What You Need To Know About Melanoma

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We know we need to be proactive about wearing sunscreen to protect our skin. But how much do you know about staying safe from melanoma, the most dangerous form of skin cancer?

Though it’s more rare than other types of the disease, melanoma accounts for the majority of skin cancer deaths. The U.S. Centers for Disease Control and Prevention reports that over 9,000 Americans die of melanoma each year, and the American Cancer Society estimates that more than 76,000 new cases of melanoma will be diagnosed this year.

Another thing you might not know: For the past 30 years, rates of melanoma have been rising, and it’s one of the most common cancers among young women. The good news is that most cases of melanoma — up to 90% of them, research suggests — are preventable. And like all skin cancers, melanoma is treatable, especially when it’s caught early.

The American Academy of Dermatology has designated the first Monday in May as Melanoma Monday in order to raise awareness of this particularly deadly form of skin cancer.

Ahead, we cover what you need to know (but might not realize) about this potentially serious disease.

This story was originally published April 26, 2016.
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Photographed by Christelle DeCsstro.
Sun exposure isn’t the only thing that affects your risk of melanoma.

You know that sun exposure is bad, but there are other lifestyle habits that can affect your risk — even your eating habits.

According to a study in the Journal of Clinical Oncology, researchers found a link between a diet high in citrus fruits and an increased risk of developing melanoma. After looking at data detailing dietary habits and incidence of melanoma from more than 100,000 adult men and women (followed for up to 26 years), the researchers found that people who drank orange juice daily had a 25% increase in risk of developing skin cancer, compared to people who never drank orange juice.

How could this be? Citrus foods contain particular "photoactive" chemicals that are known to make the skin more sensitive to the sun. These chemicals, when applied topically on skin (like grapefruit juice spilling on you, for example), can make people more susceptible to sunburns and increase their likelihood of developing melanoma. So the researchers think eating these fruits may also have a photosensitizing effect.

However, this doesn’t mean you shouldn’t eat citrus. As the researchers write, citrus can’t hurt you without being coupled with sun exposure, so the important thing to focus on is sun protection.
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Photographed by: Lauren Perlstein
It affects fair-skinned people the most — but anyone can get it.

While melanoma can affect people of any skin color, if you have pale skin, you have a greater risk, explains Aleksander Sekulic, MD, Principal for Stand Up To Cancer's Melanoma Research Alliance Dream Team and a dermatologist at the Mayo Clinic. That’s because pale skin contains less melanin, which is the technical term for the natural pigment that gives your skin, hair, and eyes their colors. This pigment is actually kind of like built-in sunscreen.

On top of that, a history of sunburns is a major risk factor for melanoma, and those tend to be more common for people with lighter skin, Dr. Sekulic says.

That said, this doesn’t mean people with darker skin don’t have to worry about melanoma. Sadly, the misconception that people of color can’t get skin cancer often leads to belated diagnosis — when the disease is less treatable. The bottom line: Everyone needs to be vigilant.
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Photographed by: Mike Garten
You can get melanoma anywhere.

You might think that areas that aren’t usually exposed to sunlight would be safe from skin cancer. But the truth is that melanoma can appear anywhere on the body, from the soles of your feet to your scalp.

In fact, while the vast majority of melanomas occur on skin that’s often exposed to the sun or that has already been sunburned (like on your face or your back), there is a type of melanoma that isn’t related to sun exposure at all. Called mucosal melanoma, this type accounts for just 1% of cases, but it most commonly shows up on the bottoms of your feet, the palms of your hands, or under your nails.
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Photograpahed by: Heather Talbert
In fact, there are multiple types of melanoma.

Thankfully, mucosal melanoma is the one of the most rare kinds of melanoma. Here’s a quick guide to the four basic types, which account for the majority of cases, according to The Skin Cancer Foundation.

1. Superficial Spreading Melanoma: This is the most common type, and accounts for 70% of all cases of melanoma. It's the one that's most commonly seen in young people; it grows along the top layer of the skin before invading deeper tissues.

