Kimberly Ivester, director at the Helen G. Nassif Community Cancer Center, joins Dr. Arnold to discuss types of skin cancer and steps you can take for prevention.
Dr. Dustin Arnold
Chief Medical Officer
UnityPoint Health – St. Luke’s Hospital
Helen G. Nassif Community Cancer Center
Dr. Arnold: This is LiveWell Talk On…Skin Cancer. I’m Dr. Dustin Arnold, Chief Medical Officer at UnityPoint Health-St. Luke’s Cedar Rapids. Skin cancer is the most common type of cancer in the United States and probably in the world. It is estimated that one in five Americans will develop skin cancer during their lifetime. However, there are measures that you can take to minimize your risk. And joining me today to talk about those is Kimberly Ivester, Director of Helen G. Nassif Community Cancer Center. Welcome.
Kimberly Ivester: Yeah, thank you.
Dr. Arnold: Let’s start off with what are the types of skin cancer? I mean, I think everybody hears about melanoma and rightly so they’re worried about it. And they should minimize that, but I know that’s not the only type of skin cancer. So could you just walk us through those?
Kimberly Ivester: Sure. So basal cell and squamous cell skin cancer carcinoma are the first and second most common. Those are ones that are treatable just by removing the area that’s associated with the cancer. Kind of involve the outer in the middle layers of the skin. So we don’t hear a lot about those because there’s not a lot of treatment or not a lot of risk. They rarely spread to other organs. But melanoma is the most common form of skin cancer. It really only encompasses about 1% of all skin cancers if you’re talking about all three of them together. But we hear the most about that because it does require treatment and has kind of more consequences associated with it.
Dr. Arnold: Because it can present very advanced silently.
Kimberly Ivester: It can, it can and it’s the one of the three that spreads as well. It can spread to other organs. And so that’s why it’s very important to catch it, catch it early so that we can provide treatment for it. Where the other ones usually for basal and squamous cell, just removing the area is really all that’s needed.
Dr. Arnold: And I’ve always remembered that melanoma can metastasize to the eye, which is one of the very few diseases that can. Which is just a trivia, certainly not to the person that has it happen to them. But it is a good medical trivia. Obviously everybody listening is going to say the sun, sun burns, etc. But is that the only cause of skin cancer?
Kimberly Ivester: Sun for sure is the majority of why skin cancers develop and other forms of UV exposure. That really accounts for about 90% of what they say of all skin cancers. Heredity does play a role specifically in melanoma. There’s stats out there that talk about if you have a first degree relative diagnosed with melanoma that you’re at a 50% greater chance of developing melanoma than just the average person. So it’s not a 50% chance that you will get melanoma. It’s just that your chances are about 50% higher than just the average person based on their risk factors and use of the sun and UV, which is like indoor tanning beds and so forth. But those really are kind of the biggest causes of skin cancer.
Dr. Arnold: You mentioned tanning beds or tanning salons. Is that any less of a risk? Tanning indoors as opposed to being out in the sun? Is there variable risk there or is it the same?
Kimberly Ivester: It’s typically the same. Really what it accounts for is the depth of the UV exposure. And so in tanning beds you’re not in there for a long period of time. And so the depth for that particular time that you’re in there isn’t as much as like if you were out in the sun for five hours and getting the sun from that. But both of them are considered, UV, UVA, UVB, and do really cause significant risk with developing skin cancer.
Dr. Arnold: I think indoor tanning, the Vogueness of that is starting to wear off. Particularly as the spray tan industry. I remember one time it was a big deal people have in their homes. It was a status symbol that if you have a tanning bed and a jacuzzi you were top notch five-star. I’ve never had either in any home that I’ve had. So I’m just wanna make that clear. You know, we’ll talk about Dr. Vander Zee and his dedication to melanoma and his plastic surgery practice. But I think Dr. Vander Zee told me once that with melanoma, it can be just one severe sunburn that can cause it. It doesn’t necessarily have to be a lifetime exposure.
Kimberly Ivester: It doesn’t. And they say the majority of your risk is actually developed before like the age of, you know, 20, 25 and based on the sun exposure that you had up to that point. Not that older people shouldn’t be careful about being in the sun. But you’re a cumulative risk like up to that point really does, significantly add to your risk factors and kind of lay out what your risk is based on your personal history, your family history and then your sun exposure as well. So yeah, that one sunburn they say can increase your risk by 35-50% above the population.
