Increase in younger patients diagnosed with skin cancer

SINGAPORE — When Mr Thomas Tan (not his real name), who is in his 30s, first spotted a pimple-sized mole on the sole of his foot in 2016, he did not think much of it. He had it checked by a doctor last year after it grew to more than 1cm in diameter and changed colour.

"I had a bad feeling about it. By then, it was already ulcerating and I thought it could be linked to diabetes," he said.

The mole turned out to be an aggressive form of skin cancer called Acral Type Melanoma – which is found in the palms, soles and under the nails – and had invaded his lymph nodes.

How Mr Tan, who holds an office job and spends most of his time indoors these days, developed skin cancer remains a mystery to him.

Prior to his diagnosis, he was not aware of the symptoms of skin cancer, which is the uncontrolled growth of abnormal skin cells to form malignant tumours. In Singapore, it is the sixth and seventh most common cancer in men and women, respectively.

"I don't go usually sun tan or do a lot of outdoor sports although I got sunburnt a few times while doing National Service and sports in my youth. But it wasn't anything excessive. Skin cancer was the last thing I had expected to get, and I was in shock for a few days after the diagnosis," said Mr Tan, who underwent extensive surgery to remove the tumour and all margins of the cancer from his foot. It left him wheelchair-bound for a month.

He is currently undergoing immunotherapy – treatment that uses the body's own immune system to fight cancer – at the National Cancer Centre Singapore (NCCS) in a bid to control the disease.

Anecdotally, experts say they are seeing an increasing number of skin cancer patients diagnosed at a younger age although the disease is still most prevalent in the elderly, according to numbers from the Singapore Cancer Registry.

Between 2013 and last year, the NCCS saw 60 per cent more new skin cancer patients under the age of 50. Of the 92 newly diagnosed cases of skin cancer seen last year, about 17 per cent were under 50.

About two in five skin cancer patients Dr Eileen Tan, a dermatologist at Mount Elizabeth Novena Hospital, treats are under 50. She has seen a 10 per cent increase in younger patients between 40 and 50 over the last five years.

The uptick of younger patients could be due to increasing health-seeking behaviour and easy access to medical care but other factors like lifestyle and low awareness of safe sun habits play a part too, said experts.

Younger adults can get skin cancer if they lead a lifestyle of excessive sun exposure without adequate protection, for example, when they do outdoor or water sports, travel to high altitude areas, said Dr Natascha Ekawati Putri, an associate consultant at NCCS' division of surgical oncology.

"Based on my experience, Singaporeans tend to have low sun protection awareness or do not usually treat sun protection as high priority," she said.

HOW MUCH SUN EXPOSURE IS TOO MUCH?

Protecting the skin from excessive exposure to ultraviolet (UV) rays – the only preventable risk factor for skin cancer – is important for people of all ages, including children, said experts.

"Many studies have consistently shown a direct correlation between the number of intense sunburn episodes during childhood and melanoma," said Dr Tan, adding that safe sun habits should start from a young age.

Melanoma is not as prevalent here as it is in countries in the West. But it is the most dangerous skin cancer due to its ability to metastasise (or spread) early, said Dr Tan. The other type of skin cancer called non-melanoma skin cancer (NMSC) is more commonly found here.

Studies suggest that getting a sunburn, which is a clear sign that the DNA in skin cells has been damaged by excessive UV radiation, just once every two years may triple skin cancer risk, according to the UK Cancer Research.

The strength of the rays, length of time the skin is exposed and whether the skin is protected with clothing or sunscreen are also important considerations when measuring the amount of sun exposure, said Dr Tan.

She advised keeping infants under the age of six months out of the sun as they are especially susceptible to its damaging effects. Their skin has little melanin, the pigment that gives colour to the skin, hair and eyes and provides some sun protection. For babies six months and older, it is safe to use a broad-spectrum sunscreen, she said.

Sun protection is also needed even for those who rarely head outdoors, on cloudy days or during wintertime travel, Dr Natascha added.

While fair-skinned individuals tend to have a higher risk of getting skin cancer (due to less melanin to protect themselves from UV rays), it is "a dangerous misconception" that those with dark skin tones are not at risk, said Dr Tan, citing a July 2016 study in the Journal of American Academy of Dermatology showed that skin cancer is deadlier in the latter group.

FAMILY HISTORY, ATYPICAL MOLES

While excessive sun exposure is the main cause of skin cancer, there are many other factors that can raise a person's risk of the disease, said Dr Tan.

They include age, family history and history of atypical moles.

Individuals with a first-degree relative – parents or siblings – diagnosed with melanoma have a 50 per cent higher chance of developing the disease than those without a family history, said Dr Grace Tan, a consultant at NCCS' division of surgical oncology.

In general, the more moles on the body, the greater one's risk for melanoma, she said. However, atypical moles, also known as dysplastic nevi, can be precursors to melanoma and having them increases the risk of the disease, she said.

Compared to the average normal mole, atypical ones are usually larger in size, irregular-shaped and tend to have an uneven colour.

"When atypical moles are found in an individual who has family members with melanoma, their condition is known as Dysplastic Nevus Syndrome or Familial Atypical Multiple Mole Melanoma Syndrome. This group is at the greatest risk of developing melanoma," said Dr Grace Tan.

The good news is, early detection and treatment of skin cancer can cure most non-melanoma skin cancers, said Dr Eileen Tan.

Presently, the gold standard treatment includes surgery to remove the skin cancer. Other treatment options include curettage and electrocautery, whereby the tumour is scraped off healthy skin and the area is desiccated to destroy remaining cancer cells, said Dr Eileen Tan.

A newer therapy for skin cancer involves photodynamic therapy, which combines oxygen, light energy and a photosensitizer to generate oxygen radicals to eliminate cancer cells, she said.

"At an early stage, surgery is usually all that is needed for treatment," said Dr Grace Tan, adding that regular self-examinations and full-body skin examinations by a skin doctor can help with early detection and treatment for those with a strong family history and/or with multiple moles.

When skin cancer advances to other parts of the body, it cannot be cured by simply removing the affected mole and will require more extensive surgery or additional treatment like chemotherapy, radiation and immunotherapy to achieve control, said Dr Natascha.

Sharing his story in conjunction with Skin Cancer Awareness Month, Mr Tan hopes to raise awareness of the disease and the importance of skin self-examinations.

"In my case, I took too long to see a doctor about my mole. If I had mentioned it earlier to the general practitioner whom I saw once or twice over the year to get medication for flu, my cancer treatment would probably be more straightforward. Right now, I'm just taking one day at a time. I hope to fall into the group of (melanoma) patients who survive this," he said.

Learn more about skin cancer at the National Cancer Centre Singapore's CancerWise Workshop on June 9 (Saturday) from 1.30pm to 3.30pm at NCCS, 11 Hospital Drive, Peter & Mary Fu Auditorium, Level 4. Admission is free. Phone registration is compulsory. Call 6225 5655 to register.

USE THE "ABCDE" RULE

When checking suspicious moles, dermatologist Dr Eileen Tan from Mount Elizabeth Novena Hospital, advises the following:

A for asymmetry: If you were to cut the mole down the middle, would the left and the right sides look different?

B for border: Are the edges blurry and undefined? Does it appear to be spreading sideways?

C for colour: Does the mole look darker or lighter than usual or does it have an area of new colour such as black, blue, purple, red, or white?

D for diameter: Is the mole larger than the eraser on the tip of a pencil?

E for elevation: Does it have a raised or bumpy surface?

If you notice the above changes, a biopsy may be required to rule out skin cancer.