Key Points for This Section

After nonmelanoma skin cancer has been diagnosed, tests are done to find out if cancer cells have spread within the skin or to other parts of the body. There are three ways that cancer spreads in the body. Staging of nonmelanoma skin cancer depends on many factors, including whether the tumor has certain "high-risk" features. The following stages are used for nonmelanoma skin cancer: Stage 0 (Carcinoma in Situ) Stage I Stage II Stage III Stage IV Treatment choices are based on the type of nonmelanoma skin cancer or precancerous skin condition diagnosed: Basal cell carcinoma Squamous cell carcinoma Actinic keratosis

After nonmelanoma skin cancer has been diagnosed, tests are done to find out if cancer cells have spread within the skin or to other parts of the body.

The process used to find out if cancer has spread within the skin or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. A biopsy is often the only test needed to determine the stage of nonmelanoma skin cancer. Lymph nodes may be examined in cases of squamous cell carcinoma to see if cancer has spread to them.

There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:

• Through tissue. Cancer invades the surrounding normal tissue.
• Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
• Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

Staging of nonmelanoma skin cancer depends on many factors, including whether the tumor has certain "high-risk" features.

Enlarge ^7
7

Millimeters (mm). A sharp pencil point is about 1 mm, a new crayon point is about 2 mm, and a new pencil eraser is about 5 mm.

The following are high-risk features for nonmelanoma skin cancer:

• The tumor is thicker than 2 millimeters.
• The tumor is described as Clark level IV (has spread into the lower layer of the dermis) or Clark level V (has spread into the layer of fat below the skin).
• The tumor has grown and spread along nerve pathways.
• The tumor began on an ear or on a lip that has hair on it.
• The tumor has cells that look very different from normal cells under a microscope.

The following stages are used for nonmelanoma skin cancer:

Stage 0 (Carcinoma in Situ)

Enlarge ^8
8

Stage 0 nonmelanoma skin carcinoma in situ. Abnormal cells are shown in the epidermis (outer layer of the skin).

In stage 0, abnormal cells are found in the squamous cell or basal cell layer of the epidermis (topmost layer of the skin). These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Enlarge ^9
9

Pea, peanut, walnut, and lime show tumor sizes.

Stage I

Enlarge ^10
10

Stage I nonmelanoma skin cancer. The tumor is no more than 2 centimeters.

In stage I, cancer has formed. The tumor is not larger than 2 centimeters at its widest point and may have one high-risk feature.

Stage II

In stage II, the tumor is either:

• larger than 2 centimeters at its widest point; or
• any size and has two or more high-risk features.

Stage III

In stage III:

• The tumor has spread to the jaw, eye socket, or side of the skull. Cancer may have spread to one lymph node on the same side of the body as the tumor. The lymph node is not larger than 3 centimeters.

or

• Cancer has spread to one lymph node on the same side of the body as the tumor. The lymph node is not larger than 3 centimeters and one of the following is true:
  • the tumor is not larger than 2 centimeters at its widest point and may have one high-risk feature; or
  • the tumor is larger than 2 centimeters at its widest point; or
  • the tumor is any size and has two or more high-risk features.

Stage IV

In stage IV, one of the following is true:

• The tumor is any size and may have spread to the jaw, eye socket, or side of the skull. Cancer has spread to one lymph node on the same side of the body as the tumor and the affected node is larger than 3 centimeters but not larger than 6 centimeters, or cancer has spread to more than one lymph node on one or both sides of the body and the affected nodes are not larger than 6 centimeters; or
• The tumor is any size and may have spread to the jaw, eye socket, skull, spine, or ribs. Cancer has spread to one lymph node that is larger than 6 centimeters; or
• The tumor is any size and has spread to the base of the skull, spine, or ribs. Cancer may have spread to the lymph nodes; or
• Cancer has spread to distant parts of the body.

Treatment choices are based on the type of nonmelanoma skin cancer or precancerous skin condition diagnosed:

Basal cell carcinoma

Basal cell carcinoma is the most common type of skin cancer. It usually occurs on areas of the skin that have been in the sun, most often the nose. Often this cancer appears as a small raised bump that has a smooth, pearly appearance. Another type looks like a scar and is flat and firm to the touch. Basal cell carcinoma may spread to tissues around the cancer, but it usually does not spread to other parts of the body.

