Skin Cancer

Anna: When somebody takes their shirt off and they have a grapefruit-sized ulcer, and they're educated and working. The reason that finally brought them to the dermatologist, who then sends them right to me, is because it was starting to smell really bad.

Brent: Welcome to Death Clock. I am your host, Brent Franson. Today we speak with Dr. Anna Pavlik about skin cancer. This is a great Understanding and Preventing Skin Cancer 101. Dr. Pavlik is a medical oncologist at Cornell, and she has spent 20 years treating and researching skin cancer. The reality of skin cancer is that, in the vast majority of cases, it's very preventable.

Brent: So doing the basics—wearing sunscreen, not getting too much sun, staying out of tanning beds, and being rigorous about watching our skin for changes in our moles, for lumps, and for discoloration—can go a long way in treating the most common types of skin cancer. What we talk about today are the three most common types: basal, squamous, and melanoma.

Brent: She's a great guest. There's a lot of optimism around being proactive about preventing skin cancer and treating it if it does come up, as it will for so many of us. She's an awesome guest. Hope you enjoy.

Brent: Dr. Anna Pavlik, welcome to the show.

Anna: Hi. Thank you for having me.

Brent: Today we're going to talk about skin cancer. I'm in Boulder, Colorado, so we've got a little elevation here. It's spring, and today happens to be 82 degrees. Sun exposure is definitely on my mind today. But before we get into all things skin cancer, can you give us a sense of your background?

Anna: I'm a medical oncologist working at Weill Cornell in New York City. I've focused my career on cutaneous malignancies, which include melanoma, squamous cell, basal cell, Merkel cell—pick a cell, I do it. I have focused on clinical research for the last 20 years, as well as skin cancer awareness and prevention.

Brent: And how did you get into skin cancer? What was the path to this expertise?

Anna: I actually have a convoluted story because I had no interest in melanoma or skin cancer initially. But when I took my first job out of fellowship, I did a little bit of everything, and there became a great need for a melanoma oncologist. I was down at NYU at that time. I hadn't thought about doing melanoma, didn't like it as a fellow, and never thought I'd spend my life doing it.

Anna: My chairman said, "I think you need to try it on for size if you want to build an academic career. It's a cancer where nothing works. So if you want to do research and make a difference, think about doing this." That made a lot of sense to me. I went into medicine because I wanted to make a difference.

Anna: So I opened my very first melanoma clinical trial in 2002, and the very first patient I enrolled had a complete response and is alive and well today. That was enough to convince me to spend my life doing melanoma research and moving the field forward.

Brent: And when you say metastatic, what does metastatic mean?

Anna: Metastatic means that the tumor that started on the patient's skin has spread to other parts of the body, such as the lungs, liver, lymph nodes, brain, or bones—anything outside the initial site.

Brent: Can we talk about what skin is? It's the largest organ, but we don't always think of it like other organs. It feels like a simple question, but sometimes the best details come from simple questions: What is skin, how do we think about it, and how do we define it?

Anna: Skin is made up of several layers. It's the protective coating that shields your inner body, muscles, and internal organs. It's the outer barrier that, if not taken care of, can become cancerous. It consists of the epidermis (the outer layer), the dermis, and the subcutaneous tissue below it.

Anna: Because there are multiple layers, when discussing skin cancers, we look at how deep the cancer is rather than just how wide it is on the surface. Depth makes a significant difference in patient outcomes.

Brent: Does it function like other organs? I usually think of organs as having very specific processes, like the kidneys, liver, or heart, where you can easily picture what flows through them and what they do. Is skin different in that respect, or is it similar and just less obvious?

Brent: It's just not as obvious.

Anna: Every organ has a job: the heart pumps blood, and the kidneys make urine and filter toxins. The skin's job is to protect everything on the inside. It arguably has the most important job in keeping internal systems functioning. For instance, in severe burn cases, the protective barrier is damaged, placing patients at high risk for infection. Everything goes haywire when the skin is disrupted.

Anna: And now they're at risk of infection. Everything really goes haywire when your skin is disrupted.

Brent: Getting into skin cancer: What are the main types? What are the most common ones?

Anna: There are three main types. The most common in adults is basal cell carcinoma. It's a slow-growing cancer that occurs when basal cells on the surface layer of the skin get damaged by UV radiation and become abnormal. These are extremely common and very rarely spread to other parts of the body.

Anna: Basal cell cancers are commonly removed by dermatologists without needing monitoring for recurrence. The main concern is when they are neglected—sometimes out of fear of a growing lesion.

