Sunburn in children can cause a dangerous cancer. The risk increases significantly

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Melanoma has become a little less terrible, because thanks to the possibilities of modern medicine, it is no longer lethal for us. Polish specialists deal with it effectively thanks to modern diagnostics and therapy that do not differ from the standards of other European Union countries. However, our detection rate is much worse, and patients are treated by doctors of two specialties – dermatologists and oncologists. The latest knowledge about melanoma is shared with us by a dermatologist, Prof. dr hab. n. med. Magdalena Czarnecka-Operacz.

1. Prof. Magdalena Czarnecka-Operacz believes that the poor detection of melanoma in Poland has three main reasons: the patient comes to the doctor too late, internists and family doctors do not pay attention to skin changes, and melanoma is dealt with by both a dermatologist and an oncologist
2. The first symptom of melanoma is a sudden focal discoloration of the skin on the originally unchanged skin
3. UVA and UVB radiation is a risk factor for the development of melanoma, which is further increased if a child under the age of 3 sunburns the skin
4. An effective sunscreen should have an SPF protection factor of at least 30
5. More current information can be found on the Onet homepage.

Monika Zieleniewska, Medonet: Let’s start with statistics. How many cases of melanoma are diagnosed in Poland each year?

Prof. Magdalena Czarnecka-Operator: We record an average of approx. 2 thousand. 400 new cases of melanoma, at least this average number is reported in recent years. However, the statistics may be somewhat biased and should be approached with caution. It happens that cases of melanoma are reported only on the basis of the clinical picture of the skin lesion, omitting the absolutely required histopathological confirmation. It may also be that they are not reported because the diagnosis has not been correctly established. However, we see that the number of skin pigmented cancers diagnosed is generally increasing.

Moreover, in Poland, compared to other European Union countries, melanoma is diagnosed much later, i.e. already in an advanced form of development. This was demonstrated by extensive epidemiological studies conducted several years ago in EU countries. Unfortunately, this is our biggest problem, because the prognosis for the patient changes depending on the severity of the disease.

Why is this happening?

This is the key question: how is this possible? Of course, we can shift the entire responsibility onto the patient and conclude that he / she reports to the doctor too late. This is some kind of possible explanation. However, it is difficult to imagine that during the three months before the diagnosis of melanoma, a patient presenting with pigmented skin lesions would not be consulted, and therefore examined for other reasons, by an internal medicine specialist or a family doctor.

Personally, I think that too little attention is paid to pigment changes. During the consultation, the physician should assess not only the condition of the throat mucosa when the patient presents symptoms of angina and cough during a classic examination of the patient, but also assess the condition of the skin during auscultation of the lungs. Moreover, melanoma in Poland is dealt with by both a dermatologist and an oncologist, which is why a large proportion of patients with pigmented lesions go to an oncologist, not a dermatologist. Of course, an oncologist knows this type of neoplastic process very well, but it is one of a very wide spectrum of neoplastic diseases and it is actually a dermatologist who should consult patients with pigmented skin lesions.

In EU countries, oncologists do not engage in the diagnosis and treatment of saithe, because it is a skin disease, and it is dermatologists who deal with it, both in terms of diagnosis and treatment. In these countries the detection rate is much better and concerns the early stages of the disease development. It seems to me that this division into two specializations that takes place in Poland is not the best solution. To sum up, it can be said that late diagnosis of melanoma, that is diagnosis of the disease in its advanced stage, has at least three causes in Poland; the patient presents with a dermatological problem too late; a doctor who consults a patient in relation to another medical problem does not pay attention to skin pigmented lesions and, thirdly, this cancer is dealt with by doctors of two different specializations: a dermatologist for diagnostics and dermatosurgical procedures and an oncologist for subsequent stages of treatment.

Let’s say what is melanoma?

First of all, it is a malignant neoplasm that potentially metastasizes if not diagnosed early enough and may have a serious prognosis if it is diagnosed at an advanced stage of development. It is derived from the cells that make up the pigment, hence it is generally understood to be a pigmented lesion that differs in color from the normal color of the skin. Melanoma does not have to be black, brown, or purple as its name suggests. There are varieties without a dye – melanin – colorless, which is even more difficult in terms of correct diagnosis.

What are the symptoms of this tumor?

The first disturbing symptom that should be noted is a sudden focal discoloration of the skin, appearing in the area of ​​the originally unchanged skin. Another disturbing element is the discoloration within a pre-existing dye mark. In addition, symptoms such as uneven pigment distribution within the pigmentary nevus, the formation of an active, erythematous perimeter or ulcer, or focal regression of the pigment, i.e. its disappearance in a fragment of the primary pigmentation lesion, should always cause concern.