Dr. Arnold: Wow, interesting, I wasn’t aware of that.
Kimberly Ivester: And you can get sunburns in a tanning bed as well.
Dr. Arnold: Right, I’ve seen that happen.
Kimberly Ivester: If you’re using them. And you’ve never used them before and people spend too much time in them, you can leave there with a very significant sunburn and that is obviously not healthy. Dr. Arnold: And that’s why it’s set for 15 minutes or something like that.
Kimberly Ivester: Yeah. Yup. For sure.
Dr. Arnold: We mentioned Dr. Vander Zee. I know he spent some time over in the cancer center and has developed his practice to accommodate melanoma. He’s done surgery on family members for that. How often is he over to the, at the cancer center?
Kimberly Ivester: So the melanoma and advanced skin cancer clinic at the cancer center, Dr. Vander Zee is over there two afternoons a week. And then the other weeks he has some clinic in his plastic’s office. But then he’s in surgery the majority of time. He sees melanoma in the clinic mostly in, I would say if not 100% of those requires some sort of surgery.
Dr. Arnold: Even if it’s just a local incision. We’ll get into prevention, preventative steps. But I’ve always had an Axiom in my medical practice when a patient will say what is this? And they’ll point to a skin lesion. I said, I’ll tell you when the pathology report comes back, let’s take it off. I’ve always had a very low threshold for that. But what are some things that a patient can watch to prevent? Well, or to catch melanoma?
Kimberly Ivester: Yeah. So when we talk to patients about melanoma and they worry about every little spot or the difference between, something that you should watch and something that’s a mole, that maybe you’ve always had. We really talk to them about knowing your skin and knowing the changes with it. So if it is an area that looks a different color, looks like it’s getting a little bigger and we talk, kind of compare it to a pencil eraser on the top of a pencil, how that’s very round, has very distinct edges. If you have an area that doesn’t have distinct edges or it’s a little kind of uneven, I guess you could say. Those are all things that we tell people to kind of watch for and watch. It can be very, very gradual. And you know, just like with many things if you’re around it every single day, you don’t notice the changes as much. And so that’s why we always encourage, our patients to have their spouse or significant other an adult child to kind of look at things as well. And then say, you know, that looks different than it did a couple months ago. I’ve never noticed that on you before, mom or that looked, , it didn’t look that color last time I saw you. And those should be something that we tell people to take seriously because you may not think it’s changed because you see it everyday and didn’t notice the changes as much. But if you know someone else notices something, we definitely recommend they go in and get it looked at that.
Dr. Arnold: Yeah. I mean, it’s so easy to remove these lesions. It’s outpatient procedures.
Kimberly Ivester: And if it’s nothing, it’s nothing and at least you know.
Dr. Arnold: Yeah exactly and that’s why I said , I’ll tell you when the path report comes back. And I’ve even had specialists say oh, that’s not going to be anything, but I’ll take it off. And then they call me up and go, wow it was something. And so I think you’ve just always safer to have it removed.
Kimberly Ivester: It’s pretty simple. There’s no reason not to.
Dr. Arnold: Well we’ve implied, we didn’t mention, but we implied avoiding prolonged exposure to UV light or sunlight puts you at risk for skin cancer. What are some other preventions? Because we can’t stay out of the sun. We need her vitamin D, we want to have activities outside. So what can we do when we go outside?
Kimberly Ivester: Yeah, I think it’s just really being aware of when you’re outside, how long you’re outside, if you have the opportunity to wear a hat or to wear a long sleeve shirt with it. And like you said no one wants to avoid being outside or in the water. But so then it comes to using the best thing that we have for prevention, which is sunscreen. And just really knowing how to use sunscreen. And the best way to use sunscreen and consistently using it. People say well I use sunscreen. I did this. Well that meant that they put it on at eight o’clock and were out in the sun until 10 o’clock at night. And didn’t reapply or use it again. And so we really educate a lot on how to use sunscreen and what kind of sunscreen and making sure you’re using the right kind as well.
Dr. Arnold: And what sun protection factor do you recommend?
Kimberly Ivester: So when they look at kind of the breakdown of all of the SPFs that are out there the recommendation is to use 30. If you get higher than 30, you’re not really getting that much more protection. It’s a difference of like 97 to 99%. Nothing is 100%.
