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Speaker 1 00:00:59 This is disability and Progress, where we bring you insights into ideas about, and discussions on disability topics. My name is Sam, I'm the host of the show. Charlene Dahl is my research woman. Hello, Charlene.
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[email protected] and give us your, give us your ideas. This week we're speaking with Dr. Christina Bull. Christina Bull is the, um, an associate professor at the University of Minnesota Medical School. Thanks for joining us Dr. Bull.
Speaker 4 00:01:54 Thank you so much for inviting me.
Speaker 1 00:01:57 Uh, today we are talking about skin cancer. Somewhere in the world there's an 80 or 90 degree day. And, um, today it's in our world on this side of the world. And, uh, so we're experiencing some rather hot weather. And what unfortunately goes with that is sun, although sun is great. What also goes with that though, is dangerous rays in skin cancer. So can you talk to us a little bit, first of all, tell us about, a little bit about history, about you and, uh, what you all do.
Speaker 4 00:02:34 Sure. So I am a dermatologist at the University of Minnesota. Mm-hmm. <affirmative>, I see both children as well as adults. And one of the most common reasons that we see patients that our clinic is to do what's called a skin check or a mole check. And so that might be a time when someone comes in and they either have moles on their body that they feel like are changing or they just, you know, want a baseline skin check. And so we would just take a look from head to toe and be sure that we're not seeing any signs of skin cancer anywhere on the body, and that all of their moles look healthy.
Speaker 1 00:03:09 And you do, you're an, uh, associate professor. Mm-hmm. <affirmative>, what do you teach as far as, I'm presuming it's dermatology or, or can skin cancer?
Speaker 4 00:03:20 That's right. So at any given moment in our clinics, we have lots of learners with us. And so we train our medical students at the University of Minnesota who are rotating through our dermatology clinics. And so we teach them about skin rashes and what to look for for skin cancer. In addition, we have a training program for, um, our graduates who want to go on to be dermatologists or skin specialists. And so oftentimes we will have our dermatology resident doctors working with us in clinic as well. In addition, we provide a lot of talks around the country at national conferences and local conferences talking about our areas of research. My particular areas of interest are skin reactions to cancer treatments. So a lot of our cancer treatments, not just skin cancer, but any type of cancer would require things like radiation and chemotherapy. And those medicines can actually have significant side effects in the skin. And so that is one of my areas of study. In addition, I see a lot of children and adults who have congenital genetic skin diseases who need just a lifetime of follow up for those things. And that's another area of my interest in research as well.
Speaker 1 00:04:43 Let's take just a little step back to talk about what is skin cancer.
Speaker 4 00:04:49 Yeah. So cancer in general just means that cells are dividing too much and they have lost some of the stop signals. So it's good for our skin to be able to heal when we have an injury, but bad if skin cells just keep dividing and dividing and like any other organ in our body, skin cells can get cancer. And so abnormal skin cells that just keep multiplying. And some of our skin cancers tend to stay mostly just on the skin and have a really low risk of spreading inside the body, but can cause a lot of pain and local destruction, skin ulcerations. But then we have our more, um, serious types of skin cancer. Melanoma would be the most common that does actually have potential of having some of those abnormally dividing cells spread into the body and wreak havoc in some of our other organs or be what we call metastatic.
Speaker 1 00:05:47 How many different kinds of skin cancers are there?
Speaker 4 00:05:50 There are actually many different types of skin cancers, but the vast majority of skin cancers that we would see fall into two categories. And so we have the melanoma skin cancer, and we can talk more about that, but that's the one where we're looking for a changing spot or a new dark spot on the skin. Much more common, however, would be our skin cancers called non-melanoma skin cancers. And skin cancers like basal cell carcinoma or squamous cell carcinoma would fit into that category. These types of cancers are actually the most common of any cancers in the United States. And these show up a little bit differently on the skin. Um, which we can also talk about, um, in a moment if, um, if you would be interested to, to learn more.
Speaker 1 00:06:41 So just curious, are all of these cancers caused by sun? Like if we didn't have people being exposed to the sun, would they get skin cancer?
Speaker 4 00:06:52 That is a very good question and something that we're learning more about all of the time. The, the vast majority of these skin cancers are caused by sun. And it may not even be the sun that we think about. Honestly, the most important sun in our lifetime is the sun that we get prior to our teen years and in our teen years. So when we were little, getting those peeling sunburns has a very large impact on our risk of getting melanoma or other types of skin cancer as adults. The other type of radiation exposure that we think about as being even worse than the sun would be tanning bed use. And so, um, the particular wavelengths in tanning beds are very carcinogenic and so even more potent than the sun at causing the d n a changes in these cells that result in skin cancer.
Speaker 1 00:07:41 Oh, I remember when people would have that tanning bed in their houses cuz they thought it was so great to have one.