The skin lesion, characteristic of melanoma, most often spreads superficially within the skin, a pigmented lesion is observed, spreading peripherally within the skin. There are also varieties of melanoma, which are derived from an already existing pigmented spot called “lentigo”, which is formed, among others, by as a result of long-term skin exposure to ultraviolet radiation and is most common in the elderly. This is the second, much rarer form of melanoma. The third, rarest, is when melanoma is in the form of a tumor. It may be a lump or a tumor depending on the size of the skin lesion. This clinical form of melanoma is hard to miss.

The professor mentioned that the prognosis of melanoma depends on when the cancer is detected. What else?

The prognosis for melanoma depends on three basic elements: first, what type of melanoma we are dealing with, second – where it is located, and third – what stage of development it is in. If it is surface melanoma, which accounts for the highest percentage of cases (60-70%), its prognosis is best, but only if it is diagnosed promptly. Melanomas have the worst prognosis, which are located in less typical places – for example, in the acral, i.e. distal parts of the upper and lower limbs, i.e. on the fingertips, on the pads, and especially if they are located under the nail plate. These pigmented lesions at the base of the nail are sometimes associated with trauma causing a hemorrhage. The patient recognizes that he is dealing with a bruise, but if it does not improve over time, this should arouse anxiety and motivate the patient to visit a dermatologist.

Location in atypical places also includes those that are not normally exposed to sunlight. These are the inner surfaces of the forearms, places where the sun rarely reaches, so the skin is not used to exposure to ultraviolet light. Usually, the prognosis is worse in cases within the eyeball, labial red or atrium of the nose.

Probably the most difficult places to diagnose melanoma in such places?

Yes. The diagnosis of melanoma is then often a matter of chance, but statistically it is a very rare location.

And what do we mean by the stage of this cancer?

The degree of advancement is assessed on various scales, including in the Breslow and Clark scales. These scales are used to assess the depth of cancer cell infiltration, i.e. the advancement and activity of the disease process. Until recently, it was believed that taking a biopsy from a suspected melanoma pigmented lesion was a mistake and the lesion should be removed immediately. Currently, it is recognized that in cases of doubt, it is worth taking a biopsy and, based on the dermatopathological assessment of the removed lesion, make a final diagnosis.

Depending on the depth of infiltration of melanoma cells as well as the patient’s age and general clinical condition, using the above-mentioned scales, we are able to determine the prognosis. And the last very important thing is a detailed assessment of certain melanoma-specific gene mutations, whether or not present in a given melanoma. Determining the nature of these mutations gives us the basis for introducing a properly selected, effective therapy. Thus, the mutations within the neoplastic cells characteristic of melanoma constitute an additional factor determining the prognosis.

Probably everyone now knows that the formation of melanoma is caused by excessive exposure of the skin to ultraviolet radiation. Let’s explain this relationship.

Melanoma is always associated with ultraviolet light, and of course it is absolutely correct. Ultraviolet radiation, both UVA and UVB radiation, is considered a risk factor for the development of melanoma, and the most harmful is the occurrence of burns, especially in the early childhood period. That’s why dermatologists are terrified that so many parents expose the skin of children up to 3 years of age to ultraviolet without applying a high degree of photoprotection, and we see it on beaches during the holidays every year. Ultraviolet light may cause the pigmentation nevus to pass into melanoma, although melanoma often develops on the skin that was originally unchanged. A child who has sunburn on the skin up to the age of 3 automatically increases the risk of not only melanoma but also other skin cancers.

Will sunscreen creams help us?

The use of agents that reduce the side effects of ultraviolet is imperative. Unfortunately, it turns out that not everyone understands photoprotection correctly. It seems to us that by using sunscreen creams, we can expose ourselves to ultraviolet for longer, which is not true. Photoprotection is effective only when the SPF protection factor is at least 30.

So filters 14 or 20 do not give us anything?

They don’t matter. Only those from 30 and up work. In the European Union, the highest factor is 50+, all these 70 or 85 are also rather a marketing activity. We have a choice of mineral photoprotectors that reflect ultraviolet, as well as chemical and mixed photoprotectors. Unfortunately, some ingredients, especially chemical photoprotectors, may have a local photosensitizing effect and it is worth paying attention to this. Let’s use, especially in children suffering from allergic skin diseases, such as atopic dermatitis, mixed or mineral filters.

Additionally, the degree of harmfulness of exposure to ultraviolet varies depending on the place where we are. Places located high above sea level are much more dangerous. The harmfulness of ultraviolet in the Tatras will be much higher than in the coastal areas. This must be remembered, although the intensity of the exposure itself is also important. Many hours of sunbathing from 12 to 15 is a commonly observed phenomenon. Besides, the closer we get to the equator, the more dangerous ultraviolet will be. Remember that it penetrates the windows, so when driving a car or standing by the window in the summer, we also expose ourselves to this radiation. Clothes don’t protect us from him. A child in a T-shirt staying in full sunlight on the beach, without the previously used photoprotector, is also exposed to the harmful effects of ultraviolet rays.

