Register
Login
×

Skin Cancer Treatment By Types and Stages [I to IV]

The skin cancer treatment usually depends on many factors, including but not limited to the type of skin cancer, stage of disease, the location of the disease, performance status of the patient, patient’s preference along with other factors.

Following are the preferred treatment approaches for different stages of skin cancer, but the final decision is taken after clinical assessment of the patient by an oncologist.

Join our skin cancer community to connect with fighters and survivors across the globe.

BASAL CELL CARCINOMA (BCC)

RISK GROUP TTEATMENT
Low Risk For low-risk BCCs, the following options are generally employed as the first-line treatment:
Curettage and Electrodesiccation (C&E) is employed for most low-risk BCCs except when the affected area contains hairs, that is, C&E should not be employed for terminal hair-bearing regions, such as the scalp, pubic and axillary regions, and beard area in men.

Standard surgical excision may be employed when a standard 4-mm clinical margin can be obtained after surgery and surgical cut can be closed using any of the following techniques: linear closure, second intention healing, or skin graft.

For individuals who cannot undergo surgery, radiotherapy is usually employed as the first-line treatment.

For patients who do not prefer to undergo surgery and radiotherapy, topical treatment with 5-Fluorouracil, imiquimod, Photodynamic therapy (PDT), or cryotherapy may be employed as the first-line treatment.
High Risk For high-risk BCCs, the following options are generally employed as the first-line treatment:
Standard surgical excision may be employed when wider margins can be obtained after surgery and surgical cut can be closed using a linear closure or by delayed repair. Alternatively, Mohs Micrographic Surgery (MMS or Excision with Intraoperative Frozen Section Assessment) or Excision with complete circumferential peripheral and deep margin assessment (CCPDMA) techniques can be utilized for removing BCC.

For individuals who cannot undergo surgery, radiotherapy is usually employed as the first-line treatment.

For patients who do not prefer to undergo surgery and radiotherapy, topical treatment with 5-Fluorouracil, imiquimod, Photodynamic therapy (PDT), or cryotherapy may be employed as the first-line treatment.

SQUAMOUS CELL CARCINOMA (SCC)

RISK GROUP TREATMENT
Low Risk For low-risk SCCs, the following options are generally employed as the first-line treatment:
C&E is employed for most low-risk SCCs except when the affected area contains hairs, that is, C&E should not be employed for terminal hair-bearing regions, such as the scalp, pubic and axillary regions, and beard area in men.

Standard surgical excision may be employed when standard 4- to 6-mm clinical margins can be obtained after surgery and surgical cut can be closed using any of the following techniques: linear closure, second intention healing, or skin graft. In the case of positive (non-clear) margin after surgical resection, radiotherapy and/or chemotherapy with a hedgehog pathway inhibitor can be employed.

For individuals who cannot undergo surgery, radiotherapy is usually employed as the first-line treatment.

For patients with SCC in situ (Bowen’s disease) and when the disease is present at an anatomically challenging location, topical treatment with 5-Fluorouracil, imiquimod, Photodynamic therapy (PDT), or cryotherapy may be employed as the first-line treatment.
High Risk For high-risk SCCs, the following options are generally employed as the first-line treatment:
Standard surgical excision may be employed when wider margins can be obtained after surgery and surgical cut can be closed using a linear closure or by delayed repair. Alternatively, MMS or CCPDMA techniques can be utilized for SCC resection. In the case of positive (non-clear) margin after surgical resection, radiotherapy should be employed.

For individuals who cannot undergo surgery, radiotherapy is usually employed as the first-line treatment.
Node-positive SCC For node-positive SCC, the preferred treatment is surgical excision of the primary tumor along with the lymph node dissection for the affected lymph nodes. The extent of surgical procedure generally depends upon the location, number, and size of the affected lymph nodes. Radiotherapy after surgery is generally recommended in the case of multiple lymph node involvement or extranodal involvement. Patients with incomplete lymph node excision should also receive systemic therapy along with the post-surgery radiotherapy.
For patients with node-positive SCC and who cannot undergo surgery, radiotherapy with or without a systemic therapy is usually employed as the first-line treatment. If tumor shrinks sufficiently, surgery may be employed later.
Metastatic SCC For patients with metastatic (widely spread) SCC, the preferred treatment is a systemic therapy that may include chemotherapy, targeted therapy, or immunotherapy.
Surgery or radiotherapy may be employed as the palliative treatment for symptomatic disease control.