It is most likely to occur as a raised or flat bump or mole with ABCDE characteristics, and it tends to show up on the torso for men, on the backs of the legs for women, and on the upper back for both genders.

2. Acral Lentiginous Melanoma: This form of melanoma is the most common among Asians and African-Americans and the least common among Caucasians.

Acral lentiginous melanoma also spreads on the superficial layer of the skin before making its way into deeper tissue. However, like mucosal melanoma, it typically appears as a black or brown spot under your nails, on the soles of your feet, or on the palms of your hands. It also can advance more quickly than other kinds.

3. Nodular Melanoma: Though nodular melanoma is mostly found in older people, it accounts for 10 to 15% of all cases of melanoma, so it’s good to know about. It’s also the most aggressive of the melanomas. Since it can grow so quickly in thickness (penetrating the skin) instead of in diameter, it is usually already invasive at the time it is diagnosed — as opposed to the other forms of melanoma, which take more time to spread and become invasive.

A nodular melanoma is often a funny-colored bump, usually black, but it can be blue, gray, white, brown, tan, red, or skin-toned.

4. Lentigo Maligna: This is the slowest-growing form of melanoma. It usually occurs in elderly people, but younger people aren't immune.

This type tends to appear on areas of the skin that are chronically sun-exposed, especially the face, ears, arms, and upper torso.
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Photographed by Jimmy Marble.
There are also different stages of melanoma.
There are five separate stages, running from Stage 0 to Stage IV, increasing in the degree of severity. Melanomas caught in the earliest stages are the most treatable.

Stage 0: This early stage of melanoma is “in situ,” meaning that it is still noninvasive and hasn’t penetrated below the surface of the skin yet. Doctors will usually treat melanoma at this stage by performing wide excision surgery to remove the melanoma, along with a small margin of the normal skin around it to ensure that all cancerous cells are extracted.

Stage I: Stage I melanoma tumors have penetrated below the skin but are small and growing at a slow rate. Melanoma at this stage is also treated by wide excision.

Stage II: By this point, the tumors have become larger. They also may be growing at a faster rate and are considered to be in an intermediate stage. Stage II melanoma is also treated by wide excision, though doctors may also advise other drugs and vaccines as part of a clinical trial to reduce the chance of the melanoma coming back.

Stage III: By the time a melanoma advances to Stage III, it has spread to the lymph nodes and can carry cancer cells to other organs of your body. Essentially, a Stage III melanoma tumor has spread beyond its original tumor site. Treatment at this stage involves surgical removal, but doctors may also recommend targeted therapy, immunotherapy, or chemotherapy.

Stage IV: Stage IV melanoma tumors have spread very distantly from the original site and have spread to internal organs. Most often, they have spread to the lungs but can also spread to the liver, brain, bones, and gastrointestinal tract. For that reason, it's often difficult to treat Stage IV melanoma. Doctors can advise surgery to remove the tumor, but as the cancer may have spread, it can involve a host of other problems. According to the American Cancer Society, a small portion of people can respond very well to treatment, and this number will grow as science advances.

What makes melanoma so dangerous is that it can advance through these stages quickly, which is why it's crucial to know the risk factors, as well as the signs and symptoms, to increase the chances of catching it early.
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Photographed by Lauren Perlstein.
You put yourself at risk anytime you’re in the sun.

Skin cancer doesn’t discriminate: Anytime you’re out in the sun, whether or not you tan or burn, you’re increasing your risk. “That idea of ‘no burn, no cancer’ is a myth. The part of the skin that’s exposed does not care whether you are there with the purpose of tanning, or if you are just [sitting] there," Dr. Sekulic says. “Every minute counts equally.”

That’s because cancer doesn’t develop due to one sunburn or one vacation — it happens over time. This is why the areas of your skin that are intermittently exposed over long periods of time are the places you need to pay special attention to when you’re doing your skin checks, Dr. Sekulic adds.
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Photographed by Amelia Alpaugh.
Still, melanoma prevention is easier than you think.