Speaker 4 00:07:47 Exactly. And like a lot of the other exposures like cigarette smoking for instance, you know, we, the the information about that being really dangerous didn't come out till later. And the same is true for tanning beds. And so there's been great legislation in making sure that children no longer have access to tanning beds, but certainly there's still plenty of, of tanning facilities around, um, our area. So just being aware that despite claims that some of the tanning, um, bed companies may make it is very dangerous.
Speaker 1 00:08:25 I wanna take a step back just for a minute because you talked about, uh, the young years of your life being just so super important about that's what really gives you your exposure to skin cancer. Can you talk a little bit about that? What happens, like what changes? Why is it that time and not when you're an adult as much?
Speaker 4 00:08:49 Yeah. So what happens is that over our lifetime our cells can slowly, slowly accumulate some damage and it usually takes many years of exposure, many exposures to cause enough damage for cells that are normal to turn into cancer. And so if cells are badly damaged very early in our life, then we have a whole lifetime to accumulate that additional damage that can ultimately result in those skin cancers. We know that experiencing five or more blistering sunburns between the age of 15 and 20 years of age increases melanoma risk by 80% and non-melanoma skin cancer by 68%. Wow. So that's quite significant.
Speaker 1 00:09:39 And they know this number of being like five or more.
Speaker 4 00:09:44 They do. And I suspect that it's because the research study looking at this groups, um, group groups answers to questions. And so it would probably be looking back at patients' recollection of how many sunburns they've had and are patients that would've answered that they had five or more would fall into this category of later having more skin cancers.
Speaker 1 00:10:09 Talk a little bit about what non melanomas, um, cancer spots look like. How could one identify them?
Speaker 4 00:10:18 Sure. The most common thing that I hear from individuals with non-melanoma skin cancer is they think that they have a pimple that just does not go away. So these spots are more likely, again, on sun exposed areas. So the face is particularly vulnerable, but also the arms, the legs and they look like, um, pink bumps or pink scaling spots. So our basal cell skin cancer is the most common type and that will show up as oftentimes just a glassy looking little pink bump on the skin, but it just doesn't go away. And so some patients note that these are very fragile, that they bleed very easily when they wash their skin and that they may heal, but even once they heal, they open up again. And so that would be something that should prompt you to, to be assessed. If you just have a true pimple on your skin, that should go away over the course of a few weeks and you know, not keep showing up in exactly the same spot.
Speaker 4 00:11:18 But if you have a bump that's in exactly the same spot that's not going away over several months, I would recommend getting that examined. Squamous cell carcinoma is our other type of non-melanoma skin cancer, and that is more likely to show up as a scaly spot. And so a scaly spot on the skin, often in sun exposed areas, a pink spot that just doesn't go away. When the squamous cell carcinomas start to get a little bit more advanced, they dive a bit deeper in the skin and we'll see symptoms like pain when people touch the spot and even crusty hard lumps that form. And so that would be another reason to go in and get that spot checked out.
Speaker 1 00:12:05 Now how are those kinds of spots treated?
Speaker 4 00:12:09 So most of our skin cancers are treated with skin surgeries, which is why it is excellent to catch them early because we certainly want to treat as small of a spot as possible. Not only is the risk of spread lower for our less advanced cancers, but also the cosmetic outcome will be much better if you treat a spot early. We have a few different ways of treating skin cancers. So for most of our skin cancers on the face, we would consider a surgical approach called Mohs surgery. And that is a procedure where you would go into a skin surgeon or um, a dermatologist who's done extra training in skin surgery and they actually would numb up the skin so that you do not feel anything painful and then remove what they can see of the skin cancer. They then immediately would freeze that skin and make microscope slides and they would look at that while you're waiting right in the clinic so that they can be sure that they have every last cell of that skin cancer removed.
Speaker 4 00:13:20 Once they're sure that all of those margins are clear from that excision, then they would do a closure or some, some stitches to the area. They have a lot of great techniques for, uh, closing the skin just as a plastic surgeon might use to make, um, you know, the the final cosmetic outcome as excellent as possible. And so that would be a great technique for removing skin cancer on the face. Some larger skin cancers on the arms, legs, or body in some locations, we don't need to use that special most technique. So in other locations that are not as cosmetically sensitive as the face, we might just do a simple excision or skin surgery to remove the skin cancer with a little safety margin of normal skin around it to be sure all of that cancer is out. Um, there are other techniques that can be used depending on the type of skin cancer. So there's a procedure where the skin can be numbed and then something called electrodesiccation and curettage where we would just scrape the dead or scrape the cancer cells away and then cauterize the skin again, all of these procedures are done with lots of numbing medicine so our patients don't experience pain during that removal process.
Speaker 1 00:14:43 That second, um, procedure sounds like it could cause more scarring.
Speaker 4 00:14:50 So some people like or prefer that procedure because it does not require excision and suturing or stitches. It just heals like, um, basically a very deep scrape in the skin. Ah, it does take a little bit longer to heal than a standard excision, but it's less deep of a wound. So there are pros and cons and something that you could talk about with your dermatologist at the time of diagnosis. There are certain subtypes of our even, uh, basal cell skin cancers that would not be app appropriate for that scraping technique. And then some that would. So there are multiple options and I always talk with my patients to know what their goals are as far as the healing process goes. Do they feel comfortable taking care of their skin cancer surgery site, things like that. I'll enter into our decision making around how to best remove a skin cancer.
