Spotting trouble: From Buffett’s diagnosis to worrying freckles and moles

Veazey Reindl came in for her annual freckle and mole check at MUSC Health Dermatology after a long, hot summer. She knew it was important. “Both my mother and grandmother on my maternal side have had some skin places that have been cancerous, and so I definitely want to stay on top of it because of what they've been through.”

Her dermatologist, Jane Scribner, M.D., described what she was doing as she prepared to take tissue samples from the Charleston woman’s back and stomach. “We did her exam. We identified two lesions that looked a little different from her other lesions. So now, we’re just going to make sure that they are not atypical.”

 

Scribner sent the samples to a laboratory for analysis to make that determination. While waiting for results can be stressful, Reindl had been through this process before. “I've had a couple things, yes. Nothing that I've had removed has been dangerous so far. So just biopsies,” she said.

Skin checks, like the one Reindl underwent, can be a crucial – but easy-to-forget – part of general health care preventive maintenance, Scribner said. The recent death of musician Jimmy Buffett from a rare form of skin cancer called Merkel cell carcinoma has highlighted just how true that is. People are taking notice.

“In the last two weeks, my patients have wanted to talk about it. Usually it's the Parrotheads, many of whom are white males, Jimmy Buffett fans, who will come in for their skin cancer treatments or their exams,” Scribner said.

“In a way that surprised me, they've been more anxious about their skin. They’re asking, ‘Are you sure that I don't have one? Do you see anything that looks like a Merkel cell today?’ Because I think that they're thinking about it more.”

Thinking about skin cancer

Skin cancer affects an estimated one in five Americans, according to the American Academy of Dermatology. At MUSC Health Dermatology, Scribner sees it just about every day.

“When we talk about the most common types of skin cancers, we are talking about basal cell and squamous cell. Melanoma is our third most common type. And then there are other types of skin cancers that are much less common, which is good, because they can be a lot more aggressive,” she said.

One of those types is Merkel cell carcinoma, which killed Buffett four years after his diagnosis. Scribner said once someone has it, they’re at high risk of seeing it recur and metastasize, and they need close monitoring. Finding it early can make a huge difference.

So how does a person know if they have skin cancer? Scribner, an assistant professor of Dermatology and Dermatologic Surgery in the College of Medicine at the Medical University of South Carolina, gave specifics for each type mentioned above.

Basal cell

“I'm diagnosing a basal cell skin cancer, which is our most common and our least aggressive type of skin cancer, perhaps once or twice a day. It's unfortunately really, really common. We do see a lot of patients, but at the same time, it's very, very common,” Scribner said.

How common? A whopping 3.6 million Americans are diagnosed with this type of cancer every year.

Basal cells are in the lower part of the skin. Their job is to constantly divide to make new cells. But they can grow out of control if they’re overexposed and unprotected from ultraviolet rays, whether those rays come from the sun or other sources, such as tanning beds. 

Actor Hugh Jackman has had multiple bouts with basal cell carcinoma and used his platform to encourage others to wear sunscreen. According to the Skin Cancer Foundation, this type of cancer has a 95% cure rate after it’s surgically removed, in most parts of the body. But it can show up again, so doctors say it’s important to watch out for. 

Warning signs of basal cell cancer include:

• A sore that doesn’t heal.
• An area that looks red and/or irritated.
• A pearly, clear, red or white bump. It can be tan or brown in people with darker skin and may look like a regular mole.
• A small growth that’s pink in color.
• A spot that looks like a scar and is white, yellow or waxy looking.

Squamous cell

The second most common type of skin cancer shows up fairly often, too. “Some of us see a case of squamous cell cancer probably every other day,” Scribner said of the team at MUSC Health Dermatology.

Squamous cells are on the upper part of skin. They shed as new cells form. But when the skin is damaged by the sun, like basal cells, squamous cells can grow abnormally and too quickly.

Warning signs of squamous cell carcinoma include:

• Red patches that look scaly.
• Open sores.
• Rough, thick or wart-like areas.
• Raised growths that go down in the center.

