This operation involves cutting out the skin cancer with a margin of healthy tissue to ensure all of the cancer is removed. It may require cutting away skin, or other soft tissue and bone.
Especially Skin Cancer on the Face, Nose and Lip
Skin Cancer (Face, Nose and Lip)
Introduction
What is Skin Cancer?
Skin cancer can be found on any part of the body. It is the most common cancer diagnosed in Australia. These cancers are either: non-melanoma skin cancers (NMSC) or melanoma. The treatment for types of skin cancer is different, so it is important to know the type of skin cancer.
Information about other types of Head and Neck Cancers can be found here.
Cancer occurs when cells become abnormal, grow uncontrollably and have the potential to spread to other parts of the body. These cells build up to form a mass (or lump).
Skin cancers occur when cells are damaged by harmful ultraviolet (UV) radiation found in light from the sun and use of solariums. Other less common causes of skin cancer can include repeated X-ray exposure, scars from burns, or occupational exposure to certain chemicals. When found early, most skin cancers can be managed with local treatment that does not have long-term side-effects.
NMSC are far more common than melanoma and are typically found on the head and neck in middle aged and older people due to long term sun exposure. People can also get skin cancers on their arms, legs and trunk.
There are two common types of NMSC:
- Basal cell carcinoma (BCC): is a tumour of the basal layer of the skin. BCCs are mostly a local problem. They usually grow slowly but can become very big and destroy tissue close to the tumour (locally) but rarely spread to other parts of the body (metastasise).
- Squamous cell carcinoma (SCC): starts in the top layer of skin cells. It often starts as hard scaly skin (actinic keratosis) and abnormal cells (dysplasia) and SCC in situ (sometimes referred to as Bowen’s disease). A small number can travel to (metastasise) nearby lymph nodes, or be locally aggressive, and require more complex treatment.
Melanomas are less common than NMSC and can occur in younger people often as a result of previous sunburns. In Australia, melanoma is the fourth most common cancer. Sunburn causes 95% of melanomas and it is very treatable when found in its early stages
Melanoma is a cancer of melanocytes, the pigment cell in the basal layer of the skin. Like other skin cancers, melanoma is only invasive when it breaks through the bottom membrane of the skin and invades deeper tissues. Melanoma is more likely to come back (recur) and to metastasise if it has invaded the deep tissue. The chance that a melanoma will spread is related to how thick or deep it has grown into the deep tissue, presence of sores (ulceration) and other microscopic features. Melanoma can grow anywhere on the body including sun exposed skin, soles of the feet, under finger and toenails and in the eye.
Merkel cell carcinoma (MCC) (cancer of neuroendocrine cells in the skin) is a rare skin cancer that may spread to the lymph nodes. It is most commonly found in older people. Sun exposed areas, including the head and neck, arms and legs are the areas usually affected. MCC can be treated with radiation therapy alone, although surgery may also be necessary.
What is skin?
The skin is divided into two main layers. These include:
- epidermis (outer layer)
- dermis (inner layer)
The epidermis contains three main 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 cancer
- fair complexion and inability to tan
- poor immune system
- family history of melanoma
- moles on the skin
- genetic predisposition (e.g. basal cell naevus syndrome, dysplastic naevus syndrome, xeroderma pigmentosum)
Symptoms and Signs of Skin Cancer
The signs and symptoms of skin cancer depend on where the cancer is, its size and how far it has spread in the body.
Symptoms and signs that indicate skin cancer 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.
You can 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.
How is Skin Cancer Diagnosed
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)
- perform an examination and may use an instrument (dermatoscope) to view the mole clearly
- order some tests.
Not everyone will need to have every test for skin cancer. Your doctor will recommend the tests that are right for you.
Common tests include:
- Biopsy: This 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:
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- 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.
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- 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.
- For both types of biopsies, 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 (e.g. warfarin), 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:
- Imaging of the area which may include an ultrasound or a CT scan with contrast.
- Needle biopsy (also called Fine Needle Aspiration or 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 uses a larger bore needle to get more tissue in the biopsy. It can provide more information than fine needle biopsy but can be more uncomfortable. Your doctor will decide the type of biopsy that is most appropriate for you.
Treatment Options for Skin Cancer
The most suitable treatment for skin cancer depends on many factors. These include:
- type, size and location of the cancer
- whether the cancer has spread
- personal factors (e.g. age, general health and treatment history)
- types of treatment available
- your preferences for treatment.
- experience of your treating doctor
Most common skin cancers (e.g. non melanoma skin cancer) will be treated by a local excision only. Skin cancers become invasive when they break through 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 simple excision, curettage (also called scooping), or Moh’s surgery), radiation therapy or other treatments including liquid nitrogen therapy (freezing), cautery (using heat) or topical medications (e.g. creams or ointments).
Surgery
Surgery is an important treatment for many skin cancers. For people, where the cancer has invaded the skin, there is a chance that the cancer may invade deeper structures and spread.
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 to reduce the risk of blood clots and chest infection
- antibiotics to reduce to 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 recover after your treatment.
Surgery for Skin Cancer
Surgery is an important treatment for many skin cancers. For people, where the cancer has invaded the skin, there is a chance that the cancer may invade deeper structures and spread.
The different operations that can be used for Skin Cancer are:
Local Excision (Wide Local Excision)
This technique is usually performed by dermatologists who have a particular interest and further specialized training. It involves serial cutting of the tumour and immediate pathologic evaluation until the margins are found to be clear of cancer. Reconstruction is often necessary.
Download PDF - Sentinel Lymph Node Biopsy
This is an investigation that may be done at the time a skin cancer is treated. It is done when there is a high risk of the cancer spreading to lymph nodes, but no nodes are obviously involved. This is most often done in people with melanoma or MCC, occasionally done for people with SCC, but rarely for BCC.