Speaker 1 00:15:51 Um, I wonder if you could now talk about carcinoma how, or melanoma, sorry. Mm-hmm. How, what does that look like and how is it identified and, and what happens when one gets that type of ca skin cancer diagnosis? Yeah,
Speaker 4 00:16:11 So melanoma is one of our more serious types of skin cancer because even though it may just look like a small spot on the skin, it has potential to spread inside the body and be life-threatening. Melanoma has an excellent prognosis when detected early. So we know that there is a approximately 99% survival rate when detected when it's just in the skin. But that number really falls once it starts to spread. And so, uh, typically we think about melanoma spreading to the lymph nodes and once that happens, our five-year survival rate is only about 68%. And if it spreads beyond that and becomes more distant to other organs, then it only has a 30% five-year survival rate. So something that we are really wanting to catch early and treat appropriately to prevent any spread, what we're looking for on the skin, and a lot of people have heard about this little pneumonic, but the a b CDEs of melanoma and that is just a great way to identify spots on your skin that may need a check by a dermatologist.
Speaker 4 00:17:28 And so when we think about the letters and what they mean, we're talking about moles. So brown spots typically on the skin and a stands for asymmetrical. So we like moles to be the same on both sides. So in our mind, if we can fold that mole in half and have it be equal on both sides, that is reassuring. But if it's sending a stream of color out in one direction or has a lot more color on one side than the other, those might be warning signs that it should be checked. Uh, B stands for border or moles on our body. We prefer when we can easily see when that, where that mole starts and stops. If the mole just has a very indistinct border or seems hazy, that could be something else that would catch our attention.
Speaker 1 00:18:17 Mm-hmm. <affirmative>
Speaker 4 00:18:18 C means color for moles. Our typical colors that we would find would include a medium brown, dark brown color, and those are normal colors within a mole. If we start to see jet black pigment, if we're seeing blue or gray tinge red, those would be things that we also would want to double check and be sure that we are not dealing with a melanoma. D stands for diameter and this is the least important. If a mole is bigger than the head of an eraser about 0.6 millimeter or 0.6 centimeters, then there would be a higher risk of melanoma. We know, however, that a lot of congenital moles or moles that people are born with can be larger than this, and those moles typically do not have a significantly higher risk of melanoma. So just something to be aware of. The very most important letter is E for evolution moles that are changing maybe even early forties. Beyond that time, if we're seeing a new dark spot on the skin or if we have a mole that's there and rapidly growing, doubling and tripling in size, that would be very worrisome that, like I mentioned, those cells are overactive dividing too quickly and maybe cancerous and should be checked.
Speaker 1 00:19:44 You talk about the, um, red color of a mole and I also know of a, you know, the red cherry angiomas. Mm-hmm. <affirmative>. What is the difference between those?
Speaker 4 00:19:54 Yeah, so cherry, cherry angiomas are very common and we have our parents to thank for those as we age
Speaker 1 00:20:00 <laugh>.
Speaker 4 00:20:01 Some of us make many over time. They are just plain little cherry colored bumps on our skin. They don't have any, any pigment to them, so we wouldn't expect to see brown or black or any other of those mole colors. They would just show up as the red color that they are on our skin. When we're seeing a a melanoma, we would be looking for a spot that looks brown like a mole, but then developing a red or purple bump within it and that would be a warning sign.
Speaker 1 00:20:35 So how quickly does melanoma spread in general?
Speaker 4 00:20:41 It depends. So there are multiple different variants of melanoma and also different risk factors that we all have. And so for instance, someone who is taking medicines because of a health problem where they are immunosuppressed like our organ transplant patients for instance, we can see the melanoma develop and spread quite quickly for most people. However, their melanoma will grow just across the top of the skin before it dives deeper. And we know that the depth of a melanoma is the most important thing as far as the overall prognosis. So I would say that if you are noticing a spot on your skin, I would reach out to a dermatologist to schedule. It isn't something that I would wait on your dermatologist that, um, in your community you may find could be booked out a long ways. And in that instance I would ask your primary doctor to reach out and just request a sooner evaluation by a dermatologist. I always save appointment slots for people who have concern about melanoma and we do not want them waiting months and months and months to get in. So certainly if you and your primary doctor have concern that you have a melanoma, that is not something I would wait on. I would certainly reach out to the dermatologist.
Speaker 1 00:22:10 And how common is it for melanoma to come back? Let's say you get a spot removed, is this something that you're always going to have to watch or once it's gone, it's gone.
