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Skin Cancer

Dear Dr B: Recently I had surgery for skin cancer called basal cell carcinoma. Besides surgery, are there any other options for the management of this cancer?

Basal cell carcinoma (BCC) is a form of skin cancer and is the most common cancer found in humans.

BCC and squamous cell carcinoma (SCC) are also known as non-melanoma skin cancers. Melanoma is the third type of skin cancer. Approximately 30 percent of the malignant skin cancers diagnosed among Albertans each year are non-melanoma skin cancers – BCC and SCC.

Non-melanoma skin cancers account for greater than one million new cases of cancer annually in the United States and are responsible for 1200 to 1500 deaths per year. Costs of US$500,000,000 have been estimated in the management of these malignancies.

BCC usually grows slowly. It is locally invasive and does not spread to distant parts of the body – liver, lung, brain, bones etc. But melanoma can spread to other organs of the body.

The clinical outcome of BCC is difficult to predict. It may remain the same size for many years or it may grow rapidly. It can cause local destruction of tissues especially on the face.

BCC can occur at any age but the incidence increases over the age of 40. The incidence among the young people is increasing due to increased exposure to the sun.

Who are prone to skin cancer?

People who have fair skin, have tendency to freckle, have high degree of sun exposure, make excessive use of sun beds, had previous radiotherapy or phototherapy, male sex, and those who have genetic predisposition.

How is BCC treated?

“The first line treatment of BCC is often surgical excision. Many alternatives are available, including curettage, cryosurgery, laser treatment, surgical excision with predetermined margins of clinically normal tissue, excision under frozen section control, Moh’s micrographic surgery, radiotherapy, topical treatment, intralesional treatment, photodynamic therapy, immunomodulators, and chemotherapy”, says an article in the British Medical Journal.
The article says that although many treatments are used for BCC, little research is available that accurately compares these different treatment methods against each other and for different types of tumour.

If BCC is not adequately treated then two thirds of recurrent tumors appear in the first three years of treatment and 18 percent appear between five and 10 years after treatment.

According to the BMJ article the following treatments are most often used in the management of BCC:

• -excisional surgery – seems to be the most effective with low recurrence rate,
• -curettage and cautery,
• -radiotherapy,
• -cryotherapy, and more recently
• -photodynamic therapy and
• -imiquimod cream – preliminary studies suggest a short term success rate of 87-88 percent for imiquimod cream in the treatment of superficial basal cell carcinoma, although this cream has not been compared with surgery.

Surgery remains the main stay of BCC management. More research is required to compare imiquimod cream with surgery. Other methods of treatment have not shown to be superior to surgery.

Prevention of skin cancer is very important. This should start in childhood. Reduce exposure to sun, use sunscreen, use wide-brimmed hat, and have suspicious looking moles removed surgically. More than 90 percent of skin cancers occur on sun-exposed areas of the body.

If you like to worship sun, then expect to burn and eventually get cancer.


Thought for the week:

“Exercise will make you fit, but fitness and health are not synonymous. Exercise alone is not enough to make you healthy. To achieve good health, exercise is an essential part of a compressive lifestyle program ……….”

Dr. Dean Ornish’s Program for Reversing Heart Disease.

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Treatment of Arthritis

Arthritis means pain, inflammation, and stiffness in one or more joints. There are many different types of arthritis. Osteoarthritis is the most common type. Arthritis can affect any joint – most commonly knees, hips, and hands.

Osteoarthritis is rare before the age of 45. But it becomes increasingly common over the age of 60. It is twice as common in females. It can run in families.

What are the risk factors? Any joints subjected to repetitive and strenuous activity are prone to get arthritis. People who are overweight are at higher risk. Injury to a joint can cause arthritis. Often there is no obvious cause.

Many patients with osteoarthritis require regular pain killers to provide comfort and mobility. There are numerous pain killers in the market for arthritis. Some can be bought over the counter, some require prescription. All pain killers have some sort of side effects which affects some people more than others.

Many of the pain killers for arthritis are known as non-steroidal anti-inflammatory drugs (NSAID). NSAIDs commonly cause upset stomach which may result in ulcers and bleeding. Sometimes this can be life threatening – especially in people over the age of 60. Some of these pills can also damage your kidneys and adversely affect your cardiovascular system.

It is estimated that NSAID induced gastric complications in the United States’ arthritic population alone is more than US$4 billion annually.

NSAIDs are the most commonly prescribed drugs in North America. In Canada alone, more than 10 million prescriptions are written for NSAIDs – this does not include the purchase of NSAIDs over the counter.

Is there a safer and effective alternative to taking pills by mouth?

There has been some research going on the local application of NSAIDs. Topical or local application of the NSAIDs, such as diclofenac solution, has been reported to have fewer side effects.

