Health

HEALTH • Summer 2017 15 0 5 10 15 20 25 New cases or deaths per 100,000 people New cases Deaths '75 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 '08 '10 '12 '14 25.2 2.6 Tips to prevent and detect skin cancer Source: Skin Cancer Foundation • Try to stay in the shade, especially between 10 am and 4 pm • Cover up, and use sunscreen with an SPF of 15 or higher for everyday use; 30 or higher for extended outdoor activity • Avoid tanning beds • Examine your skin head-to-toe every month and see a physician each year for a skin exam • Watch for moles that are irregular in outline, change color or texture, grow, are bigger than a pencil eraser, or appear after age 21 • Look for any spot or sore that does not heal or that continues to itch, hurt, crust, scab, erode, or bleed common and much less dangerous. They only rarely spread to other parts of the body, and doctors can usually remove them safely. But that doesn't mean it's a pleasant process. Even if the tumor is small, cutting it away can leave painful scars. To make this easier on patients, some hospitals use a process known as Mohs surgery. Last year, HealthAlliance Hospital in Leominster built a new clinic so that patients from North Central Massachusetts, who would otherwise have to travel to UMass Medical Center in Worcester to get Mohs surgery, could be seen locally. "The Worcester campus was seeing a high volume trend of patients that would have to wait to be seen because of the long waitlist," said Geri Tusalem, senior director of perioperative services at HealthAlliance, who oversees the Mohs surgery clinic. Tusalem said some older patients in particular didn't like traveling, and many people prefer to stay in the hospital where they see their dermatologist and primary care physician. Mohs surgery involves slicing one tiny layer at a time from a tumor. After each slice, the surgeon examines the tissue under a microscope to see if it contains cancer cells. Then, they can stop as soon as they get to healthy skin rather than risk cutting too deep. That's especially important when a tumor is on a visible spot where patients want to avoid scarring, or in areas like the tip of the nose or ear where there's not much extra skin to close up the wound, Tusalem said. Because of the need to look at each slice of tissue, the surgery can take one to five hours, depending on how deep the tumor goes. Fortunately, rather than having to stay in a standard operating room, the clinic lets patients spend that time in a Tempur-Pedic chair, with a television available. Amid new treatments, advanced melanoma declines Melanoma is a more serious matter than other skin cancers, but there's good news there as well. Dr. Kala Seetharaman, medical director for hematology and oncology at MetroWest Medical Center in Framingham, said that in most cases a biopsy is able to remove the entire tumor. After that, patients need to be extra careful to keep an eye on their skin. "If they have one legion, they're at risk for another one," Seetharaman said. She said that if there's even a small chance the cancer could have spread to a patient's lymph nodes, doctors will sample them too. In cases where the skin tumor is particularly thick or where the cancer has spread, Seetharaman said doctors will recommend further treatment. It's only when a cancer has spread, making it a stage 4 disease, that medical oncologists like Seetharaman need to get involved. And she said that today fewer people end up in that position now than 10 years ago, thanks to increased public awareness. She now sees only five to 10 patients a year, she said. "People are more aware of the skin lesions," she said. "More tools are available to identify the lesions." And even for those who do end up with a melanoma that has spread, there are new options that weren't available just a few years ago. Seetharaman explained that melanoma can hijack the immune system's "checkpoints," which tell the body whether or not to attack a disease. "That's how the cells keep growing and spread to the brain or liver," she said. But immunotherapy drugs developed in recent US melanoma diagnoses and deaths * Based on statistics from the SEER-9 registries Source: National Cancer Institute, https://seer.cancer.gov/statfacts/html/melan.html years can retrain the immune system to recognize and attack melanoma. David Shepro, medical director of the cancer program at Saint Vincent Hospital in Worcester, said trials have shown these drugs can have a big impact. In one case, 50 percent of patients who received immunotherapy treatment were alive after five years, compared with 30 percent of those who got a placebo. "That's really quite a big difference in the world we live in," he said. "That's 20 [additional] people out of 100 that are alive at five years." But Shepro said the drugs aren't right for everyone. Messing with the immune system can have serious side-effects, like causing the body to attack its own liver or lung. Drug trials generally enroll patients who are otherwise healthy, but, in the real world, people with additional health problems may not be able to tolerate the new drugs. Financial concerns For all the good news about skin cancer, there's still plenty of progress to make. One important issue with the new drugs is their cost. A single therapy may run up to $120,000 a year, Shepro said, and some patients need to use two drugs at once. Some patients with high- deductible insurance plans, or plans that require them to pay a percentage of their total cost of treatment, simply don't have the money. A social worker and financial counselor try to help patients get support from private foundations or funds created by the pharmaceutical industry, but it's not easy. "This is an everyday occurrence, struggling with these kinds of things," he said. H

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