Speaker 4 00:22:25 So for melanoma, the surgery is again the number one treatment option. We would remove the melanoma on the skin and then in some instances if that melanoma was deep in the skin, also do a sampling of the lymph nodes that are closest to be sure that it hasn't spread. If the melanoma is found to have just been in the skin and it's completely removed with a surgery, then the risk of that melanoma coming back is very, very, very low. But you are then also more likely to make another melanoma. So for people who have had one melanoma, they're at much higher rates of making a second one. And that probably is related to both genetic factors as well as knowing that they've had the environmental exposures like the sunburns or tanning bed use that predispose them to have one. So then they're more likely to have another. Anyone who we see for a melanoma becomes close friends with us. We need to follow them very closely for a while <laugh>. So they, uh, are seeing us often for at least five years after their melanoma diagnosis to first of all ensure that we're seeing no signs of the initial melanoma from coming back, but also doing a full skin check ensuring that they don't have a second melanoma coming up.
Speaker 1 00:23:58 I was just gonna ask you how genetics plays into this equation. It sounds like it might.
Speaker 4 00:24:05 It does. And so probably about 2% of people who have melanoma have a genetic predisposition to having it. But it is recommended that if you have a first degree family member with melanoma, that you also be screened. That is an independent risk factor. And so a first degree family member would be a parent, a sibling, or a child. And in those instances we then would do a baseline assessment for someone and typically see them yearly for skin checks to be sure that they are not also developing a melanoma like their family member.
Speaker 1 00:24:48 Okay. Is there an ethnicity preference or a race preference for melanoma or skin cancers? Do you see more on Caucasian or more on other types of
Speaker 4 00:25:01 This is truly an area for health disparity, unfortunately. So even though Caucasian people do develop the ma vast majority of skin cancers, melanoma and other skin cancers can still happen in people who have more pigment or more color in their skin. But oftentimes people with darker skin tones do not, um, come in at the same point, uh, in the evolution of their skin cancer. So often the diagnosis is delayed to a point where the melanoma has spread in our patients with darker skin tones. So melanoma also is more likely in our patients with darker skin to be unrelated to sun exposure, less likely related and show up in sun protected areas, places people may not check regularly, like the bottoms of their feet, for instance. Um, the melanoma can also happen under a nail and just show up as a streak of dark pigment in the nail. So all of those things result in worse survival in our patients who have darker skin tones who do get diagnosed with a melanoma.
Speaker 1 00:26:19 So let's, let's talk about that a minute because I did read about that, that you could get a melanoma under your nail and which totally surprised me. Talk about what that looks like and what happens then.
Speaker 4 00:26:32 So melanoma can come up at any place in our skin. And what it looks like when it happens in the nail is a dark streak running down the, the length of the nail.
Speaker 4 00:26:45 We would see that the spot would start as a dark spot at the base of the nail closest to where the cuticle is, but then just continued to spread toward the tip of the nail over time. The width of that color band tends to get wider as the melanoma grows. Other things we might see would be color or what looks like a mole or, or lots of different pigment at the cuticle or at the tip of the finger. And then also we could see splitting of the nail related to this. It is common for people who do have some pigment in their skin to have dark lines in their nails. And oftentimes people who develop those dark streaks will have more of a grayish color to the nail and might have multiple fingernails or toenails with those lines through them. But the difference is that in melanoma, this would truly be a very jet black or, uh, darkly pigmented line or have other multiple different colors of brown and black within it and be growing and sprouting.
Speaker 1 00:27:53 And I don't, I guess what causes that under the nail part.
Speaker 4 00:28:00 Melanoma comes from the color cells in our skin and we have color cells in all parts of our skin, including in that cuticle area and back where the nail is made toward what we call the nail matrix. And so just like melanoma erupting in other parts of our body where we have a color cell or melanocyte that keeps dividing, the same is true for melanoma by the nail bed. There may be certain other genetic factors that would be more common in in nail melanoma and again, perhaps less likely related to sun exposure. But, but again, the process of those cells being abnormal and the way that the melanoma can behave and spread is similar. The difference is just like you said, a lot of people aren't aware that a melanoma can happen in that location and they may put off going to the doctor for it or not realize what a problem that this could potentially be for them.
Speaker 1 00:28:59 So I'd like to dive into talking about sun protection. Uh, specifically I wanna start out by talking about sunscreens, be it good or bad. Um, consumers report that I often read actually, uh, hosts a a you know, kind of a comparison on many things. And I recently saw a comparison on sunscreen in there. And sunscreen apparently is not, is not created equally <laugh>. So you could have a 40, uh, block sunscreen on one type of, uh, sun lotion and a 40 block on another. And apparently there's not a good guarantee if they're, they really do protect equally. Is this what I understand? Can you give us shed some light on that?
Speaker 4 00:29:54 Sure. I would say that the sunscreens, um, have had some, um, some issues in the last several years as far as people realizing that even though the sunscreens are approved for use, they really haven't been studied as well as we would like, as well as many other topical things have been, um, studied. And so there's been some bad press to be honest about some of our sunscreens. I'm just going to talk first about the two different categories of sunscreen. Okay. We think about sunscreens as being either mineral based sunscreens, and these would be products that would contain active ingredients of zinc or titanium mm-hmm. <affirmative>. So those would be the words to be looking for. And these are just inert minerals and when you put them on your skin, they just sit on top of your skin and they reflect the sun and they work as soon as you put them on.