MELANOMA

STAGE TREATMENT
0 For Stage 0 melanoma, wide surgical resection with 1 cm margin to remove all cancerous tissue is the preferred treatment approach. For some patients with positive margins, topical imiquimod or radiotherapy may be employed.
For patients with melanoma in a challenging location, MMS or topical imiquimod can be employed as the first-line treatment as per physician discretion and patient preference.
I For Stage I melanoma, wide surgical resection with 1 cm to 2 cm margin is considered the preferred treatment approach. The margin of normal skin tissue removed should be based on the location and thickness of the primary tumor.
It is generally recommended to perform a sentinel lymph node biopsy for melanoma. If cancer is detected in the sentinel lymph node, complete lymph node dissection of the involved node is recommended.
II For Stage II melanoma, wide surgical resection with 1 cm to 2 cm margin is considered the preferred treatment approach. The margin of normal skin tissue removed should be based on the location and thickness of the primary tumor.
It is generally recommended to perform a sentinel lymph node biopsy for melanoma. If cancer is detected in the sentinel lymph node, complete lymph node dissection of the involved node is recommended.

Biochemotherapy or immunotherapy may be employed after surgical resection of node-negative disease or after lymph node dissection.
III For Stage III melanoma, wide surgical resection with 1 cm to 2 cm margin for the primary tumor and complete lymph node dissection for the affected lymph node is considered the preferred treatment approach.
Immunotherapy, biochemotherapy, or targeted therapy may be employed after surgical resection. Radiotherapy may sometimes be employed, especially in case of multiple node involvement or aggressive/poorly differentiated subtype.
IV For Stage IV melanoma with a limited number of resectable primary and secondary tumors, wide surgical resection with 1 cm to 2 cm margin for the primary tumor and secondary tumors is considered the preferred treatment approach. Sentinel lymph node biopsy is usually performed, and complete lymph node dissection is employed in the case of a node-positive disease. The remaining disease may be treated with radiotherapy.
For multiple regional secondary tumors that cannot be managed by complete surgical resection, intralesional chemotherapy, laser ablation, topical imiquimod, or radiotherapy may be employed.

For widespread disease, Immunotherapy or targeted therapy is considered as the preferred treatment approach. Patients who progress on the first-line therapy may receive second-line therapy with agents not used in the first-line treatment.

Palliative treatment may be provided to relieve advanced-disease symptoms.

Following is the brief description of various treatment types employed for different skin cancers:

  1. Surgery: Surgery is the treatment of choice for most early-stage and some higher stage Skin cancers that have not spread to distant body parts and can be completely removed. The goal of surgery is to remove entire cancerous tissue along with some healthy tissue to ensure no cancer cell is left behind. This is possible for some early-stage disease at a favorable location where the tumor is confined to a specific area, and complete resection can be performed with ease.

    However, a complete resection is not always possible, such as in the case of advanced-stage disease, the disease involving a vital organ/structure, or when a surgical resection will lead to a significant cosmetic disfigurement. In such cases, surgery may still be employed with an objective to remove maximum possible cancerous tissue along with the administration of other treatment (e.g. topical treatment, systemic treatment, or radiotherapy) to kill the remaining cancer cells in the body.

    Surgery may also be performed to collect biopsy sample in some cases. In case of node-positive disease, surgery is required to remove the affected lymph node (the procedure is called lymph node dissection). Sometimes, a reconstructive surgery is required to improve/restore appearance.