Anna: When left untreated, they can grow large enough to require medical intervention before safe surgical removal. The second most common type is squamous cell carcinoma.

Anna: This occurs when squamous cells in the skin layers are damaged by chronic UV exposure. It's common in outdoor workers, people living at high altitudes, and organ transplant recipients whose immunity is suppressed. These are also managed primarily by dermatologists.

Anna: They are removed via surgical excision or Mohs surgery and rarely require an oncologist unless left unchecked, in which case they can become invasive and spread over time.

Anna: The third most common is melanoma. Although third in frequency, it is the most deadly because it can quickly grow deeper into the bloodstream or lymphatic system and spread metastatically throughout the body.

Brent: Would you rank them in that same order for severity: basal as least severe, squamous second, and melanoma most severe?

Anna: Absolutely.

Brent: Basal and squamous carcinomas are typically not high risk in terms of life expectancy. They are highly treatable and usually don't require an oncologist.

Brent: What does standard treatment and follow-up look like for standard basal or squamous cases when caught early?

Anna: Those patients typically don't need to see an oncologist. They present with small, sometimes scaly lesions or spots that bleed and won't heal, often on the nose or tips of the ears.

Anna: The face and scalp are common areas. The dermatologist performs a biopsy, usually a shave biopsy, removing the top layer for pathology analysis.

Anna: Once confirmed as basal or squamous cell carcinoma, treatment involves a local excision or Mohs surgery, which removes the lesion with microscopic precision.

Anna: They shave off thin layers and check the tissue incrementally until clear margins are reached. This allows for precise removal and much better healing than a standard excision.

Brent: So in standard basal or squamous cases, it doesn't reduce life expectancy or cause broader health complications—it's essentially removing a non-healing spot.

Brent: After removal, you just monitor it closely with your dermatologist, right?

Anna: Yes. Having one skin cancer puts you at higher risk for others due to prior UV exposure. Patients typically see a dermatologist two to four times a year for surveillance.

Brent: So regular visits help catch new issues early. During those checks, the dermatologist evaluates the skin surface to judge if a biopsy is needed.

Anna: They perform a full-body skin exam using a dermatoscope to examine lesions under magnification, deciding which spots warrant a biopsy.

Anna: We look for the "ugly duckling"—a mole that looks distinctly darker, larger, or different from the surrounding spots on a patient's body.

Brent: What specific signs should someone look out for on their own body regarding basal and squamous cell cancers?

Brent: Or what am I asking my husband or wife to keep an eye on?

Anna: Basal and squamous cell cancers often appear as small, pink, pearly, itchy, or scabby lesions. Any new spot that suddenly appears and persists should be checked by a dermatologist.

Anna: Well, that thing needs to be looked at if it wasn't there before.

Brent: There are normal skin changes, though—like temporary darkening after sun exposure that fades over time. How do you distinguish those?

Brent: That is not concerning.

Anna: Overall skin color changes or tans are normal responses to UV radiation, where the body deposits melanin for protection. Conditions like vitiligo also alter pigmentation, causing white spots.

Anna: Normal pigmentation shifts happen, but a distinct new lesion or spot that persists should be evaluated.

Brent: What is the best way to prevent skin cancer? Avoid tanning beds, limit sun exposure, and wear sunscreen?

Anna: Prevention is key. Older generations often grew up believing tans were healthy, using tanning beds and skipping sunscreen. Today we see higher rates of skin damage from those habits.

Anna: Avoid peak sun hours between 10 AM and 4 PM when UV intensity is highest. If outdoors, wear protective clothing, broad-brimmed hats, UV-blocking sunglasses, and sunscreen daily.

Anna: Remember to reapply sunscreen regularly when sweating or exercising, using an adequate amount for full protection.

Anna: A standard rule of thumb is applying about a shot-glass full of sunscreen per application. Most people use far less than necessary.

Anna: I don't know, that's an awful lot of sunscreen, at least when I was putting it on. So I'm sure most people don't use the appropriate amount.

Brent: How does skin tone affect risk? Are fairer skin tones at significantly higher risk, or do genetics play a larger role?

Anna: Skin color plays a role, but it's not the sole factor. Darker skin provides more natural protection, but UV damage and melanoma can still occur without sun safety.

Anna: Individuals with fair skin, freckles, light eyes, and red or blond hair are at the highest overall risk for skin cancers.

Brent: What about daily sunscreen usage for kids and adults? Is applying facial lotion with SPF 30 every day safe and recommended long-term?