Speaker 4 00:30:53 And they're not really absorbed into the skin, they just are reflective. The other type of sunscreen and the sunscreen that you are talking about where there's been some more problems and questions are chemical sunscreens and these type of sunscreens we put on has the lotion and then a chemical reaction actually has to happen in your skin. And that takes about 15 minutes and it results in this, the sun's rays when it hits your skin being depleted of energy through a series of reactions with the sunscreen so that it is no longer able to cause damage. And those chemical sunscreens, um, have been found to contain some, uh, ingredients that potentially could be dangerous when exposed to. And so sunscreens that contain the, the chemical, um, active ingredients in certain cases can degrade to release certain products that we wouldn't want in contact with our skin.
Speaker 4 00:31:55 And so that new information has led to some additional testing of these sunscreens and the food and drug administration being alerted to the fact that, hey, we may need to look into these a little bit more. A lot of these products were just grandfathered in and they really haven't been studied as well. And so different sunscreens, particularly the chemical based sunscreens may have different activity against the sun. They may block different wavelengths of light or not all wavelengths of light, and it can be really challenging to actually achieve the S P F that's listed on the label. In order to get that number, we would think about needing to use at least one ounce, which is like a shot glass size of sunscreen for an adult size body. And when we look at the average application of sunscreen, people tend not to put on enough. And so usually we're not actually even getting the S P F that is listed on the container. Um, wow. Yes. And so, so in general in dermatology, we've been really, since this information has come out, advocating more for the use of our mineral sunscreen, so our zinc and titanium based products
Speaker 1 00:33:15 That could explain how sometimes even though I put on sunscreen really thick or especially around my back and shoulders, sometimes I feel like, Hey, I've been pasting myself with sunscreen <laugh> and yet my back and shoulders tend to be the most sensitive and still get some kind of sun, which I really try hard not to do that. Um, it feels like no matter how much I paced that it doesn't protect my whole area equally.
Speaker 4 00:33:45 Yeah. And some of it too is just frequent enough application. So being sure to apply it every two hours or more if you are doing an activity where you're sweating or swimming. A lot of times in dermatology we think about sunscreen as a last resort for sun protection. So something to think about at the end, but doing other things at first to, to block the sun better. Those kind of other protective options would be wearing sun protective clothing. There are some very, uh, fashionable swim shirts over. I remember maybe 10 years ago if you looked for a rash guard or a a long sleeved swim shirt, there were not many options available. But now even the top luxury brands are making beautiful rash guard swim shirts for adults and they're actually available at all price points. You can go to target and buy a great swim shirt.
Speaker 4 00:34:41 We have an excellent Minnesota company called Cooley Bar that makes great sun per protective clothing. So all of those would be options. And so if you're really going to be out during prime swim hour or prime sun hours to be swimming or outdoors wearing sun protective clothing would be key. The other thing that's important is wearing sunglasses. We know our eyes are susceptible to melanoma as well, as well as, um, you know, skin cancers around the eyes, so wearing sunglasses and then also sun hats. The biggest pitfall for hats would be that many people just wear a baseball hat or a hat that has the visor just in the front. And that is great if the sun is always straight overhead, but most of the time the sun is coming at us at an angle and still, and so a fair amount of our face is still getting hit by that sun. So we like the hats that have a big rim that goes all the way around. So those would be other ways to protect ourself from this son that don't rely on us remembering to put on sunscreen every two hours.
Speaker 1 00:35:49 We're talking about skin cancer and I want to know, I've always wondered, you know, years ago these great nifty little sprays, sun sprays came out, as I'm sure you're familiar with, um, people like love them because they feel like, oh, they're so easy, you just spray it on. It doesn't seem to be as greasy, blah, blah blah. So talk about the difference between a spray and a lotion and is it an equal cover?
Speaker 4 00:36:19 Yeah, the first thing I'll say about sun protection and sunscreen is that it's only good if you're using it. And so if a spray is the only thing that you can get your significant other or your your kid to use it is better than nothing. Um, so I don't want to discourage people from using sun protection sprays have a few problems. The number one problem is it's just challenging to get enough of it on, just like I was talking about with the, uh, regular lotion type of sunscreen. With a spray, you really would have to spray on at least two applications to get the S P F that's listed on the bottle. The other concern is that a lot of, or most of the sprays would be chemical sunscreens as opposed to the mineral sunscreens I was talking about. Right. And then finally we just don't know much about inhalation.
Speaker 4 00:37:19 And so my concern always is with little kids, you can tell them not to breathe it in, but gosh, I mean, I have little ones and, and I would not trust them not to inhale as I was spraying that on them. And, and we just aren't sure what that could do in the respiratory track or the lungs. And so again, if spray is the only thing you can get your kids to use, then go for it. But there are a lot of other, uh, good options that are convenient in the same way that a spray might be. Other vehicles that I would prefer that, that also my kids like who hate having lotion put on them would be the sunscreen sticks. And so they look like little deodorant sticks, but actually they're blocks of sunscreen. And depending on how old your kid is, they can actually just put it on themself and they're kind of fun to use.