There are special textiles available on the market, intended for people including with dysplastic nevus syndrome or with a family history of ultraviolet-opaque melanomas, and it is worth remembering. We can buy them in Poland to protect the skin as much as possible on vacation. The sun also penetrates the clouds, so on apparently sunless days we are also exposed to the harmful effects of ultraviolet radiation.

How do we treat melanoma?

At scientific and educational meetings on melanoma issues, it is often said that nowadays melanoma, just like AIDS, does not die. However, on condition that it is recognized early enough. Treatment varies depending on the clinical and histopathological type of melanoma, its location and stage. It begins with the removal of the entire skin lesion that we suspect is melanoma. We cut it out with a very small margin of healthy skin, from 1 to 3 mm. Centimeter margins are no longer cut, as it does not statistically improve survival. Then, the lesion should be assessed dermatopathologically, immunopathologically and in terms of the aforementioned variants of genetic mutations as soon as possible.

If we confirm melanoma, we make further decisions taking all these elements into account. Sometimes it is enough to just widen the incision and check that the skin surrounding the melanoma is free of cancerous cells, or the sentinel lymph node may need to be removed. Then, depending on the results of subsequent tests, we make a decision about treatment. We currently have the possibility of modern biological treatment (including immunotherapy specifically targeting cancer cells), which is very effective. We choose them depending on the type of mutations displayed by melanoma cells.

Does melanoma recur?

In a patient who has suffered from melanoma once, another episode of the disease is definitely more likely. If the focus has been completely removed and we have confirmation that all structures surrounding the lesion have been removed, then the likelihood of recurrence at this point is negligible. Of course, if someone has made a mistake and has laser removed a melanoma in the belief that it is a pigmented nevus, we no longer have the possibility to evaluate the removed skin lesion. In this situation, if a fragment of the melanoma structure remains, this is where a recurrence may occur.

The tendency to develop melanoma is also genetically determined. I am thinking of people with a light phenotype, i.e. fair skin, with a history of family burden – grandfather, great-grandfather, mother or siblings suffered from melanoma, as well as people with dysplastic nevus syndrome. We talk about the syndrome of dysplastic changes if more than 50% are present. nevus over 2 mm in diameter. In both of these groups of patients it may be difficult to talk about recurrence, but undoubtedly there is a higher risk of developing another melanoma. Therefore, we must monitor the moles very carefully, because melanoma can appear both in the area of ​​pigmented moles and in the area of ​​the skin that was originally unchanged. Easily sunburn is a risk factor in very fair-skinned people.

In fact, it requires constant monitoring by a dermatologist.

As I mentioned, in most European Union countries, melanoma is a disease diagnosed and treated by a dermatologist. From the moment of suspicion through diagnosis, surgical removal and modern general dermato-oncological treatment. All surgical and dermatological therapies and biological treatments are in the hands of a dermatologist. In Poland, we have a division between dermatology and oncology. Thus, the most comfortable situation for patients and doctors is when a dermatologist, dermatosurgeon, dermatopathologist and oncologist work closely together. Oncology has much better therapeutic possibilities and has better drugs for the treatment of melanoma. Creating a center dedicated to melanoma with cooperating dermatologists and oncologists would be the best option. Each of the specialists would speak on their own subject; dermatologists in relation to dermoscopy – the ability to diagnose, dermatosurgeons – operating, while oncology would support us primarily in the field of modern therapies.

Do such centers already exist in Poland?

Yes, we have a great one at the Medical University of Gdańsk. There, too, it is possible to assess dysplastic moles. There are patients who have more than 200 pigmented nevi, so it is difficult to imagine manual dermoscopic evaluation. However, there is a special device that allows us to scan all skin lesions by dermoscopy, digitally record them and perform an automatic initial assessment. In the next stage, a team of dermatologists and oncologists starts work. In dermato-oncology centers such possibilities exist; I am very impressed with the Gdańsk center.

I understand that all modern melanoma therapies are available in our country?

Yes, we have nothing to be ashamed of. Modern therapies are available, there is only one but – for oncologists. The diagnosis and basic dermatological surgery are in the hands of dermatologists. For further therapy, we refer the patient to an oncology center.

We encourage you to listen to the latest episode of the RESET podcast. This time we devote it to epigenetics. What is? How can we influence our genes? Do our elderly grandparents give us a chance for a long and healthy life? What is trauma inheritance and is it possible to somehow oppose this phenomenon? Listen: