STOWE, VT. — All squamous cell carcinomas require attention, but not all of them require emergency attention, said Dr. Glenn D. Goldman at a dermatology conference sponsored by the University of Vermont.
Thanks to effective public health campaigns in recent years, there has been a dramatic increase in patient and physician awareness of the potential seriousness of squamous cell carcinoma. The flip side of this successful educational program has been its contribution to the notion that all patients with a positive biopsy for the cancer must have a dermatology consult within days of the report.
“I can't tell you how many calls we get from patients and providers requesting immediate consultations because when they go through the [appointment office], they're told we are booking out a couple of months,” said Dr. Goldman of the division of dermatology at the University of Vermont. “As a result, I am constantly squeezing people into my schedule for 'emergency' consults, which drives the nurse manager nuts. And a lot of the time, when the patient comes in, it's clear that it's not really urgent, which drives me nuts.
“The truth is, not all squamous cell carcinomas are created equal. Many are minimally invasive and slowly advancing, whereas others are very invasive and advancing daily,” said Dr. Goldman. And although it's important that all squamous cell carcinomas be thoroughly removed and appropriately treated in a timely manner, some require more immediate attention than others, and it's usually not that difficult to tell the difference, he said.
“There are a handful of clues that will let you know you're dealing with a bad squamous cell carcinoma,” Dr. Goldman said. When any of these are present, “it's a sign that the lesion is aggressive and needs to be treated quickly and with great care.”
The first indicator of a bad lesion is that it is new and has developed rapidly within a short period. “Often, someone will come in with a squame that has been sitting there literally for years without changing much, and it could probably sit there for another year without causing a problem,” said Dr. Goldman. “It's the person who just noticed this thing a few weeks ago, and since then it has grown and changed daily, that you have to worry about.”
Also of concern is the patient who “is experiencing true neuropathic pain—not just the type of pain caused by a squame that feels like a screw if you put pressure on it—but the dull, searing neuropathic pain that doesn't go away,” said Dr. Goldman. Such pain could indicate nerve damage from metastases, he noted.
Immunosuppressed patients, such as transplant patients or those with chronic lymphocytic leukemia, who develop squamous cell carcinomas generally require aggressive treatment because their lesions often multiply and enlarge quickly, said Dr. Goldman.
Finally, “old men with squamous cell carcinoma tend to have bad luck with it, particularly if it is on the temple, which is one of the areas at highest risk for metastases,” Dr. Goldman said. “This is fairly well known in the derm community, but it's not written about much in the national literature.”
There also are several telltale indicators that a squamous cell carcinoma is not going to be difficult to cure and doesn't require immediate action. These include lesions that start as a patch or a plaque and those that are slow growing and nontender, Dr. Goldman said. Often, with such growths, “the biopsy itself is the cure,” he said. “More than 60% of the time, the biopsy will have gotten the whole thing. The clinical exam will reveal no residual squamous cell carcinoma, and the pathology will bear this out.”
Although these less serious squamous cell carcinomas do require treatment, “they can easily wait 1 to 2 months before being treated,” Dr. Goldman said.