Speaker 4 00:38:09 And then it's not mom rubbing lotion around my face and eyes. The other thing that has come out more recently would be the mineral powders. And so there are several brands of these available I find the most easily on Amazon, but they contain zinc or uh, titanium based minerals and they come as almost like a little makeup compact brush and mm-hmm. <affirmative> tip it upside down and then the mineral powder comes onto the brush and you can apply it. And again, these are waterproof, very safe and an alternative to putting on a cream for people who dislike that sticky feeling a
Speaker 1 00:38:49 Powder. Wow. Yeah.
Speaker 4 00:38:51 Yeah. That
Speaker 1 00:38:52 Seems so weird. I would think it would clump.
Speaker 4 00:38:55 Yeah. It, it really doesn't. And the price point is a little bit higher, but it does go a long ways. And the other nice thing is that for people who have darker skin skin tones, it does not leave that white cast that we can see with some of our mineral based. Oh,
Speaker 1 00:39:10 <laugh>, I always look like that
Speaker 4 00:39:13 <laugh>.
Speaker 1 00:39:14 I've paste the mineral stuff on now and I'm like, well, the other one wasn't working. So I've kind of gone to mineral sunscreens and I know I, I always look white. Somebody's always reaching over and rubbing my should shoulders. You need to get that rubbed it.
Speaker 4 00:39:30 Oh, it sounds like you're doing a good job, <laugh>.
Speaker 1 00:39:34 Um, I, so the powder is is just like an application that you just put on like makeup kind of?
Speaker 4 00:39:44 Yes. And for people who wanna have a little bit of that, that tinted coverage, it comes in tints, but they also make brands for children that don't have a tint to them.
Speaker 1 00:39:58 So are the, are all the, you know, titanium oxide, are they all created equal then? Pretty much
Speaker 4 00:40:07 The biggest difference between them is just that pasty look that you were talking about. So some of them have more micronized formulations of the minerals and so they look a little less pasty when you put them on or have less of that white cast. Some of it is just experimenting a little bit with the different products that are out there to see what you like and what works best for you. For our patients with darker skin tones, there are also mineral based sunscreens that have a tint to them. And that way, even though you're getting that really great mineral coverage, you are not having that, that white sheen to your skin. And so looking for tinted sunscreens could be a great option.
Speaker 1 00:40:53 Interesting. I wanna talk a minute about, you know, some, there are the portion of people out there who say, you know, I don't use sunscreen because I feel like the chemicals in it, you can't trust. I take more of X amount of vitamins and that protects me. Or, um, whatever they're doing. And I, a couple of them I've watched, they don't seem to burn as much, but I do worry about not having that sunscreen protection. Can you talk a little bit about that and the dangers in that? And even if they're not burning, is there a danger?
Speaker 4 00:41:32 There is. So with our types of skin cancer, we do know that our basal cell skin cancer is more related to sunburns, whereas our squamous cell type of skin cancer is related to more cumulative sun exposure over time. So mm-hmm. <affirmative> our sun over a lifetime, even if you're not burning, can result in increased risk of skin cancer. There are some vitamins available that do impart some natural S P F. The problem is that the S P F that they add to your skin is very low. So maybe somewhere between a a two and a five, um, S P F
Speaker 1 00:42:11 And hardly anything.
Speaker 4 00:42:12 Yeah. So it's just not really adequate. I would completely agree with the concerns about certain chemicals in sunscreens, but the zinc and titanium we do know to be safe. And so I would encourage people who have concerns about the chemical sunscreens, just to go straight to the mineral sunscreens, these are sunscreens that we use safely, even on babies. Um, it's the same ingredients that are actually in diaper paste <laugh>, the, the zinc oxide. So we know we've been using this for a long time and it has a very good safety profile. And also for those individuals doing what we had talked about, wearing really good sun protective clothing, not going outdoors during prime sun hours, all of those other sun protective practices could help. Um, but ultimately studies do show that, uh, that sun protection does help prevent skin cancer.
Speaker 1 00:43:10 I believe I've read stuff about, um, the sun also breaking down your skin a little faster. So any of your females that are concerned about aging <laugh>, that seems to be a prime thing, that it does show that people age faster when they're in the sun a lot. Is this correct? Oh,
Speaker 4 00:43:30 That is so true. About 90% of our skin aging comes from the sun are UV exposure over time. So it is a huge factor for aging. And again, unfortunately, just thinking about that early sun exposure being most important when we're, we're not thinking about it and not worried about getting wrinkles, you know, 40 years from, from then. Um, but you are, you are right that that is one of the biggest reasons also to protect ourself. There's a lot of sun induced aging that happens. So a lot of times people will start to get dark spots on their face or arms and, you know, they'll say to me, gosh, you know, what is this coming from and why am I making these all of a sudden? And, and again, it's from not only current sun exposure, but sort of a lifetime of that sun exposure inducing more pigmentation in the skin is a mechanism for protection.
