There are three common types of skin cancer:
Basal cell carcinoma: Basal cell carcinoma (BCC) is the commonest type of skin cancer diagnosed in Northern Ireland but also globally. It is most often seen on areas of skin exposed to the sun i.e head and neck. It is a cancer that arises from the small round cells found in the base of the the outer layer of the skin (epidermis). BCC’s are sometimes referred to as rodent ulcers. They are usually caused by over exposure to ultraviolet (UV) light. People with fair skin are most at risk. If you sunbathe a lot, use sun beds or work outdoors you are at greater risk.
Squamous cell carcinoma: Squamous cell carcinoma (SCC) is derived from cells (keratinocytes) that form the surface of the skin. It is the second most common type of skin cancer in the UK. It is usually caused by much too much exposure to ultraviolet (UV) light from the sun or sun beds. They are most commonly seen on exposed body parts such as the head and neck including lips and ears and also forearms and hands. SCC has a small risk of spread to other parts of the body (metastasise).
Malignant melanoma: Cutaneous melanoma is a much less common type of skin cancer than basal cell carcinoma and squamous cell carcinoma. Although melanoma accounts for only around 10% of all skin cancers it is potentially the most serious type if not treated early. It is a cancer of the pigment cells of the skin (melanocytes). Melanomas develop when the normal pigment cell grows in an uncontrolled way. They can develop in or close to a mole (cluster of normal pigment cells) but can also appear in skin that is normal. Melanoma most commonly appears in women on the legs and in men on the body.
One of the most important causes of melanoma is over exposure to UV light in sunlight or sun beds particularly in the first 20 years of life. The first sign of melanoma is often change in the size shape or colour of a previous mole. It can also appear as new darker area of skin. If you are worried about change in an existing mole or the appearance of a new mole then have it checked with your family doctor who will refer you to a specialist if there is any doubt. If detected early then the melanoma can be removed before it has time to spread deeper into the skin or other parts of the body.
Please note that this section details services provided to adult patients. Please follow the link for information on Children’s Cancers.
If a GP suspects a patient of having symptoms of skin cancer, they will be referred to a hospital for investigation and for specialist advice on diagnosis and treatment. Patients will be referred to members of the specialist skin cancer team at the Belfast City Hospital and the Royal Victoria Hospital.
Patients will be contacted regarding an appointment.
Investigations and diagnosis
At their first appointment, patients are seen by a member of the skin cancer specialist team. This is usually a dermatologist but may also be a plastic surgeon . The specialist will ask the patient about their symptoms and general health before examining the skin. The specialist may use a dermatoscope to examine the area. This is a hand held microscope used by doctors and nurse specialists to view a mole or suspicious area of skin. The diagnosis is often clear from the appearance of the skin but sometimes further investigations are needed to confirm the diagnosis.
Dermoscopy Screening – This screening may be carried out by the doctor or nurse practitioner as part of an initial assessment to assist with diagnosis and treatment of the skin lesion. It is also used to monitor change in moles over time. The imaging procedure is painless and involves the use of light. The procedure may also be combined with digital photography.
Biopsy – This is a minor surgical procedure carried out under local anaesthetic. In the majority of cases a small area of abnormal skin (biopsy) or the entire lesion ( excision biopsy) is removed and sent to the laboratory for analysis. The examination of the suspected area under the microscope will assist in the diagnosis and also provide valuable information to help plan further management.
Patients will usually if possible have these tests done on the day but may need to be brought a back at another time if more time is required.
Most patients following a diagnosis of skin cancer will not require further investigations. In some cases after diagnosis further tests may be needed to determine if cancer cells have spread beyond the skin to nearby lymph nodes or other organs. These investigations may also assist in the planning of further treatment.
These investigations may include:
- Blood tests
- CT (computerised tomography scan)
- MRI (magnetic resonance imaging)
- Bone scan
- PET (positron emission tomography)
- Biopsy of lymph node or other tissue
Following investigations, patients will discuss their results and the treatment options available with their specialist.
In order to provide the highest quality of care, skin cancer is treated by a team of specialists who work together in a multi-disciplinary team (MDT). The team includes:
- Consultant Dermatologists
- Clinical Oncologists
- Consultant Plastic Surgeons
- Consultant Pathologists
- Dermatology Nurse Practitioner
- Clinical Nurse Specialists (CNSs)
- Palliative Care Team
- Allied Health Professionals
- Administration Staff
The Skin Cancer MDT meets every Thursday in the Belfast City Hospital to discuss complex cases of patients with suspected or confirmed skin cancer. Detailed discussions between relevant specialists takes place, looking at all the available results for each skin cancer patient to ensure that the best treatment plan possible has been agreed. A record of this discussion will be sent by a letter to the patient’s GP following this meeting. Members of the specialist skin cancer team from both the Belfast and South Eastern Health and Social Care Trust attend this meeting.
There are a range of treatments which will be tailored to treat your skin cancer. If you have a confirmed diagnosis the treatment given depends upon a patients individual circumstances and the nature of their cancer. The doctor will discuss this with the patient in detail.
Basal cell carcinoma and Squamous cell carcinoma (non melanoma skin cancer)
Most non melanoma skin cancers are treated by surgery. This involves removing (excising) the skin cancer including a margin of normal skin around it. This technique is usually done under local anaesthetic. The wound can normally be closed with stitches but sometimes in larger and more complex skin cancers a graft or skin flap is required.
In some cases Mohs’ micrographic surgery may be necessary. This is a very specialised type of surgery also known as margin control excision performed under local anaesthetic. It is particularly useful for basal cell cancers which do not have a clear edge, are at difficult sites on the face or when the basal cell cancer has come back again. This technique aims to make sure that all the tumour is removed while preserving as much normal skin as is possible.
- Mohs’ Micrographic Surgery
- Photodynamic Therapy
- Topical chemotherapy
- Topical immunotherapy
The main treatment for melanoma is surgery. After biopsy when the diagnosis has been confirmed a second surgery or wide local excision is usually required. This is to make sure that all the melanoma has been removed. If a large area is removed a skin graft may be required. If the melanoma has spread to the lymph nodes then surgery to remove the affected lymph glands may be needed.
Before a patient undergoes any type of treatment, they will have their treatment plan explained and usually will asked to give written consent. This is an important process to ensure that the patient fully understands the nature of their treatment.
Occasionally other treatments are used after surgery if there is high risk that the melanoma may come back. These are known as adjuvant treatments and are usually given as part of a clinical trial.
If a melanoma comes back after treatment and spreads to other organs then other treatments may be used either alone or in combination to try to shrink the tumour and control symptoms. For more information on the treatment of advanced melanoma click here.
Once a patient has completed their skin cancer treatment they will continue on an outpatient review programme.
The main reason for this is to make sure that the skin cancer has not come back or spread elsewhere and to provide the patient with support and information. At these appointments, the patient will be seen by a member of the skin cancer multidisciplinary team.
Review appointments or appointments with the patient’s GP are also a good opportunity to discuss any worries or problems.
In general patients who have already had a skin a cancer are at a greater risk of developing another skin cancer. They are also more at risk of developing a recurrence at the site where the tumour was before. Therefore it is important to check the skin for changes once a month.
If any new symptoms are noticed, or if there are any worries between outpatient visits the patient should discuss these with their GP who will arrange for an earlier appointment if necessary.
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