Skin cancer doesn’t just hit those with fair skin; young adults with constant sun exposure at risk

SINGAPORE — They did not think skin cancer would strike them. One thought it was something that happened to older people with a genetic history, and the other thought it affected people with fair skin.

Skin cancer survivors Mr R Selvan and Ms Lim JM are among the growing group of younger adults in Singapore diagnosed with the disease.

Ms Lim was only 26 years old when she was diagnosed in 2017.

Mr Selvan, who discovered the cancer last year, is in his late 40s.

They do not want to be identified because their relatives, friends and colleagues do not know about their condition.

In both cases, a mole on their left cheek, which changed in size, colour and shape over time, turned out to be basal cell carcinoma.

This type of skin cancer is more commonly seen in older persons and usually takes years of cumulative damage by ultraviolet light to develop.

Ms Lim, who works as a kidney transplant coordinator, said that she feared for her life when she learnt of her diagnosis. She enjoyed hiking and beach holidays but rarely bothered using sun protection.

“I could not comprehend how a person my age, with no family history of cancer, could develop a malignant disease. The doctor told me that my cancer was most probably directly related to sun damage to my skin during my outdoor holidays,” she said.

Like Ms Lim, Mr Selvan, who works in media production, said that the diagnosis caught him by surprise and he was “consumed by despair” when he first tested positive for the cancer.

An avid outdoor sports enthusiast since he was a teenager, the most he did was to apply sunscreen occasionally when he played football. He would sometimes wear a hat when he was outdoor but not while playing sports.

“I could not believe that healthy and active sportsmen like myself could get cancer,” he said.

“Although I had played outdoor sports every day without UV protection, I never realised I was susceptible to skin cancer as I thought the disease was more common among light-skinned people, not individuals with darker skin tone like myself. Now I know it can strike anyone.”

WHAT YOU NEED TO KNOW

Singapore has one of the highest levels of ultraviolet radiation in the world throughout the year.

And skin experts have repeatedly harped on the importance of good sun protection habits, which ideally should be incorporated into one’s daily routine.

Yet, skin-safe practices such as applying a broad-spectrum sunscreen and covering up with protective clothing while out and about in the sun have not caught on here.  

With more young people picking up outdoor sports and activities and favouring beach holidays, skin doctors interviewed by TODAY said that lax attitudes towards sun protection could lead to severe outcomes.

The effects of the year-round onslaught of harsh UV rays on unprotected skin are already visible: The number of people diagnosed with skin cancer has increased in the last 50 years.

Dr Suzanne Cheng, senior consultant at the National Skin Centre, said that the most common skin cancers, basal cell carcinoma and squamous cell carcinoma, are related to chronic sun exposure throughout an individual’s lifetime.

Another type known as melanoma is related to intermittent, intense sun exposure, particularly in childhood or adolescence.

Data published by the Singapore Cancer Registry shows that the age-specific incidence rate for non-melanoma skin cancers in the above-65 age group has more than doubled in the last 50 years: From 47.9 per 100,000 between 1968 and 1972 to 109.6 per 100,000 between 2013 and 2017.

While the rise of non-melanoma skin cancers remains the greatest in the older age group, dermatologist Angeline Yong from Angeline Yong Dermatology pointed out a similar rising trend in the 35 to 64 age group. Ms Lim and Mr Selvan were her patients.

Referring to figures from the cancer registry, Dr Cheng from the National Skin Centre said that there were 1,017 cases of non-melanoma skin cancers in this younger age group between 2013 and 2017, compared with 942 cases between 2008 and 2012.

The youngest skin cancer patient she has encountered was a 30-year-old Chinese woman.

WHAT IS THE BIGGEST RISK FACTOR

Dr Yong said that the main risk factor for skin cancer among younger adults is sun exposure.

“Active, outdoor-loving Singaporeans are at a higher risk of skin cancer, especially those who enjoy their outdoor activities with minimal or no sun protection.”

Even for those who do not stay outdoors for long but want to look tan for cosmetic reasons, Dr Cheng said that the use of tanning beds to seek a “healthy glow” also increases the risk of skin cancer in young patients — in particular, melanoma.

Earlier detection, better access to dermatologists and healthcare, as well as changes in the diagnostic criteria for melanoma could have also contributed to an increase in younger people being diagnosed with skin cancer, she added.

The misperception that skin cancer occurs only in fair-skinned people and not Asians may also explain why sun protection habits are not being taken seriously here, Dr Cheng said.

“The higher amounts of melanin (skin pigment) in darker skin offers increased protection from ultraviolet radiation, the leading cause of skin cancer. However, (people with darker skin) should still use sunblock because prolonged exposure and sunburn can result in cancer,” Dr Yong said.

Dr Cheng said that people with 50 moles, atypical moles or large moles, genetic syndromes such as xeroderma pigmentosum, or a weakened immune system — for example, while on immunosuppression drugs for kidney transplant — also have a higher risk of developing skin cancer.

These people would require regular skin surveillance.

Age is also a risk factor, and as life expectancy increases, the incidence of skin cancer is expected to rise, she added.

WHAT ARE THE SIGNS TO WATCH FOR

Dr Yong said that the most common sign of suspected skin cancer is a raised brown or black growth on sun-exposed areas such as the face, ears, scalp and forearms.

It can also affect areas less exposed to the sun such as soles of the feet, lower legs and palms, as well as around the anus and on the genitals.