Scribner said most cases can be easily treated. But if a person allows the cancer to grow, it can spread to other parts of the body. Almost 2 million cases of squamous cell cancer are diagnosed in the United States every year.

Melanoma

The third most common type, melanoma, can be more dangerous.“Since I am also a  pathologist and read skin pathology slides, I'm diagnosing melanomas once or twice a week,” Scribner said. Slides refers to skin samples sent into the lab for analysis under the microscope.

“With melanoma, we excise and then follow.” That can include continuing care through the Jenny Sullivan Sanford Melanoma & Skin Cancer Program at the MUSC Hollings Cancer Center after the cancer is surgically removed. The program is one of only 14 in the country named a Melanoma Center of Excellence by the Melanoma Hope Network.

Melanoma develops when the cells that give skin its color grow out of control. It’s more likely than basal and squamous cell cancers to spread if not caught and treated early. Melanoma usually starts on the chest and back in men and the legs in women. It can also show up on the neck and face.

Scribner said she uses the ABCDE system to watch for melanoma.

• A stands for asymmetrical.
• B means irregular borders within a mole or freckle – notched, not smooth or round.
• C stands for color. “Is it all one uniform color or different colors,” Scribner said she asks herself. "Different shades within the same mole or a mole that is a different color than all the others can be a warning sign."
• D stands for diameter. “Is it greater than six millimeters – the size of a pencil eraser?”
• E stands for evolving. “Is it changing and growing greater than six millimeters – again, the size of a pencil eraser?”

The answers can tell a patient – and doctor – what may be happening.

Research is underway at Hollings and elsewhere to find new treatments for melanoma. That includes immunotherapy, which can help a patient’s own body fight back, and T-cell therapy. The American Cancer Society estimates more than 97,000 new melanomas will be diagnosed this year.

Merkel cell

The number of Merkel cell cases is much lower – about 3,000 cases in the U.S. per year. But Jimmy Buffett’s death just four years after his diagnosis is a stark reminder of its deadly potential.

The factors Scribner looks for in Merkel cell cancer are different from melanoma. “For Merkel, it’s AEIOU.”

• A is asymptomatic. “It doesn't hurt.”
• E is expanding rapidly.
• I is immunosuppression. “Merkel cell cancer is more common in patients who are immunocompromised. So that can be someone who is genetically immunocompromised but also organ transplant patients, people with or HIV or another factor,” Scribner said.
• O is over the age of 50.
• U is ultraviolet exposure.

When warning signs arise, there’s no time to wait. “It's going to be a red, pearly pimple that grows very, very rapidly. The aggressive growth is one of the reasons why it's such an aggressive skin cancer,” Scribner said.

“Standard of care for Merkel cell begins with wide local excision, or surgical removal, and quite frequently additional radiation at the site of the excision. If there was also lymph node involvement, sometimes they radiate the lymph node basin.”

Message for everyone

Scribner said it’s easy for people in a coastal area such as the Lowcountry to see being in the sun as the norm. But protecting skin from the sun is essential, she said.

“Unfortunately, many of my patients this end of summer are very tan, and I use that as an opportunity to talk to them about sun protection and sunscreen. Tanned skin is damaged skin, and it's much cheaper to be proactive and buy sunscreen and hats and take care of their sun exposure than it is to later in life feel like they want to reverse that damage.”

But skin cancer can also show up in areas that are not exposed to the sun, Scribner said.“We all develop freckles and age spots and spots that look darker after the summer, but if those things don't fade or if something continues to grow or if something is not healing and then continues to darken, especially in unexposed areas, then we would want someone to come in.”

Veazey Reindl, the woman whose mother and grandmother suffered from skin cancer, encouraged others to get checked, too. “Yearly skin checks are a good thing to do because skin changes very quickly, especially being in the sun. Living in a place like Charleston where there are so many fun outdoor activities, you should always wear sunscreen.”