Speaker 4 00:44:24 So things like also, um, the bruising of the skin that I see in a lot of my patients who, you know, beyond their middle age years will start to get much more easy bruising on their forearms with minimal trauma. And it's because the sun degrades some of the protective cushions around our blood vessels. And when those are gone, even minor bumps to the skin can cause big bruising or skin thinning, skin tearing. Sun also degrades a lot of the elastic tissue in the skin and it can increase things like blood vessels forming. So mid midface redness and those tiny little telangiectasias on the face and chest. And, um, in addition it can exacerbate a lot of skin conditions like rosacea.
Speaker 1 00:45:15 Does vitamin C help repair some of that bruising?
Speaker 4 00:45:20 Um, there are some studies looking at certain vitamins to help, um, but ulti ultimately it does not take that tendency away. Yeah.
Speaker 1 00:45:31 And what do you consider prime sun time?
Speaker 4 00:45:36 Our most prime sun time would be between 10 and two. A really great trick though that I use, because often my husband will ask me, do I need sunscreen to go outside right now? So most of us carry around phones that have a weather app, and if you open up your weather app and just scroll in your area towards the sort of the bottom of the page, it'll list what the UV index is. And so right now in St. Paul, it looks like the UV index is nine very high, if that number is three or higher, it tells us that we do need sun protection to be outdoors. And so it's, it's nice because it's something that you have with when you travel, no matter where you are. Most of us have our cell phone with our weather app. So a super easy way to check to know am I safe right now or do I need to to use on protection?
Speaker 1 00:46:30 Yes. An excellent thing to have on hand. I What happens if somebody is already going through chemo? Obviously I believe one of the effects is much more skin sensitivity. How do they deal with that? And they wanna be outside in the sun in the summer?
Speaker 4 00:46:54 Yeah, so there are lots of different chemo meds and so first of all, they should have with their doctor to determine if they are on any medicines that would make them more sun sensitive. Some treatment agents do sensitize people to the sun and so they need to be especially cautious, but others may not carry that same risk. Again, the sun protective clothing is key and the mineral based sunscreens, I don't think that anyone needs to avoid being outside if they want to be, but just, just taking the right precautions can be helpful for people who are undergoing chemo and may have lost hair related to that. Having a great, awesome hat will help protect both their head and their face if they have a nice visor to it. So there are lots of great options for both Sun Protective clothing and safe sunscreens.
Speaker 1 00:47:51 Talk a little bit about what's happening in sun, um, skin cancer research now.
Speaker 4 00:47:58 There has been some amazing breakthroughs. So it used to be that when someone had melanoma, we really did not have great treatment for them. It was a cancer that had one of the worst prognos prognosis compared to other types of, of cancers. Um, I'd say over the, the last 10 years or so, there have been some treatments that have become available that are what we call targeted treatments. And what that means is that they work with certain pathways of cell division in the body to really block those cancer cells from dividing and growing. So a lot of our patients, even with metastatic melanoma, have been doing much better when placed on, on these medications. And some of the medications help block the cancer pathways, so block the cells from turning over. And some of these drugs actually boost our own immune system. So in our immune system we have types of cells that can detect and kill the cancer cells. And so some of these drugs, um, like our PD one inhibitors actually stimulate our, our body's own ability to attack the cancer cells and kill them. Mm-hmm. <affirmative>. So we have been using these drugs either alone, the targeted treatments or in combination with those drugs that improve our own, um, immune system and killing of the cancer cells for people who do have metastatic disease.
Speaker 1 00:49:38 Excellent. Um, where is skin cancer on the perspective of cancers? Like where does that fall?
Speaker 4 00:49:49 So I've mentioned that skin cancer overall when you add all the different types of cancers together is the most type common type of cancer in the United States. Our more serious skin cancer melanoma, um, is the fifth most commonly diagnosed cancer for both men and women as of 2022.
Speaker 1 00:50:11 Wow.
Speaker 4 00:50:13 So fairly common.
Speaker 1 00:50:15 And what's the most common age that you see? Age range that you see coming in
Speaker 4 00:50:23 Skin cancer risk increases with age. And so typically our patients are going to be, you know, in their sixties, seventies, eighties. Unfortunately when people get diagnosed with skin cancer at early ages, we see more women in that age group. So women are more likely to be diagnosed early in life with skin cancer and then sort of past middle age men are more likely to be diagnosed with skin cancer.
Speaker 1 00:50:51 Huh. If you could give us just a couple things that are not as commonly known about skin cancer, what would you tell us?