Download PDF - Reconstructive Surgery
This may be considered if a large area of tissue is removed. This operation is done by your head and neck surgeon or a surgeon who specialises in reconstructive surgery. Reconstructive surgery may involve:
- Skin grafting, which is taking skin from another part of your body (such as your thigh) and transplanting it to cover the area where you had surgery.
- Flap repair, which involves taking local tissue (Local Flap Surgery) or from another part of your body (Free Flap Surgery) to rebuild the area where you have had surgery.
Download PDF - Neck Dissection
Download PDF - Return to Activity Following Neck Dissection
This involves removal of lymph nodes from your neck. This is important in more advanced skin cancers even when there is no sign of cancer in the lymph nodes on your scan, because there is a risk of microscopic cancer in the lymph glands of the neck.
This is the removal of one of your parotid glands (pair of major salivary glands located in front of each ear) and the surrounding tissue, because of direct invasion into the gland or because of spread to lymph nodes lying within the salivary gland.
Facial Nerve Sacrifice (Radical Parotidectomy)
This is the removal of your facial nerve, which controls changes in face or expressions. It is used when a cancer in the parotid gland has spread to the nearby facial nerve.
Download PDF - Lateral Temporal Bone Surgery
This is the removal of some or all of the bone behind the ear. It is used when a cancer in the parotid gland has spread into the nearby bone.
Download PDF - Orbital Exenteration
This is the removal of the soft tissue of the eye and eyelid. It is used when a cancer has spread into the skin near the eye and cannot be treated any other way.
SIDE EFFECTS OF SURGERY
Treatment for skin cancer may lead to late side effects. You may not experience all of the side effects, however, talk to your doctor if you are concerned.
Side Effects of Surgery
Treatment for skin cancer may lead to late side effects. You may not experience all the side effects, however talk to your doctor if you are concerned.
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 radiation therapy: This is 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 radiation therapy: This is done after surgery. It is used as an additional treatment to kill any cancer cells that may not have been removed during surgery.
- Palliative radiation therapy: This is 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 and cannot be cured.
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 consistently 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 therapist 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 jawbone.
- Diet and nutrition: 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:
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- 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.
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- 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 are available. 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.
Each person responds to radiation therapy differently. Some people may experience a few side effects while others may not experience any at all.
Common early side effects of radiation therapy may include:
- tiredness
- skin irritation in the treated area e.g. redness, dryness and itching, weeping skin, scaling and sometimes skin breakdown by the end of treatment
- local loss of beard (in men) or hair if the scalp is treated
- nasal cavity crusting, congestion and bleeding of nose, if 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 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 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 skin cancers, both melanoma and non-melanoma, may be recommended types of systemic treatment called immunotherapy. Many people with skin cancers may also be asked to take part in a clinical trial of different types of these drugs.
Questions to Ask
Being diagnosed with cancer can be overwhelming and confusing. There are a lot of information and treatment decisions to make at a distressing time for you and your family. To help you understand everything and get the information you need to make decisions about your health, consider asking the following questions to your cancer care team:
- Exactly what type of skin cancer do I have? Where is it located?
- Why did I get this cancer?
- What stage is the cancer? What are the chances of cure with treatment?
- What are my treatment options? Which treatment do you recommend for me and why?
- Have you discussed my case at a Multidisciplinary Team meeting and what were the recommendations?
- Who will be part of the cancer care team, and what does each person do? Should I see another specialist before treatment, such as a radiation oncologist, medical oncologist, plastic surgeon, dentist, dietician or speech pathologist?
- What are the possible side effects of treatment in the short- and long-term? How can they be prevented or managed?
- Will the treatment affect my ability to eat, swallow, or speak? Will I need a feeding tube?
- What will happen if I don't have any treatment?
- How much will the treatment and/or operation cost? Will Medicare or my health insurance cover it?
- What follow-up tests will I need? How often will they be?
- Am I suitable for any clinical trials?
- What lifestyle changes (diet, exercise) do you recommend I make?
- Who can I call if I have any problems or questions?
- Where can I find emotional support for me and my family? Is there a support group or psychologist you can recommend?
- If I wanted to get a second opinion, can you provide all my medical details?
Follow-Up Care
Regardless of the type of skin cancer, once a person has had one skin cancer, they are at increased risk for the same or other types of skin cancer. Regular follow-up is recommended and is best in partnership with your GP and dermatologist. It is very important that you attend follow up appointments/visits with your doctor. How often you should attend a follow up can be different, but commonly it is every 3 -4 months for the first 2 years.
If you have had a major resection, involving surgery of the lymph nodes, ongoing follow-up of this area is required, in addition to routine checking of your skin by your GP or dermatologist.
You may also need to have follow-up scans to catch any early signs of recurrence of the cancer. This may include CT, MRI and PET scanning. Remember you should contact your cancer doctor or GP if you have any concerns in the time between your visits.
Mental Health for People with Cancer
Sometimes this is referred to as psychosocial aspects or survivorship. Being diagnosed with cancer and having treatment can lead to extra worries or concerns for you and the people caring for you. Depending on the treatment, you may experience any of the following:
- low mood or depression
- anxiety
- disfigurement
- difficulties with eating
- difficulties with speaking
- changes in sexual activity.
You may get through the diagnosis and treatment for skin cancer but may find it difficult to deal with some of the side effects of treatment. Speak with your doctor about any difficulties you may be experiencing. Your doctor may give you a referral to a psychologist or another healthcare professional who can help you. Speak with your family and friends too about any concerns you may have.
You may find it helps to join a patient support group and speak with others who are having treatment for head and neck cancer. You can also find help and advice in online self-help resources such as Beyond Blue.
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