update in dermatology
A 9-Letter Word For Retirement: Sunscreen Riley McLean-Mandell, MD
As a Mohs surgeon, my job is to remove skin cancer, check the margin to make sure it’s clear and repair the defect from removal, all in the same day under local anesthetic. Like many physicians who are happy in their roles, I feel like the luckiest woman in the world most days at work. My patients are awake, and we talk throughout their visit. I’m not rushed in our conversation, since it takes place while we perform the procedure. We chat about grandchildren, hobbies, jobs ... essentially, anything but politics is fair game. In this way, I get to know my patients relatively well, and I love seeing the same patients multiple times per year. However, for the sake of my current and future patients, I would love nothing more than to put myself out of a job.
...BETWEEN 19% AND 44% OF INDIVIDUALS WITH ONE SKIN CANCER WILL GO ON TO DEVELOP ADDITIONAL PRIMARY SKIN CANCERS. A DAY DOESN’T GO BY THAT I’M NOT ASKED, “WHY AM I GETTING SKIN CANCER NOW? I HAVEN’T BEEN OUT IN THE SUN FOR YEARS!” My career is dependent on individuals getting skin cancer. This is happening at an alarming rate, with one in five Americans developing a skin malignancy at some point in their lives. Each year, there are 4.3 million basal cell carcinomas, 1 million squamous cell carcinomas and more than 196,000 new melanomas diagnosed, which cost our country $8 billion annually. The risk factors for skin cancer include being fair-skinned, having a family history of skin cancer, having high cumulative sun exposure and having a history of radiation, immunosuppression and more. It’s unfortunate that by the time an individual has developed skin cancer, they have enough of these risk factors that they are at high risk of developing additional skin cancers. In fact, between 19% and 44% of individuals with one skin cancer will go on to develop additional primary skin cancers. A day doesn’t go by that I’m not asked, “Why am I getting skin cancer now? I haven’t been out in the sun for years!” Patients frequently apologize for their cancer, explaining that they didn’t know about the risks of skin cancer. We talk about baby oil and aluminum-covered
album cover reflectors and mothers who sent their children out to “get some healthy sun.” It’s all true – until the last several decades, there weren’t great sunscreen options and we didn’t know how much of a role sun exposure played. Now we do. Despite the current war on sunscreen, with evidence pointing to several chemical sunscreens’ damaging effects on coral reefs and a recent New England Journal of Medicine article on systemic absorption of chemical sunscreens, you and I and all our patients still need it. We know for certain that UV irradiation from the sun is a carcinogen. We know for certain that it causes wrinkling, freckles and age spots. We also know for certain its association with nonmelanoma skin cancer and melanoma. My goal now, to help care for my patients, is to put myself out of a job as a skin cancer surgeon. I tell anyone who will listen about the importance of sun protection. For individuals who worry about the systemic absorption or environmental impact of chemical sunscreens, I recommend mineral sunscreens with titanium dioxide or zinc oxide. For those who dislike sunscreen, I espouse the benefit of sun-protective shirts, hats and sunglasses and avoiding peak hours of the sun (10 a.m.-2 p.m.). For everyone, I remind them that even if they have some sun damage on their skin, enacting healthy habits will reduce their risk of subsequent skin cancers. Patients who have a significant degree of background sun damage can be proactive, too. We have topical creams and treatments that can blast away sun damage to reduce the risk of developing skin cancer. So as my parting words: Be of good cheer. We’re getting better at this, preventing the damage that leads you to my office. Someday, hopefully, I’ll be out of a job (and not because of coronavirus!) and sitting on a beach somewhere because no one needs me. But you can be sure on that blessed day, I’ll be covered in sunscreen, huddled under an umbrella and wrapped in sun-protective clothes. Data regarding skin cancers summarized from skincancer.org. Riley McLean-Mandell, MD, is a board-certified dermatologist who serves as an assistant professor and full-time Mohs surgeon at UMass Memorial Medical Center. She is a proud graduate of UMass Medical School for undergraduate and graduate medical education. She is a member of the American Academy of Dermatology, the Women’s Dermatologic Society and the American College of Mohs Surgeons.
May/June 2020 Worcester Medicine | 11
