area

Once the skin layer has been removed from the donor site, it is placed over the wound where the cancer has been removed. It can then either be laid over the area or secured in place with stitches. You will have a dressing over the grafted area and this is left in place while the graft heals. The skin graft will connect with the blood supply from the area and this allows it to „take' and survive. This usually takes 5–7 days.

The donor site

You will also have a dressing on the donor site to protect it from infection. For a partial thickness skin graft, healing will take about two weeks, but the area may remain red for some time after this.

With a full thickness graft, the donor area will take about five days to heal.

The donor area can often feel more uncomfortable than the grafted area and you may need to take regular painkillers.

After the surgery

You can usually go home the same day or you may need a short stay in hospital. This depends on where the graft is and how big it is.

If the grafted area is on your hand, you may have a sling to help keep your arm raised as much as possible. If the graft is on your leg, it is important to keep your leg up when possible. This helps prevent swelling and reduces pain.

You will need to take things gently for the first two weeks to allow the graft to heal properly. The grafted area is quite fragile, so it is important not to rub or brush against the graft or the dressing, or to put any pressure on the area.

Avoid any kind of exercise that might stretch or injure the graft for a few weeks. Start with some gentle exercise and build it up. You might need to take some time off work, depending on where the graft is and the kind of work you do. Your specialist will give you more advice on this.

Complications and side effects

Sometimes the grafted area may bleed or get infected. This may cause the graft to fail. It is important to contact your doctors if the area becomes painful , red and swollen. You are more likely to have problems with the graft if you smoke.

Both the grafted and donor areas will develop scars. These should gradually fade. They usually heal well with time, especially if they are on the face. Using a moisturising cream can help keep the skin supple.

There will be some difference between the grafted skin and the skin in the surrounding area. This should lessen over time. If you are concerned about the appearance of the area, you could try camouflage make-up. Some hospitals have specialist nurses who can show you the best way to apply this.

Your feelings

You may have many different emotions , including anxiety and fear. These are normal reactions and are part of the process many people go through in trying to come to terms with their condition.

How you feel about the way you look is an important part of self-esteem, so if your skin graft has affected your appearance even slightly, this can also have an effect on your feelings.

Everybody has their own way of coping with difficult situations; some people find it helpful to talk to friends or family, while others prefer to seek help from people outside their situation. Some people prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is available if you need it.

Cryotherapy for skin cancer

If your cancer is very small and only affecting the surface layers of the skin it may be possible to remove it by freezing it. This is called cryotherapy or cryosurgery . Liquid nitrogen is sprayed on the cancer to freeze it. The cold can be a bit painful when the liquid nitrogen is applied (some patients describe the feeling as like a bee- sting).

After the treatment you may feel an aching or throbbing sensation in the area for a minute or two. Within an hour or so the area may blister. This is to be expected, and the blister may contain blood. Fluid may need to be drained from the blister using a sterile needle, but the top of the blister should be left intact. The treated area needs to be covered with a dressing until a scab forms.

About two weeks after the treatment, the scab drops off and the cancer cells should have cleared. You may have a white scar in the area. Occasionally, you may need more than one cryotherapy treatment to get rid of the tumour completely.

Radiotherapy for skin cancer

Radiotherapy treats cancer by using high-energy rays to destroy the cancer cells, while doing as little harm as possible to normal cells.

Radiotherapy works well for skin cancers and is particularly useful in areas where surgery might be difficult or disfiguring (such as the face), and for tumours that have penetrated deeply into the skin.

The treatment is given in the hospital radiotherapy department. Often only a single treatment is needed, but sometimes several doses of treatment are necessary and these are given over a period of one or more weeks. Your doctor will discuss your individual treatment plan with you.

The radiotherapy treatment affects only a small area of skin and will not make you feel unwell. For a week or two after treatment, the treated skin will be red and inflamed. During this time, it will look as though the treatment has made things worse rather than better. This is normal. After a few weeks the area will dry up and form a crust or scab.

Over another week or so, the scab will peel away, leaving healed skin underneath. At first, this new skin will look pinker than the skin around it. This will gradually fade, and the treated area will come to look like the skin around it, although it can eventually be slightly paler.

Radiotherapy to areas that produce hair, such as the head, can make the hair fall out in the treated area. Your hair may grow back within 6–12 months, depending on the dose of radiotherapy and the length of treatment you've had. Some people find that the hair loss is permanent.

Your clinical oncologist can discuss with you whether your hair is likely to grow back once the treatment has ended. Radiotherapy does not make you radioactive and it is perfectly safe for you to be around other people, including children, throughout your treatment.

Photodynamic therapy for skin cancer

Photodynamic therapy (PDT) is a newer treatment for skin cancer.