    Relative to the site of disease, surgery is generally associated with the risk of change in cosmetic appearance or disfigurement and other common surgery-associated complications, such as pain, chances of infection, bleeding, damage to nearby structures like arteries or nerves etc. Thus, surgery may not be employed in old-aged or otherwise frail individuals. Also, some individuals may not prefer surgery due to cosmetic reasons.

  2. Curettage and Electrodesiccation (C&E): In this technique, superficial skin layer containing cancerous cells is first removed via a curette (a long, thin instrument with a sharp looped edge on one end) and the area is then denatured using an electrode to destroy any remnant cancer cells. This process is repeated once or twice after the first procedure to achieve complete cancer cells removal.

    This technique is generally employed for early-stage skin cancers that can be managed by removing superficial skin layers. This is a fast and cost-effective technique. This technique is not generally utilized for areas with hair growth, such as the scalp, pubic, axillary regions, and beard area in males due to a risk of tumor extension to the hair follicles that cannot be adequately removed. The procedure does not cause many side-effects but pain and a scar at the procedure site are common.

  3. Mohs Micrographic Surgery (MMS) or Excision with Intraoperative Frozen Section Assessment: This surgical technique is generally utilized when a high-risk skin cancer is involved, when the exact depth of tumor is not assessable, or when treating skin cancer in anatomically challenging location where preservation of healthy skin tissue is crucial, for example, skin cancer near eyes, eyelids, central face, ears, and fingers.

    In this technique, successive thin layers of skin tissue containing cancer are removed and checked under a microscope for the presence of cancer cells until the cancer-free margins are obtained. This technique helps in reducing the chances of cancer coming back, but this is a complex procedure and requires much more time than standard surgical resection.

  4. Excision with Complete Circumferential Peripheral and Deep Margin Assessment (CCPDMA): Like MMS technique, this technique enables intraoperative assessment of tumor margin. The added advantage is that both peripheral and deep margins are assessed simultaneously using frozen dissected sections. Thus, this procedure is faster than MMS and has all the advantages of MMS.

  5. Topical treatments: These treatments provide local control and are generally employed for carcinoma in situ or some early-stage skin cancers confined to the superficial skin layers. These treatments may also be employed for some advanced-stage disease to treat secondary cancers limited to superficial skin layers.

    Alternatively, these treatments can be employed in combination with other treatments like surgery to kill remaining cancer cells. Imiquimod and 5-Fluorouracil are the two most commonly used topical agents for treating skin cancers. These may be associated with minor side-effects such as skin reactions and flu-like symptoms.

  6. Cryotherapy/Cryosurgery: In this technique, some early-stage skin cancers are treated using a supercooled agent, for example, liquid nitrogen. One to three freeze-thaw cycles are utilized to kill the cancerous cells present in superficial skin layers. The treatment may result in a wound that takes time to heal completely or may lead to the development of a scar tissue. The overall cosmetic outcome is poorer compared to other topical treatments, but the procedure is fast and cost-effective.

  7. Photodynamic Therapy (PDT): In this technique, a liquid is injected into the area near the skin cancer. The liquid contains a drug, for example, methyl amino levulinate (MAL) or 5-amino levulinic acid (ALA). These drugs have a high affinity for cancerous cells and get accumulated in the cancerous cells over several hours or days.

    Inside the cancerous cells, the drugs get converted into a different chemical and render the cancerous cells sensitive to light. The cancer is then exposed to a light source to kill cancer cells. This technique cannot be utilized for deep-sited cancer cells. However, this technique provides better cosmetic output and thus generally utilized for treating superficial cancerous lesions on the face or scalp.

  8. Radiation Therapy: Radiation therapy uses high-energy x-rays or other high-energy radiations which are directed to the affected area to kill cancerous cells. For the treatment of skin cancer, radiotherapy is generally employed using an external radiation source, for example, external beam radiation therapy (EBRT).

    Radiotherapy can be employed alone as the first-line treatment for certain early-stage skin cancers when the patient does not prefer surgery for cosmetic reasons, in the case of skin cancers that cannot be completely removed by surgery, or in some patients who cannot tolerate surgery. Radiotherapy can also be combined with other treatment options such as surgery to kill remaining cancer cells when complete removal is not achieved with surgery.