Asians, in particular, may develop a type of melanoma that occurs over the palms of the hands, under the nails and soles of the feet.

Dr Yong said to look out for the following red flags:

• new moles

• moles that increase in size

• an outline of a mole that becomes irregular or ragged

• a spot that has been changing in colour, or is varied or has a pearl-like sheen

• a spot that becomes raised or develops a lump within it

• the surface of a mole becoming rough, scaly or ulcerated

• moles that itch or tingle

• moles or spots that bleed or weep

• spots that look different from the others

• lesions or sores that never completely heal

However, early-stage skin cancers can be difficult to identify and detect because they are usually painless and can resemble benign spots and moles.

Dr Yong said that dermatologists typically use a magnifying device called a dermatoscope for visual assessments, but visual screening is never 100 per cent accurate.

“If a patient is willing, a biopsy for histologic confirmation is always the safest way to process with any unusual lesions or moles.”

In Mr Selvan’s case, he noticed the mole on his cheek in 2016 but only discovered that it was cancerous in January last year.

He decided to undergo an elective excision of the mole to have it checked while he was seeking treatment for an unrelated skin condition.

“Honestly, if it wasn’t for my scalp psoriasis, I would never have had the mole checked,” he said.

Although skin cancer is potentially fatal, the two most common forms of skin cancer here, basal cell carcinoma and squamous cell carcinoma, are highly curable when detected early and treated properly, Dr Cheng said.

They accounted for 0.2 per cent of the total cancer deaths from 2013 to 2017.

Melanoma, on the other hand, causes the greatest number of skin cancer-related deaths worldwide, she added.

“Skin cancer is potentially fatal when the cancer cells spread from the primary site to other parts of the body via the bloodstream or lymphatics.

“This can occur with melanoma and squamous cell carcinoma, but is unlikely to occur with basal cell carcinoma unless the tumour is left neglected for a long time,” Dr Cheng said.

WHAT ARE THE TREATMENT OPTIONS

Treatment options depends on the type of skin cancer and its stage. Surgery is the standard treatment.

“Most skin cancer patients will not need systemic chemotherapy after surgery unless the cancer has already migrated to other parts of the body such as the lymph nodes, which may happen in high-risk squamous cell carcinoma or malignant melanoma, but is uncommon in basal cell carcinoma,” Dr Yong said.

Both Mr Selvan and Ms Lim underwent a type of surgery known as Mohs micrographic surgery, which involves the surgeon removing skin growth layer by layer while simultaneously examining each layer under a microscope until there are no abnormal tissues left.

They have both healed well from the surgery with minimal scarring.

Ms Lim said: “Although the surgery left a scar, it wasn’t very visible and did not bother me. Over time, the scar has become less obvious and now resembles an inconspicuous stretch mark. You would have to look at it closely to see it.”

Performed as an outpatient procedure, Mohs surgery is good for dealing with larger, recurring or difficult-to-treat skin cancers.

Dr Yong, who is a Mohs micrographic surgeon, often uses the technique on the face to conserve as much skin as possible and reduce scarring.

She said that other treatment options include:

• Cryosurgery: Used to freeze and kill cancer cells.

• Excisional surgery: Also known as wide excision, where cancerous tissue and the surrounding margin of healthy skin are cut out during the procedure.

• Curettage and electro-dessication: The growth is removed by scraping off layers of cancer cells using a device with a circular blade called a curette, and then using an electric needle to destroy remaining cancer cells.

• Photo-dynamic therapy: This involves using a combination of drugs that is sensitive to a special kind of light. When exposed to that light, a chemical reaction is produced to kill skin cancer cells.

• Radiation therapy: Uses high-powered energy beams such as X-rays to kill cancer cells. This may be an option when the cancer cannot be completely removed with surgery or the patient is not suitable for surgery.

• Chemotherapy: Chemicals or drugs are used to kill cancer cells. This can be administered as topical creams or lotions (for cancers limited to the top layer of the skin), or orally and intravenously to treat skin cancers that have spread to other parts of the body.

• Biologic therapy: Also known as immunotherapy, this treatment stimulates the body’s immune system to kill cancer cells. This may be used if the cancer has spread to other parts of the body.

HOW TO PROTECT YOUR SKIN

The best remedy, however, is still prevention. Dr Cheng gave these sun protection tips to reduce skin cancer risk:

• Avoid sun exposure between 10am and 4pm.

• Cover up with broad-rimmed hats, sunglasses, visors, clothing and umbrellas when out in the sun. Opt for protective swimwear and umbrellas with Ultraviolet Protection Factor (UPF) 50, which is a rating system to measure how much of the sun’s ultraviolet rays are absorbed or blocked by the fabric.

• Apply a broad-spectrum sunscreen of at least Sun Protection Factor (SPF) 30 to exposed areas of the skin including the ears. Use a water-resistant sunscreen when doing intensive sports where you perspire a lot or when swimming. Reapply every two hours.

Dr Cheng said that these habits should start from childhood so that it becomes part of daily routine.

They should start as early as six months old for babies regularly exposed to the sun, Dr Yong said.

Sun protection is recommended not only for outdoor activities, but even when a person is sitting near a window during day time.

After their surgery, Ms Lim and Mr Selvan no longer take their skin health for granted. Similar to brushing their teeth, they have made sun protection a part of their daily routine.

Mr Selvan also advocates self-checks on the skin. “If you notice a new mole that is getting larger, consult a doctor and undergo further examination,” he said.