NON-SURGICAL SKIN CANCER TREATMENTS
Half of all fair-skinned Australians will develop Basal Cell Carcinoma - a common type of skin cancer - before they are 70 years of age. Basal Cell Carcinoma is relatively slow-growing (compared to Squamous Cell Carcinoma and Melanoma) and so is suitable for non-surgical treatment.
Faster growing skin cancers require surgery. Non-surgical treatment is statistically not as effective as surgical treatment. However, it may be a preferable option in some cases as it avoids some of the drawbacks of surgery, such as pain and discomfort, bleeding and potential infection.
Also known as 'cryotherapy', 'cryosurgery' or 'dry ice therapy', this very commonly used non-surgical procedure is for the treatment of a range of skin conditions such as sunspots (solar keratosis), superficial basal cell carcinoma, viral warts, seborrhoeic keratosis, solar lentigo and Bowens disease (also known as squamous cell carcinoma in situ).
The procedure involves using liquid nitrogen to freeze the affected skin. It works by destroying the abnormal skin cells (and a small number of the healthy cells surrounding the abnormal cells) - when these cells return to room temperature, they rupture and die. The resulting redness or blistering of the area heals after about two weeks leaving healthy skin once any scab has fallen off.
A complication to be aware of is something called 'hypopigmentation' where the natural pigment of the skin can be paler than usual after treatment. This is due to the destruction of melanocytes - the cells that produce pigment in the skin. This is more noticeable in people with darker skin, but does not always occur and is often temporary if it does.
The liquid nitrogen (which is at a temperature of around -196C) is either sprayed on to the affected area using a type of spray gun or dabbed on using cotton wool. A short 2-5 second burst with the spray gun is all that is needed to remove most sunspots, while other conditions such as Bowens disease require a slightly more prolonged exposure of 5-10 seconds or a series of spray treatments.
The treatment can be a little painful, with an initial sharp stinging pain followed by a much less intense pain which sometimes lasts for a few hours.
Cryotherapy has a 95-98% effectiveness for basal cell carcinoma and an 80-99% effectiveness in treating sunspots.
Cryotherapy is not suitable for certain conditions, for example, it is generally not used on the face or the head, partially for cosmetic reasons and partly due to a slightly lower success rate for conditions in these areas. It is also not a suitable treatment for pigmented skin lesions (e.g. moles) as these should be removed for pathology testing.
It's also important to note that sunspots are continually forming and that cryotherapy only removes existing sunspots - they may - and will return if the skin continues to be exposed to the sun.
CURETTE & CAUTERY
A curette is a small spoon-shaped medical instrument used to scrape away abnormal skin cells in soft tissue such as those found in basal cell carcinoma, sunspots (solar keratosis) and superficial squamous cell carcinoma (intraepidermal carcinoma). The procedure involves a local anaesthetic and the tissue removed is sent off for pathology analysis. Before the treatment, a 'shave biopsy' is usually performed where a layer of the affected skin is removed to verify the diagnosis.
After the tissue is removed, the area is burnt or 'cauterised' (sometimes referred to as 'desiccation'), where a low-level electric current is applied to stop any bleeding and destroy any abnormal cells that have not been removed by the curette. After the procedure is completed, the affected area is treated with an antibiotic cream and covered with a protective dressing. The affected area of skin generally heals within a few weeks, leaving a pink or white scar. Patients can drive after the procedure is completed since only local anaesthetic is used.
This treatment cannot be used on any discoloured lesions, which may be aggressive melanomas.
Results can vary; however, the procedure has a success rate of up to 99% for basal cell carcinoma where the lesion is smaller than 1cm across and 84% where the lesion is larger than 2cm across. It is generally more effective on new skin cancers as opposed to recurring skin cancers where scar tissue is present.
Efudix® - active ingredient fluorouracil - is one of a range of drugs referred to as ' topical anti-cancer', or 'anti-neoplastic' or 'cytotoxic', which are used to treat skin conditions such as sunspots (solar keratoses) generally caused by sun exposure or by ageing, and that may otherwise develop into skin cancer. It is also used to treat Bowen's disease. It has been in use as an anti-cancer treatment for more than thirty years.Abnormal cells that are cancerous or pre-cancerous cells, in the skin, absorb the fluorouracil (also known as '5FU') which blocks the cell's ability to synthesis DNA and the cell dies. Healthy cells are not affected.Efudix®, as a topical treatment, does not penetrate the skin enough to be effective against forms of skin cancer that have taken hold underneath the skin - it is only suitable for those that have formed on or very close to the skin's surface.
