Thursday, 29 September 2016

"Doctor does this mole matter?"

What would you say is the most common cancer in the UK? 
It is not lung cancer, breast cancer or bowel cancer. Nor is it prostate, ovarian or cancer of the cervix. The answer believe it or not, is skin cancer, with 100,000 new cases diagnosed in the UK each year. That’s 274 a day.
The good news is that it is both treatable, and in many cases preventable. An individual’s risk is determined by a mixture of factors including not just sun exposure, but genetics, the number of moles you have and how fair skinned you are. Doctors grade skin types by what is known as the Fitzpatrick scale, from the fair skinned ‘Type 1’ (always burns, never tans, pale white; blond or red hair; blue eyes; freckles) to the dark skinned ‘Type 6’ (Never burns, never tans, deeply pigmented dark brown to darkest brown skin). Generally your risk is higher the lower your ‘type’.
We have known for years that ultraviolet exposure (UV) from the sun is the primary cause, with sunburn being a particular trigger for changes in skin cells. The benefit of sun cream, covering up with sleeves and a hat, and generally avoiding over exposure to the sun have well established benefits. Yet still skin cancer remains at the top of the list.

‘If in doubt, cut it out’
This rather dramatic quote underlines the best treatment we have for skin cancer once it has occurred – the simple excision.
Having worked for several years Down Under, I have benefitted from a great deal of experience dealing with various spots, growths, moles and other skin lesions that crop up. In Australia, the effect of the near constant sun, combined with a relatively thin layer of ozone over the continent combine to create a very high risk of skin cancer. Compared to Europeans, Australians have a 30 times higher incidence of skin cancer. This is thought to be entirely due to sun exposure. As such, removing skin lesions is part of the daily work load for GPs there. Many cancers caught early require only a simple excision which can be done in the treatment room of a GP surgery with the proper facilities.  For myself, this meant on a daily basis I would switch between consulting in my office to removing skin lesions in the treatment room. In addition to skin cancers, more everyday skin lesions such as skin tags, unsightly moles, sebaceous cysts, and fatty lumps known as lipomas would also make an appearance.
There are 3 main types of skin cancer. The less harmful Basal Cell Carcinoma (BCC) which does not spread and can be treated easily in the early stages, is the most common. Melanoma is the aggressive, most serious type which can spread to other body areas and can be lethal, even affecting young adults. A third type, the Squamous Cell Carcinoma (SCC) can be very serious also, though benefits from early identification and excision. 
The difficulty for the average person is identifying which moles might be troublesome, and which are nothing to worry about.


How to distinguish between skin cancer and a ‘safe’ mole
One of the most effective, and evidence based way of separating the two, is to have your mole assessed by a doctor trained in dermoscopy. This is a type of assessment where the lesion is viewed through a specialised tool known as a dermoscope. The instrument magnifies and illuminates the mole, while providing polarised light which allows structures beneath the skin to be seen. With training, the worrying lesions can be separated from the safe lesions relatively quickly. It is astonishing what features and details this process reveals, while being simple, safe and painless. Picking out the ‘safe’ from the ‘dangerous’ avoids unnecessary excisions, and allows for timely intervention where there is concern.
There are some simple things to look out for which might indicate the need for a review. In general terms, any mole that is changing, whether it is growing, becoming itchy, changing colour or bleeding, should be assessed. Not all changes in well-established moles indicate cancer, but this is one of the main signals that there may be a risk. At home, a simple survey of your skin will reveal most pigmented (ie coloured) skin lesions. Particular features to look out for fit nicely in to the ABCDE rule:
  • A is for Asymmetry: One half of a mole or birthmark does not match the other.
  • B is for Border: The edges are irregular, ragged, notched, or blurred.
  • C is for Color: The colour is not the same all over and may include different shades of brown or black, or sometimes with patches of pink, red, white, or blue.
  • D is for Diameter: The spot is larger than 6 millimeters across although melanomas can sometimes be smaller than this. 
  • E is for Evolving: The mole is changing in size, shape, or color.

Visit cancer.org for more details on what to look for in your moles. We know from studies that individuals with over 100 moles are at particular risk, and it is recommended that these individuals seek a skin review every 12 months or so.

A typical excision – the ‘minor op’
If it is deemed necessary to have a mole removed, the process is relatively easy, usually involving a few simple steps.
First, there is a discussion explaining what to expect, and what the risks are. This is known as consent, ensuring the patient is well informed about the procedure. Risks are generally very low. Typically they are limited to the following:
  • Scar. Whenever the skin is cut, a scar will form. Usually this is a simple pale line once healed.
  • Infection. The risk here is low as we always use a sterile approach to even the smallest procedure. However, any time the skin is injected or cut, there remains a small risk of infection
  • Recurrence. Some skin lesions can come back, sometimes years later. The intention is to remove the lesion fully and completely, however this risk is not zero.

Once consented, the procedure involves a few typical steps. Initially the doctor is likely to mark the skin, indicating where the excision cuts will be made. Then the skin is cleaned with a surgical solution, followed by a local anaesthetic injection. The injection stings briefly (like at the dentist) but quickly numbs the region. Then the mole is removed, usually with a curved cut above and below (an ellipse). Where needed, stitches are used to close the gap, and a sterile waterproof dressing is then applied. 
Some procedures, like removing a cyst or fatty lump are a little more involved, however the general principles are the same. You are able to wash or shower with the dressing in place, and the sutures are usually removed after 7 days, when the wound can be checked.

Getting checked
Oxford Private Medical Practice we offer assessment of skin lesions with dermoscopy, and where needed, excision including pathology assessment, meaning our colleagues in the laboratory examine the tissue closely to determine specifically the diagnosis. In addition, we can offer excision of moles, skin tags, cysts, scars – really any skin lesion which is causing distress or discomfort. There are some sites which require more specialist intervention than can be offered in primary care setting, and so an assessment is needed before planning any surgery. However, minor operations for everyday skin lesions are simple, relatively painless, and can provide excellent results without the need for a lengthy wait to see a hospital specialist, or a prolonged recovery stage.
If you are concerned about a particular mole, would like to have a skin lesion removed, or simply want peace of mind from a full skin check, feel free to contact the surgery to book an appointment.


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