Dr. Arnold: Oh really? That’s interesting.
Kimberly Ivester: Yeah, nothing is 100% protective. But anything over 30, really doesn’t give you that much more protection and it can be more expensive. So then you kind of are like the value of using that. And I always tell you know, people when you kind of look out there at all the information, it doesn’t matter how expensive it is. It’s not going to work any better than something that’s less expensive. As long as it says that it’s broad spectrum, which just means that it covers both UVA and UVB. Sunscreens can no longer say they’re waterproof. Like when I was growing up, that was the big thing that my mom always looked for waterproof if we were going to be in. And waterproof that, that doesn’t exist. It can talk about water resistance. Or we tell people to use the sunscreen that’s the oil free because that usually bonds better to the skin. Like if you’re going to be in water. So kind of checking those things. And then the biggest thing is just really reapplying every two hours. Every two hours is what’s recommended. The other thing that people do wrong a lot is they’ll spray their kids down or put the lotion on their kids and send them out. And you really should be doing that 15-20 minutes before you’re going out and give it time to kind of soak in and settle in. Because that 15-20 minutes of exposure can start their sunburn right there.
Dr. Arnold: You know, that’s a parenting milestone. People say, oh parenting milestone when they can drive, when they’re potty trained. To me it was when the girls could put on their own suntan reliably. Which they’re 15 and 18 now and I still not reliable. But now you’re at the point that well if you get sunburn now it’s your fault.
Kimberly Ivester: Exactly. Yup. And you’re going to deal with consequences of the soreness. So yeah, it’s really about applying that. Another question we get a lot is the difference between the lotions and the spray. And there is no difference in protection between them. But when you’re spraying on, kids are running away from you because it’s cold when you first spray it. Or you know, you’re just kind of going like this and half of it’s just getting in the air and not on. So it’s okay to use the spray and it’s definitely more convenient sometimes as long as you’re actually applying it. Like put the spray on and then actually take your hand and kind of rub it in a little bit. So there really is no difference between the spray and the lotion. That’s a huge question that we get a lot. The spray doesn’t go quite as far as the lotion, so you’re buying a little bit more. But if you’re okay with that, either one of them is fine and people always forget some of the spots that are more prone, the top of your feet when you’re wearing flip flops. People don’t think to put sunscreen on there and that’s a huge place people get sunburn. The back of your neck, the top of your ears, if you’re not going to have a hat on. Even the top of your hands, you’re putting the lotion on with your hands, but you got to get it on the top of your hands as well. So just kind of remembering, you know, those parts. And then sunscreen, there are sunscreen and some chapsticks as well. Because your lips can get some burnt as well. So just kind of thinking about the areas that you normally wouldn’t think would get sunburned, you know that can.
Dr. Arnold: So you mentioned that SPF 100, I don’t even know they make a 100, but I’m sure they do or they don’t.
Kimberly Ivester: I’m not sure. I think the highest I’ve seen is 50, 55.
Dr. Arnold: I’ve seen an 80, 85 before. Tonya buys that because she’s just convinced that it protects more.
Kimberly Ivester: And it doesn’t.
Dr. Arnold: Which I’m going to remind her. So on the flip side of that, SPF 8 really is not providing a lot of protection either.
Kimberly Ivester: You know, the difference between, like an 8 and a 30 is about 8 to 10% protection. So I guess you’d have to kind of play out your risks for that. I think people use the 8’s and I’m not sure if there’s a 10. I know there’s a 15, but they use them thinking like, oh I’ll just get a base tan and that by using this, I won’t get burnt but I’ll just get a base tan. There is no such thing as like a safe tan or a base tan. If your skin is not the color of your natural skin, then you have skin damage. I mean that’s just how they say it. So I think some people use the lower ones thinking like, well, it’ll just give me a tan. It won’t give me a burn. But it’s not providing you probably as enough protection as what you need from that standpoint.
Dr. Arnold: And the spray tan doesn’t provide any protection right?
Kimberly Ivester: No. And I think people ask us a lot about that as well on are sprays tans safe? And you know, even though they’ve been out there for probably, gosh I’m completely guessing here, but maybe five, six, years. It’ll be interesting to see more longterm data on if what you’re getting sprayed with is harmful, or not. Whether you’re ingesting it when you’re in the room and getting sprayed or just having that because it’s soaking into your skin. So it’ll be interesting to see know if down the road there’s something that comes out from that as well. But no, a spray tan is not giving you protection from the sun, it has no SPF in it. It has nothing like that in it. So, and again, I think people do that thinking, well, this is my base tan and I can go out in the sun and not get burned. But that’s not true. It doesn’t work that way.