Generally, the course of treatment runs for three weeks when the cream must be applied twice a day. It is particularly useful for treating multiple sunspots and especially those that are present on the head and scalp. The cream must be used as a thin layer, and hands must be washed thoroughly immediately after application. It is preferable to apply the cream once in the morning and again early evening, and it is best to avoid using it before going to bed. It is also essential to stay out of the sun during treatment - in which case it may be worth waiting until the winter months to start the procedure.
Efudix® cream will cause a fair amount of inflammation of the skin - this is a good thing as it shows that the active ingredient has the right effect. The redness subsides typically after about ten days, and it can be treated if necessary with a cold compress or medium strength steroid creams.
The treatment is essentially the same when used to treat Bowen's disease, but the course of treatment lasts 4-6 weeks.
Efudix® is contraindicated for women who are pregnant or planning a pregnancy.
Aldara® - active ingredient Imiquimod - is a topical cream used for the treatment of sunspots (solar keratoses), basal cell carcinoma and Bowen's disease. It has a success rate of around 80% for these conditions, which is about the same success rate as Efudix®. Originally developed as a treatment for perianal and genital warts, Aldara is what is called an 'immune response modifier' and works by activating the body's own immune system. As a result, the immune system recognises the cancer cells as abnormal cells and attacks them.
It needs to be applied three times a week if Aldara® is being used to treat sunspots. An initial course of treatment would ordinarily run for four weeks. If sunspots remain, another four weeks of treatment may be required, and this may be repeated to a total of sixteen weeks if needed. Treatment is once a day as above for five consecutive days (e.g. Monday-Friday) for a total of six weeks If Aldara® cream is being used to treat superficial basal cell carcinoma or Bowens disease.
It is essential to wash your hands and the treatment area using a mild soap before applying Aldara® cream to the skin. The cream should be applied to the surface in a thin layer and then gently rubbed in until there is no excess cream remaining on the skin. Lesions should be covered with the cream as well as a 1cm margin around it. Do not shower or bathe during for 6-10 hour after applying. After this period, the area/s of skin where Aldara® was used should be washed with water and mild soap. It is strongly recommended that patients avoid exposure to sunlight and wear protective clothing when going outside during the day during treatment.
Aldara® is more effective on smaller lesions than on larger ones and is regarded as less capable than surgical excision and removal of lesions. It is recommended where surgery is not the preferred option, e.g. when the patient is likely to form keloid scarring, where they are receiving treatment with blood thinners or where they are at higher risk of wound infection (such as below the knee).
Radiotherapy (also known as 'radiation therapy') works by directing radiation, for example, x-rays, gamma rays, electron or proton beams, at the site of a cancerous tumour, which kills or damages the abnormal cancerous cells. This stops them from continuing to grow and prevents them from multiplying.
It is used in the treatment of skin cancer, especially large lesions and invasive tumours, and is used to treat both Basal Cell Carcinomas and Squamous Cell Carcinomas. It is an option for patients who do not want to undergo surgery, or where the area of skin affected is not suitable for surgical removal, such as areas near the eyes, nose or on the forehead.
Radiotherapy is often used in conjunction with other treatments, for example, after surgery to remove a lesion or tumour to kill any remaining abnormal cells near the site that may have been missed. When it is an additional treatment, it is referred to as 'adjuvant' treatment. It can also be used to help in the treatment of skin cancer that has spread to other organs in the body or the lymph nodes.
There are some side effects with radiotherapy treatment - skin that has been treated can become red or blister and peel, or the skin colour may change. Any hair in the area of skin being treated may fall out.
Radiotherapy is a specialist procedure that is only performed in a hospital by an expert radiation oncologist on an outpatient basis. Most courses of radiotherapy run over several weeks, although the actual treatment itself generally takes less than 30 minutes.