Sun damage can strike anytime, anywhere, but this doesn’t mean that you need to stay inside all day. After all, who wants to be a hermit and not enjoy the sun?

The key to staying safe isn’t sun abstinence; it’s being conscientious about protecting yourself with sunblock, wearing a hat to cover your face, and choosing “off-peak” times to be outside instead of laying out when the sun is at its hottest and brightest in the day (typically around noon to 3 p.m.).

Most clothing is actually already sun-protective, Dr. Sekulic says, but it’s still smart to wear sunscreen, even on areas of your body that are covered up. When shopping for sunscreen, he suggests making sure that it has an SPF level of at least 30, and that it’s broad-spectrum — meaning it protects against both UVA and UVB rays.
And don’t forget: Reapply.

“It’s estimated in about two hours that a significant portion of sunscreen is broken down in the sun,” Dr. Sekulic says. Reapply every two hours, and even more often than that if you’re in and out of the water at the pool or the beach.
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Photographed by: Lauren Perlstein
You should do a skin check regularly.

Dr. Sekulic recommends doing thorough self-examination at least every three to four months throughout the year. After all, no one knows your body better than you, and you’ll know best if something looks out of the ordinary.

Giving your whole body a once-over after a shower is a great start, but you’ll want to be more thorough to catch any abnormal spots. Follow the Skin Cancer Foundation’s recommended step-by-step guide to checking your entire body from head to toe. And don’t forget to get a hand mirror and double-check those blind spots: your back, your underarms, the undersides of your breasts, and in your hair.

And if you’re worried about it, you might also consider checking in with your doctor. The American Academy of Dermatology recommends talking with a dermatologist, who can help you assess your individual risks by looking at your family history and your skin type — and suggest a screening schedule that makes sense for you.
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Photographed by: Lauren Perlstein
Remember: ABCDE

During your skin checks, you should be looking for new growths as well as changes to moles you already have. The “ABCDE” acronym can help you remember the signs of a troublesome spot, Dr. Sekulic says.

Asymmetry: Instead of being closer to an even circle, one side of the spots does not match the other if you draw a line straight down the middle.

Border: An irregular border instead of smooth, even borders.

Color: Healthy moles tend to be all one color, usually an even shade of brown. But melanomas can feature more than one color (brown in spots, but also red or black).

Diameter: Melanoma lesions are usually larger than 6mm (roughly the size of a pencil eraser).

Evolution: Because melanoma can start in a healthy mole, it’s important to look for funky changes. If a mole seems like it’s growing, or if it suddenly changes in color, it’s best to consult a doctor ASAP. This doesn’t mean, however, that melanoma always starts with a mole that you already have. It can also appear out of nowhere as a new spot.
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Photographed by: Lauren Perlstein.
And don’t forget about the ugly duckling.

The ABCDE method is great for detecting invasive melanoma early on, but relying solely on it could mean missing malignant melanoma spots that are smaller than 6mm in size.
Enter: The ugly duckling concept.

Rather than analyzing moles and spots individually, the ugly duckling method proposes that you also look at these spots in relation to each other. If one mole stands out from its surrounding moles in any way (for example, it’s larger or darker), that mole would be the ugly duckling.

If you find an “ugly duckling” that has any of the ABCDEs, get it checked out by a doctor immediately.
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Photographed by Jessica Nash.
There’s only one way to accurately diagnose melanoma.

While skin checks can be telling in and of themselves, the only way to really be sure whether or not you have melanoma is to undergo a biopsy.

If something on your skin appears abnormal, your dermatologist will perform a skin biopsy.

Skin biopsies are performed using a local anesthetic, injected with a very small needle. Just like when you’re getting a flu shot, you’ll feel a prick, but it should take care of any pain during the procedure. Your doctor will then remove as much of the suspicious area as possible to send off for testing. Skin biopsies will likely leave at least a small scar, depending on the amount of skin that is removed.

If melanoma is found in the skin samples, the lab pathologist will further analyze the sample to determine the stage of melanoma as well as the most effective methods of treatment.
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