Brent: I mean, what do we know? Or or the other question really is I wake up every day, I put a lotion on my face that has SPF 30 in it. Is that harmful? I mean, it's they're kind of no free lunches. What do we know about the harm of of sunscreen?

Anna: Sunscreens have not been linked to long-term health risks. Mineral-based sunscreens containing titanium dioxide or zinc oxide provide effective physical barriers. The best sunscreen is simply the one you will use consistently.

Anna: For kids, protective swim shirts, wide hats, and mineral sunscreens work exceptionally well to prevent early sun damage.

Anna: So there's, there's multiple ways.

Brent: So daily SPF moisturizer on the face is a clear win?

Anna: Absolutely. Keeping sunscreen easily accessible and applying it daily protects against unpredictable UV exposure, especially in higher altitude regions like Colorado.

Brent: How does treatment change if basal or squamous cell cancers are caught late or neglected?

Brent: What's the difference in that treatment?

Anna: Advanced basal cell carcinoma can often be treated targetedly with daily oral medications that inhibit specific genetic pathways to shrink the tumor quickly.

Anna: For advanced squamous cell carcinoma, because UV damage induces high mutation rates, the tumors respond remarkably well to immunotherapy compared to traditional chemotherapy.

Anna: Immunotherapy harnesses the patient's own immune system to fight off cancer, producing durable responses in roughly 50% to 60% of cases.

Anna: We now have medicines called immunotherapy that stimulates the body's own immune system to fight off the cancers. And many times those responses are completely durable. So that's also very encouraging. It happens. You get responses about 50 to 60% of the time. Unfortunately, it's not everybody, but it's a nice tool to have.

Brent: So the outlook for basal and squamous cell skin cancers is generally very positive, with effective surgical and medical options even in advanced cases.

Brent: What is the general prevalence of these non-melanoma skin cancers over a lifetime?

Anna: About 1 in 2 to 1 in 3 people will develop a non-melanoma skin cancer over their lifetime, with risk increasing as life expectancy rises.

Brent: Are men or women more, more impacted?

Anna: Overall prevalence between men and women is fairly equal, though typical exposure sites differ—men often get lesions on the scalp and ears, whereas women may see them on the legs due to sun exposure habits.

Anna: But there used to be a time when women used to wear pantyhose in the winter and didn't wear anything in the summer, and so they were more apt to get them on the back of their legs.

Brent: So the differences relate to exposure patterns rather than underlying biological susceptibility.

Brent: How is melanoma different, and what causes it?

Anna: Melanoma usually presents as a dark, pigmented spot. It can develop from an existing mole that changes over time, or arise new as a nodular melanoma that mimics a cyst.

Anna: The primary cause remains accumulated UV radiation from sun exposure and tanning beds.

Brent: Is developing melanoma vs. squamous cell carcinoma tied strictly to exposure amounts, or is there an element of luck or underlying susceptibility?

Anna: It involves multiple variables: fair skin, light hair, freckling, history of severe childhood sunburns, and frequency of indoor tanning booth use all significantly raise risk.

Anna: So lots of variables.

Brent: So if I have more severe sun exposure over an extended period of time, that probably increases that it could be the fairness of the skin. And then somewhere along the way, there's here something we don't know or just bad luck. Basically it could be all three of those.

Anna: Genetic factors play a role in fewer than 10% of melanoma cases.

Brent: How does melanoma differ in severity and treatment pathways compared to non-melanoma skin cancers?

Anna: When caught early, melanoma is highly curable through wide surgical excision. Regular skin checks with a dermatologist are essential for early detection.

Anna: For stage 1 or 2 melanomas, local excision is performed, sometimes alongside a sentinel lymph node biopsy to evaluate depth and local spread.

Anna: If the melanoma is shallow and hasn't reached lymph nodes, simple surgical removal and ongoing routine monitoring suffice. Deeper or metastatic cases transition to oncological care.

Brent: What signs should someone look for regarding melanoma specifically? Is it distinct from basal or squamous signs?

Anna: We follow the ABCDE guidelines: A for Asymmetry (moles should be symmetrical); B for Borders (borders should be crisp, not irregular or feathery); C for Color (color should be uniform rather than multi-toned);

Anna: D for Diameter (larger than a standard pencil eraser warrants checking);

Anna: and E for Evolution (any existing mole changing in size, shape, color, or starting to bleed should be formally evaluated).

Brent: What happens in more severe melanoma cases when it isn't caught immediately on the surface?

Anna: Melanoma can grow downward into deeper skin layers and lymphatic channels before visible changes are noticed on the surface.