Speaker 4 00:51:06 So I would say that skin cancer is exceptionally treatable. And so it's not something that if you're worried about, um, that you should put off treatment, it is something that, especially when caught early, most of the time we would just remove that spot and, and do a small skin surgery and it would be gone. And so I think that a lot of people worry, um, about what the skin cancer treatment will be like and put off going in, but I would provide reassurance that the skin cancer surgery, we do everything we can to make it as comfortable as possible. That most of the time the treatment is very quick, less than an hour, and typically patients have minimal pain during and and after. Um, the other thing that I would encour would encourage or continue to encourage for all of the families listening out there who have children mm-hmm. <affirmative>, is to really do a great job with sun protection in those early years. I remember growing up when my, my mom and dad would think it was cute when I had freckles and
Speaker 1 00:52:15 Oh yes, you know,
Speaker 4 00:52:16 A good glowing tent at the end of the summer, but we know that even those little freckles are a sign of solar injury. So just doing a really great job helping your ski your kids to protect themselves with sun protection. We
Speaker 1 00:52:29 Used to get shoved outside, like all day, go outside, don't come back <laugh>
Speaker 4 00:52:35 And that don't remember,
Speaker 1 00:52:37 I don't ever
Speaker 4 00:52:38 Remember carrying sunscreen. Oh gosh. No, no, we didn't either. And you know, I, I love kids to be outside, but I, and I don't want them sitting inside and watching video games and things all day, but just do it safely.
Speaker 1 00:52:53 Is there anything that tells you like how you sunburn can, um, tell you what kind of skin cancer you're, you're pre exposing yourself to?
Speaker 4 00:53:05 Yeah, so we think about different skin pigment types and in dermatology we think about the people who oftentimes might have English or Scottish or Irish heritage mm-hmm. <affirmative> who just don't ever tan. They either burn or they're peeling and that's it. And, and those are the people really at the highest risk that have higher rates of all types of skin cancer. And then we think about our, our people who will burn first and then they tan. And those people also have a significant increased risk of skin cancer. I think that our patients who perhaps always tan and don't burn mm-hmm. <affirmative> sometimes don't think as much about their risk of skin cancer, but I just want to improve awareness that, that yes, even if you have darker pigment in your skin, you still should be careful and still watching for skin cancer. And just thinking about also the aging factors of the sun exposure that we talked about as good reasons to protect your skin. Um, and then also knowing that our patients with darker skin types, they may not get skin cancer in those classically sun exposed areas. So just checking all of those hidden spots to be sure they're not seeing a new dark spot coming up.
Speaker 1 00:54:26 Well, I like to give my research person a chance to ask questions because once in a while she comes up with some real excellent ones. So, Charlene, I, is there anything I missed? <laugh>?
Speaker 3 00:54:39 No, you you did pretty well. Uh, I just, I did not know, know that the, uh, the beginning of skin cancer is in your childhood. That that's very, yeah. Important information. Uh, um, is there a difference in gender? More women than men overall get, uh, cancers, skin cancers? Yeah.
Speaker 4 00:55:08 Still more men overall. And we don't really know why we think that there's always a lag as far as when we start to see skin cancers versus exposure. And we wonder if this is perhaps related to the fact that more men had jobs working outdoors or landscaping jobs or maybe weren't as great about some protection. When we see that more younger women are getting skin cancer, we wonder about the role of tanning beds and if that had played a role, thinking about more younger women using tanning beds than men and, uh, just changes in clothing choice over time, um, just for being outdoors what bathing suits might be looking like or what types of clothes people right. Be wearing over generations contributing. So, so still, still, our men are a little up there and, and I know my dad and my grandpa, for instance, would be the last people to put on sunscreen.
Speaker 1 00:56:04 Oh, yes. I, I I know many guys are like that,
Speaker 4 00:56:08 But I
Speaker 3 00:56:08 Have most of the time with their shirts off outside
Speaker 4 00:56:11 <laugh>. Yes, yes. But it's important for them too. And so if we can, can remind them. I know my kids are really great at reminding us to, to put our son protection on, but, but just doing the best we can to, to be aware, um, of those risks.
Speaker 1 00:56:28 Well, Dr. Gohl, thank you so much for coming on. We really appreciate your time and, uh, I hope the research keeps sp, you know, spinning forward. I think research and cancer has come a long way and, um, seems to be going faster and faster, and that's a good thing to see.
Speaker 4 00:56:45 It is. It's a really exciting time. And, and thank you so much for inviting me. Um, and, and certainly reach out to, to your local dermatologist or or clinic at the u if people have any questions or, or need skin checks.
Speaker 1 00:57:02 Thank you.
Speaker 4 00:57:03 Thank you. Thank you, doc.
Speaker 1 00:57:05 This has been disability and progress. K ffa, I 90.3 fm, Minneapolis, and kfa i.org. This is Disability and Progress. We, the views expressed on this show are not necessarily those of Kfa I or its board of directors. If you'd like to make a comment, you may email us at Disability and progress, sam jasmine.com. Let us know what you wanna hear or what you don't wanna hear. We value your feedback. My name is Sam. I've been the host of this show. We've been speaking with Dr. Christina Bull, who is an associate professor at the University of Minnesota Medical School. Charlene Doll is my research woman. Erin is my podcaster, and today Miguel was my engineer. Thanks so much for tuning in. Goodbye kpi.