Squamous cell carcinoma

Squamous cell carcinoma occurs on areas of the skin that have been in the sun, such as the ears, lower lip, and the back of the hands. Squamous cell carcinoma may also appear on areas of the skin that have been burned or exposed to chemicals or radiation. Often this cancer appears as a firm red bump. Sometimes the tumor may feel scaly or bleed or develop a crust. Squamous cell tumors may spread to nearby lymph nodes.

Actinic keratosis

Actinic keratosis is a skin condition that is not cancer, but sometimes changes into squamous cell carcinoma. It usually occurs in areas that have been exposed to the sun, such as the face, the back of the hands, and the lower lip. It appears as rough, red, pink, or brown, raised, scaly patches on the skin, or cracking or peeling of the lower lip that is not helped by lip balm or petroleum jelly.

Key Points for This Section

There are different types of treatment for patients with nonmelanoma skin cancer and actinic keratosis. Four types of standard treatment are used: Surgery Radiation therapy Chemotherapy Photodynamic therapy New types of treatment are being tested in clinical trials. Biologic therapy Patients may want to think about taking part in a clinical trial. Patients can enter clinical trials before, during, or after starting their cancer treatment. Follow-up tests may be needed.

There are different types of treatment for patients with nonmelanoma skin cancer and actinic keratosis.

Different types of treatment are available for patients with nonmelanoma skin cancer and actinic keratosis. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Four types of standard treatment are used:

Surgery

One or more of the following surgical procedures may be used to treat nonmelanoma skin cancer or actinic keratosis:

• Mohs micrographic surgery: The tumor is cut from the skin in thin layers. During surgery, the edges of the tumor and each layer of tumor removed are viewed through a microscope to check for cancer cells. Layers continue to be removed until no more cancer cells are seen. This type of surgery removes as little normal tissue as possible and is often used to remove skin cancer on the face.
  Enlarge ^{11
  11}

  Mohs surgery. A surgical procedure to remove skin cancer in several steps. First, a thin layer of cancerous tissue is removed. Then, a second thin layer of tissue is removed and viewed under a microscope to check for cancer cells. More layers are removed one at a time until the tissue viewed under a microscope shows no remaining cancer. This type of surgery is used to remove as little normal tissue as possible and is often used to remove skin cancer on the face.
• Simple excision: The tumor is cut from the skin along with some of the normal skin around it.
• Shave excision: The abnormal area is shaved off the surface of the skin with a small blade.
• Electrodesiccation and curettage: The tumor is cut from the skin with a curette (a sharp, spoon-shaped tool). A needle-shaped electrode is then used to treat the area with an electric current that stops the bleeding and destroys cancer cells that remain around the edge of the wound. The process may be repeated one to three times during the surgery to remove all of the cancer.
• Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormal tissue, such as carcinoma in situ. This type of treatment is also called cryotherapy.
  Enlarge ^{12
  12}

  Cryosurgery. An instrument with a nozzle is used to spray liquid nitrogen or liquid carbon dioxide to freeze and destroy abnormal tissue.
• Laser surgery: A surgical procedure that uses a laser beam (a narrow beam of intense light) as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.
• Dermabrasion: Removal of the top layer of skin using a rotating wheel or small particles to rub away skin cells.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Chemotherapy for nonmelanoma skin cancer and actinic keratosis is usually topical (applied to the skin in a cream or lotion). The way the chemotherapy is given depends on the condition being treated.

Retinoids (drugs related to vitamin A) are sometimes used to treat or prevent nonmelanoma skin cancer. The retinoids may be taken by mouth or applied to the skin. The use of retinoids is being studied in clinical trials for treatment of squamous cell carcinoma.

Photodynamic therapy

Photodynamic therapy (PDT) is a cancer treatment that uses a drug and a certain type of laser light to kill cancer cells. A drug that is not active until it is exposed to light is injected into a vein. The drug collects more in cancer cells than in normal cells. For skin cancer, laser light is shined onto the skin and the drug becomes active and kills the cancer cells. Photodynamic therapy causes little damage to healthy tissue.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied. Information about clinical trials is available from the NCI Web site ¹³.

Biologic therapy

Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's listing of clinical trials.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.