PDT uses light sources combined with a light-sensitive drug (sometimes called a photosensitising agent) to destroy cancer cells. PDT is particularly suitable in areas where the cancer develops in skin directly overlying bone, such as Bowen's disease on the shins and hands.

Before your treatment the doctor may remove any scabs from the area. A photosensitising cream (for example, Metvix®, which contains methyl aminolevulinate) will then be applied to your skin. It will be left on for a specific time period, usually between 3–6 hours, depending on the type of cream that is used. This is so that it can penetrate into the skin.

After the cream is removed, the doctor shines a special light onto the treatment area. The light treatment usually lasts somewhere between 8–45 minutes depending on the light source used.

Afterwards a dressing is put on to cover the area and protect it from light. You may need to keep the dressing on the treated area for up to 36 hours after your treatment. You will be given instructions about this before you leave hospital.

Usually only one treatment of PDT is needed, but occasionally two or three further treatments may be given if your skin cancer is thick. Your doctor or nurse will be able to give you more detailed information about your specific PDT treatment.

Side effects of PDT for skin cancer

Pain Before your PDT treatment, your doctor or specialist nurse may advise you to take a couple of paracetamol tablets to prevent any possible pain. For many people this is all they need, but occasionally a local anaesthetic is given before treatment.

At the end of treatment a steroid cream may be applied to the treated area to stop it becoming painful. When you go home you may be given steroid cream to use if the area becomes painful.

Sensitivity to light The treated area of skin will be sensitive to daylight and bright, indoor lighting. This effect will probably last for about 24 hours. You will need to keep the treated area of skin covered during this time to avoid the skin becoming burnt. After that you can wash, bathe or shower as usual, but you will still need to treat your skin gently and not rub the area until it has healed.

Healing

After PDT, a crust may form over the treated area. The crust will fall off naturally in a few weeks, leaving the healed new skin underneath. Usually there is no scarring and the appearance of the healed skin is very good.

Topical chemotherapy for skin cancer

If chemotherapy is used, it's usually applied directly to the skin cancer as a cream or lotion – this is called topical chemotherapy.

Usually a drug called 5-fluorouracil (Efudix®), which is commonly known as 5FU, is used. You will be asked to put the cream on at home. Your doctor or specialist nurse will explain how to do this.

The chemotherapy cream is usually applied once or twice a day for a number of weeks. If possible, a waterproof dressing should be put over the cream, although it can sometimes be difficult to put a dressing on some areas of the body.

The treatment should make the skin red and inflamed. Once the area becomes sore and weepy, the treatment will need to be stopped. Your doctor can prescribe a steroid cream to reduce the inflammation if it's too sore. The skin will take a week or two to heal after the treatment has finished.

Exposure to the sun can make the inflammation worse, so you should protect the area until it has healed. Usually there are no other side effects with this type of chemotherapy.

Topical immunotherapy for skin cancer

Immunotherapy is the name given to cancer treatments that use the immune system to attack cancer cells.

An immunotherapy cream called imiquimod (Aldara®) stimulates the immune system and may be used to treat some small, superficial basal cell cancers or Bowen's disease. It's usually used in areas where surgery may be difficult or for people who have more than one tumour.

You will be given the cream to take home and asked to apply it once a day for a number of weeks. Some redness or crusting of the skin occurs during the treatment but there should be no permanent scarring. If the skin reaction is very strong your doctor may give you a steroid cream to use.

Occasionally the cream may cause shivers with flu-like symptoms. If this is the case, you should let your doctor or specialist nurse know as they may advise you to stop using it.

Your doctor or specialist nurse can give you more detailed instructions on how to use your immunotherapy cream and how to manage any side effects.

Research - clinical trials for skin cancer

Cancer research trials are carried out to try to find new and better treatments for cancer.

Trials that are carried out on patients are known as clinical trials .

Clinical trials may be carried out to:

• test new treatments, such as new chemotherapy drugs, gene
• therapies or cancer vaccines
• look at new combinations of existing treatments, or change the
• way they are given, to make them more effective or to reduce side effects
• compare the effectiveness of drugs used for symptom control
• find out how cancer treatments work
• see which treatments are the most cost-effective.

Trials are the only reliable way to find out if a different operation,type of chemotherapy, radiotherapy, or other treatment is better than what is already available.

Taking part in a trial

You may be asked to take part in a treatment research trial. There can be many benefits in doing this. Trials help to improve knowledge about cancer and develop new treatments. You will also be carefully monitored during and after the study. Usually several hospitals around the country take part in these trials.

It is important to consider that some treatments that look promising at first are often later found not to be as good as existing treatments, or to have side effects that outweigh the benefits.

If you decide not to take part in a trial your decision will be respected and you do not have to give a reason. There will be no change in the way that you are treated by the hospital staff and you will be offered the standard treatment for your situation.