Diclofenac solution contains a substance called dimethyl sulfoxide (DMSO) which enhances the absorption of NSAID through the skin to provide relief of symptoms when applied to a joint with arthritis – most commonly the knees.

A recent study, using diclofenac solution (commercially available as Pennsaid), showed that four weeks of treatment with this topical solution relieved the symptoms of primary knee osteoarthritis significantly better than a placebo.

Systemic side effects were minimal and local reaction was insignificant except for some dryness of the skin. The study, published in the Canadian Medical Association Journal, concludes that given the current practice guidelines, this topical NSAID treatment is a reasonable new option for the management of osteoarthritis of the knee.

The next reasonable question is, should you be using this if you have osteoarthritis? And a reasonable answer is – speak to your family physician first. Your physician should be able to provide you with a reasonable advice.

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Thought for the week:

This is from my friend George: “Don’t let worry kill you, let the church help!” Now this will keep you thinking (or worried) for a long time if you saw this on your church notice board!

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Screening For Ovarian Cancer

Dear Dr. B: I am worried about ovarian cancer. Is there a screening program for this condition?

According to Alberta Cancer Board, in year 2001, 11,730 Albertans were newly diagnosed with all types of invasive cancer, and 4,785 died from cancer. Of these, two percent of the deaths were related to ovarian cancer compared to nine percent of the deaths due to breast cancer.

In Canada, ovarian cancer is the fifth leading cause of cancer deaths among Canadian women. It causes 1500 deaths per year.

So, the number of cancer deaths due to ovarian cancer is not that high. But the problem is ovarian cancer is generally detected at an advanced stage and is associated with a five-year survival rate of about 30 percent, says an article in the Canadian Medical Association Journal (CMAJ).

The survival rates for ovarian cancer can be more than 90 percent if the cancer is detected at an early stage. But there are no effective screening methods for detecting ovarian cancer.

The CMAJ article discusses two screening strategies: ultrasound alone, or the multimodal screening approach using serum tumor marker CA125 followed by ultrasound.

Pelvic or transvaginal ultrasound has low specificity for ovarian cancer and thus many women undergo unnecessary further investigations if the findings on the ultrasound are non-specific.

One of the serum tumor markers for ovarian cancer is CA 125. It has a limited specificity. The marker is also present in the presence of other types of cancers (pancreas, breast, bladder, liver, and lung) and in some benign conditions. But the specificity of the CA 125 can be improved by adding ultrasound as a second line of investigation.

Who is at increased risk of ovarian cancer?
-10 percent of women with ovarian cancer have hereditary risk factor
-90 percent of ovarian cancers occur in post-menopausal women over the age of 50.

So, what do we know about screening for ovarian cancer?

The CMAJ article says:

-many aspects of ovarian cancer screening are poorly understood
-it is not known whether screening saves lives
-screening for ovarian cancer is not currently recommended for the general population
-over the next few years we may know more about screening once we get results from the number of trials going on in the world
-screening is an option for women with family history of ovarian cancer.

If you are worried about ovarian cancer then you should talk to your family doctor who can make the necessary recommendations to you.

A thought for the week:


“Childhood whining typically peaks some time under age seven. If you have a child who’s older and a chronic whiner, it may be because you are, too. The more we whine, the more our children will.” Barbara Meltz in The Boston Globe.

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Second Hand Smoke

Dear Dr. B: I have a friend who smokes outside her house around her two little children. Isn’t it bad to smoke in the presence of children whether it is indoors or outdoors?

Yes, smoking in the presence of children is bad – whether it is indoors or outdoors. A study carried out by Swedish researchers shows children of smokers have nicotine in their bodies, even if their parents smoke outdoors.

The Medical Post reports that the Swedish researchers studied 366 children age two to three years whose parents smoked. The parents of 216 of the children always smoked outside with doors and windows closed.

The researchers found that theses children had twice as much nicotine in their body as children of non-smokers. If both parents smoked indoors, children had 15 times higher levels than children of non-smokers.

Another study has shown that there is a correlation between passive smoking and respiratory illness (cough, wheezing etc.) in children.

Everyone knows the dangers of smoking. If you are a smoker or if you know somebody who smokes then give them the following ten reasons why one should give up on smoking:

1. Albertans smoke more than the national average.

2. In 2000-2001, 683,900 Albertans were smokers.

3. Tobacco causes one in five deaths in Alberta.

4. Tobacco use is the leading cause of preventable illness, disability and death in Alberta and Canada.

5. Tobacco is the cause of an average of 3,400 premature deaths each year in Alberta.

6. Smokers have two to four times the risk of heart attack and sudden death from coronary artery disease than non-smokers.

7. Smoking around children can negatively impact their health.

8. Smoking during pregnancy is associated with low birth weight and health problems in infancy and later on.

9. Exposure to second-hand smoke can increase non-smokers’ likelihood of developing asthma, heart disease and lung cancer and

10. Nicotine is addictive.

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