Malignant Melanoma Skin Cancers in Women
Frederick R. Jelovsek MD
Malignant melanoma is a potentially fatal skin cancer that is not very common, but it is the most frequent cancer in women ages 25-29 and the second most frequent cancer in those age 30-34. In these age groups, melanoma is more frequent in women than men. It is important to diagnose these dark, pigmented skin lesions early because late-stage, disseminated melanoma rarely responds to therapy.
A recent article, Guerry IV D: Melanoma in Women : Prevention, detection and treatment. The Female Patient 1999;24:33-42, outlines which women are at risk for this and what steps to take for early detection of skin melanomas.
Which women are at most risk for melanomas?
Melanomas occur most frequently in persons of Caucasian race, especially those with light colored hair or iris eye color. Their skin is more susceptible to ultraviolet light rays. Any woman that freckles and burns in the sun regularly without tanning has increased susceptibility. Living in the "sunbelt" has a two-fold risk. The use of tanning parlors makes a woman at higher risk but the most dangerous exposure is thought to occur with off-season recreation or exposure that produces a sunburn in skin that has not been exposed to the sun for awhile. In other words, a mid-winter trip to the Caribbean can sometimes be dangerous in the long run.
A personal or family history of melanoma or other common skin cancers increases the risk for melanoma. A woman who has a large number of common moles (i.e., greater than 25 lesions) is also melanoma-prone. Some families have an inherited increased risk of melanoma but fewer than 10% of melanoma cases are the result of strong genetic susceptibility. If a woman has had a mole biopsied and it turned out to be a "dysplastic nevi", then she has a two-fold risk of melanoma. If she has had 10 or more of those dysplastic nevi, the risk for melanoma is raised by a factor of 12.
How do you detect or screen for possible melanomas?
There is no special method to detect melanomas. A careful examination of the skin is the only method; no special equipment is needed. In women, melanomas occur many times on the arms and legs, but also on the back and upper chest. A partner or spouse can help look at all the freckles, moles and any pigmented (darkened) skin lesions.
What should you look for? The mnemonic used is "ABCDE":
- Asymmetry: melanomas generally have an irregular border.
- Border irregularity: the border is irregular and often notched.
- Color variation: although melanomas are usually dark brown or black, they may sometimes have a range of colors including tan, brown, blue, pink or white.
- Diameter: eventually melanomas become larger than ordinary moles. Any pigmented spot greater than 5 mm (1/5 inch) in diameter should be examined and followed carefully.
- Elevation: some early melanomas are slightly elevated. A pigmented lesion that elevates quickly or develops a bump should be checked immediately. Ulceration, bleeding and oozing are generally late signs of a melanoma that is likely to already be advanced.
Do hormones, birth control pills or pregnancy increase the incidence or severity of melanoma?
One study noted a a six-fold increase in melanoma risk in women who noticed that their moles darkened and increased in diameter during pregnancy. Several other studies, however, have shown no convincing evidence that birth control pills, hormone replacement or pregnancy worsen the risk for melanoma. In spite of the lack of evidence of a hormonal effect, some physicians advocate deferring pregnancy after treatment for a melanoma until the highest risk of recurrence, the first 3 years, have passed. Estrogens in pills, hormones and pregnancy stimulate melanin production in the skin but do not appear to be a major stimulant for the cells containing the melanin such as moles or freckles.
What happens if a melanoma lesion is found?
Treatment for a melanoma is usually a wide local excision of the skin around and underneath the pigmented lesion. Generally a lesion that is confined to the most superficial layer of skin and is less than a millimeter (mm) thick is excised with a 5-10 mm margin of normal skin tissue and closed primarily with suture. Thicker lesions are removed with margins of 1.0 - 4.0 cm (10-40 mm). The nearby lymph nodes are also excised and if they are involved, all of the nearby lymph nodes are removed with "radical " surgery. Subsequent chemotherapy or immunotherapy treatments are often given to treat or prevent recurrence.
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