Anna: Microscopic cells can reach local lymph nodes. While systemic preventive systemic treatments help reduce recurrence, metastatic disease requires advanced oncological therapies.

Brent: In those metastatic cases, do treatments move toward conventional chemotherapy and radiation, or are specialized options used?

Anna: Melanoma is notably resistant to traditional chemotherapy, making immunotherapy the primary treatment strategy by prompting the body's immune system to target cancer cells.

Anna: Advances in tumor genetics allow us to sequence the tumor's DNA to identify specific mutations, enabling targeted therapies that effectively neutralize tumor growth pathways.

Anna: Radiation is now rarely needed given these modern systemic tools.

Brent: What are the side effects of immunotherapy versus traditional, you know, chemotherapy or radiation?

Anna: Chemotherapy broadly attacks rapidly dividing cells, causing side effects like hair loss, nausea, and infection risk. Immunotherapy activates T-cells to rev up immune response specifically.

Anna: Because it stimulates immunity, side effects present as autoimmune inflammatory reactions—such as skin rashes, arthritis flare-ups, or colitis.

Anna: It can also cause thyroid gland inflammation, requiring lifelong thyroid hormone replacement in exchange for controlling the melanoma.

Anna: Not the worst thing in the world, but it's a problem that we give them as a consequence of therapy. But it's lifelong treatment because once, once the body attacks and shuts down the thyroid gland, it's not coming back in.

Brent: What are current mortality and survival rates for metastatic melanoma?

Anna: In the early 2000s, metastatic melanoma had a 95% mortality rate. Today, long-term survival for metastatic cases has reached roughly 60% due to modern treatments.

Brent: How significantly has overall life expectancy improved for those living with the disease?

Anna: Survival times have shifted dramatically. Twenty years ago, median survival for metastatic disease was six to twelve months. Current targeted and immunotherapies buy patients years or even decades of quality life.

Anna: Sometimes it's a couple of years, sometimes it's a decade. It really is tumor dependent. But yes, people are living with their cancers and living well because the therapy is not toxic.

Brent: What key guidelines summary would you give for preventative skin care and early vigilance?

Brent: Like what? What would those bullets be?

Anna: Always wear sunscreen, avoid tanning beds, use protective clothing, and establish routine visits with a dermatologist based on family history and skin risk factors.

Anna: If you get a patient who gets a melanoma at the age of 80, I'm not as concerned about telling them about their kids because they've had 80 years worth of sun exposure. It really is all about prevention. And the more that we start prevention at an earlier age, the less skin cancer we're going to see in the long run.

Brent: At what age should individuals start scheduling annual skin screening visits with a dermatologist?

Brent: Like at what age is it like, hey, everybody should be having a I do an annual check with the dermatologist.

Anna: Starting regular dermatology checks around age 40 to 50 is recommended, as non-melanoma skin lesions become increasingly common past age 50.

Anna: Forget melanoma. Let's take that out of the picture. But just your routine. Good skin care year. As we get older, we're all going to get one.

Brent: Given scheduling lead times for specialist appointments, booking well in advance is essential.

Brent: You got to schedule ahead.

Anna: Yes, specialist wait times can be long, so scheduling early is wise. If a concerning spot appears, notify the office right away.

Brent: What upcoming advancements, such as AI or novel immunotherapies, are you most optimistic about for skin cancer treatment?

Brent: How how optimistic are you about what's.

Anna: AI tools assist dermatologists in calculating mole risks to determine whether biopsies are necessary, reducing unneeded procedures.

Anna: In treatment, cellular therapies like Tumor-Infiltrating Lymphocytes (TILs) extract immune cells from a patient's tumor, expand them by billions in a lab, and reinfuse them to directly target remaining cancer.

Anna: Tumors in melanoma called Til cells or T lymphocytes, taking them to the lab, growing them in the lab. So we're growing the patient's own melanoma fighting cells in the lab to the millions and billions of cells. We then bring them into the hospital and give them back their own T cells. And those T cells should really be educated to go and attack the remaining tumors in the body.

Anna: We are making huge strides with cell therapy, hoping to raise effective treatment response rates toward 80% in the near future.

Brent: Dr. Anna Pavlik, thank you so much for joining us, and thank you for your incredible work and dedication over the past 20 years.

Anna: You're welcome. Thanks for having me today.

Brent: Death Clock is recorded in Boulder, Colorado, and San Francisco, California. Produced by Patrick Gudino, music by Patrick Lee, and hosted by Brent Franson, founder and CEO of Death Clock.