Dr. Arnold: It just prevents you from looking, when you do get sunburned from looking like an uninformed tourist. You just look so that’s the only up side to that.
Kimberly Ivester: Yeah, possibly. Yes, for sure.
Dr. Arnold: So we talked about self screening and literature has the A, B, C, D and E of skin cancer. You could you walk us through those?
Kimberly Ivester: So those really, kind of what we talked about is just in regards to how they look. So the A is related to the Asymmetry or kind of the shape of it and how it looks. The B is related to the Border and if the border is again, like a pencil eraser or if it has some like rough edges on it from that standpoint. C stands for Color. The color again, if it changes if they bleed doesn’t necessarily mean that it’s a cancer or not, but it means that it’s changing. And again, something that you would want to get looked into. Diameter is for the D and that talks about obviously the size of it and if it grows in diameter, especially if it’s growing one way versus kind of all the way around. Which then again is going to give it that irregular border. E, is was one that was recently added. It always used to just be the ABCDs and they’ve added E which is Evolution. Which again, is what we talked about. Is it changing over time? Again, the individual probably won’t notice as much as somebody else would notice. And so that’s where if somebody says like, I’ve never noticed that on you before or it looks different mom last time when I saw you six months ago. You need to take that serious because that’s a huge part of it.
Dr. Arnold: And it can sneak up on you. I’ll never forget that when I was a house staff in the early nineties that we had a transport tech that had what looked like a mole on the back of his head. And he had a military cut, you know. And so here he is walking around a tertiary healthcare center. Multiple doctors, multiple nurses are noticing this for decades or a decade at least. And my last year as a senior resident. We took care of him for metastatic melanoma. So here nobody had ever stopped him and say, hey, are you getting that looked at? And I’ve always, I’m sure I’ve offended some people. But ever since that, I’ll mention to people hey, have had that looked at? You know, and sometimes they look at you like you’re crazy, get away from me. But I would much rather have that happen.
Kimberly Ivester: For sure, and I have done that a couple of times too. You see the same people over and over, sitting in front of you at church or you know, wherever. And I’m like, wow. I wonder if he’s ever looked at and you just, you know at the end of the day, it’s like if you can help them out a little bit, then I would.
Dr. Arnold: I would say a significant majority say no I haven’t. Thank you. But there are some that look at you like you’re odd. So I always tell the house staff and other physicians that skin is the largest organ in the human body and particularly in the inpatient side, nobody’s paying attention to it. So pay attention to it. And I think that applies to the outpatient world as well. One last question. Why did you go into oncology?
Kimberly Ivester: Why did I go into oncology? Oncology was one of you had when you were in nursing school or when I was in nursing school, we had three areas that we got to pick to go kind of shadow or monitor and oncology was one of mine. And then I ended up doing what was called a preceptorship and the nurse that I spent that six months she was just amazing. And she really got me to love it. And I think, at the end of the day with oncology, those patients, you’re with them a lot and for a long period of time. With their treatment and even things afterwards. So you really get to develop that relationship with them and it’s not just see them once and you may never see them again. And so, I really enjoyed that part of it as well.
Dr. Arnold: It’s just to give a shout out to or acknowledgement that we’ve done several dozen podcasts and several of them with members of the Helen G. Nassif Community Cancer Center. And it’s so apparent the ownership and the pride they take in their work and how they connect to the patient and how they see the whole person. They don’t just see a cancer. They see a person that has cancer and that’s, that’s a compliment to you, Kimberly and your leadership over there.
Kimberly Ivester: Yeah, we’ve got a great staff.
Dr. Arnold: You certainly do. This has been really great information. Thanks for taking time to come by and talk about skin cancer. Again, this was Kimberly Ivester, director of the Helen G. Nassif Community Cancer Center. For more information, visit communitycancercenter.org/clinics/advanced-melanoma-skin-cancer/. If you have a topic you’d like to suggest for our live well talk on podcast, shoot us an email at firstname.lastname@example.org and we encourage you to tell your family, friends, neighbors about our podcast. Until next time, be well.