    It is sometimes used for palliation of symptoms of the widespread disease, such as pain, bleeding, and obstructive problems. It is generally associated with several side effects like skin reactions, sores/ulcers, nausea, vomiting, dry mouth/eyes, loss of hairs in the irradiated area, chances of secondary cancer development, and accidental damage to nearby organs.

  9. Chemotherapy: Chemotherapy means treatment with anti-cancer drugs that kill or decrease the growth of rapidly growing cancer cells. Chemotherapy is generally employed for the treatment of advanced-stage skin cancers that have spread to distant body parts and cannot be removed completely with surgical resection. Depending on the physician’s preference and patient’s condition, it may also be combined with other treatment options, like radiotherapy, to accelerate the benefit achievement.

    Many pharmaceutical companies are conducting a number of clinical trials to find out new drugs and drug-combinations with increased efficacy and specificity to target cancer cells. Chemotherapy may be associated with side effects due to its effect on normal body cells apart from cancerous cells. Common side effects of chemotherapy include nausea, vomiting, hair-loss, diarrhoea, mouth ulcers, increased chances of infection, fatigue, decrease in the number of blood cells, etc.

  10. Targeted Therapy: Targeted drugs work differently than chemotherapy drugs that they target a specific gene or protein characteristic of the cancer cells that help them to divide and grow indefinitely. They are generally used alone or in combination with chemotherapy for the treatment of advanced-stage skin cancers or skin cancers that possess specific protein/gene change.

    The side effects of targeted therapy are generally mild, but these can be severe in some cases, for example, autoimmune reactions. These therapies require an appropriate immunohistochemical/genetic evaluation of biopsy sample to ensure the efficacy of treatment. Example of targeted drugs include vismodegib and sonidegib that target proteins involved in this hedgehog pathway (commonly found in BCC); vemurafenib and dabrafenib that target BRAF protein, a characteristic protein found in more than 50% of melanoma; trametinib and cobimetinib that target MEK protein, a protein generally found in melanoma with BRAF mutation; and imatinib that targets C-KIT gene/protein commonly found in melanoma affecting non-cutaneous locations, hands, soles of the feet, under the nails, and areas with maximum sun exposure.

  11. Immunotherapy: Immunotherapy involves skin cancer treatment with drugs that stimulate a person’s own immune system to identify and kill cancer cells. These agents are generally employed for the treatment of advanced-stage/widespread melanoma that cannot be managed with surgery or local treatment. These agents have transformed the way advanced-stage disease is managed and have improved overall treatment outcome.

    Many different classes of agents have been designed to target different protein or cell-component to produce their effects. Examples of such agents include the immune checkpoint inhibitors, nivolumab and pembrolizumab, that target PD-1 protein on T-cells and activate them to kill melanoma cells; CTLA-4 inhibitor, Ipilimumab, that blocks CTLA-4 protein on T-cells and activate them to kill melanoma cells; and cytokines, interferon-alfa and interleukin-2, that are man-made version of natural proteins and help in boosting the immune system to kill cancer cells and one of the good option for skin cancer treatment.

  12. Palliative Treatment: It does not directly treat skin cancers but helps in improving the overall quality of life by providing relief from the symptoms and by reducing the suffering caused by the disease. It is generally given as supportive care for advanced-stage skin cancers along with other primary treatments. It may include but not limited to: using drugs or other interventions to reduce swelling, pain, bleeding, and other symptoms such as nausea, vomiting, and diarrhoea; surgical interventions or radiotherapy may also be employed.

It is very important to assess the benefits of each treatment option versus the possible risks and side effects before making a treatment decision. Patient’s choice and health condition are also important to make a treatment choice.

Following are the goals of treating skin cancer:

  • Prolongation of life.
  • Reduction of symptoms.
  • Improvement of overall quality of life
Join our community of fighters and survivors, motivate and uplift each other to fight cancer together.