Patrick Hwu, MD: A Melanoma Overview

Dr. Patrick Hwu gives overview of melanoma at the American Association for Cancer Research (AACR) Annual 2012 meeting in Chicago.

Patrick Hwu, MD is the Department Chair, Department of Melanoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX. Dr. Hwu is considered one of the leading tumor immunologists in the country, and a primary force in the development of novel vaccine and adoptive T-cell therapies. (AACR) Annual 2012 meeting in Chicago.

The Group Room at the American Association for Cancer Research (AACR) Annual Meeting 2012 was made possible, in part, by:

VIDEO TRANSCRIPT

Selma Schimmel, Founder & CEO, Vital Options International

This is Selma Schimmel reporting for the Group Room at AACR, the annual meeting of the American Association for Cancer Research in Chicago. Happy to be joined now by Dr. Patrick Hwu, Department Chair in the Department of Melanoma Medical Oncology, Division of Cancer Medicine at the University of Texas, MD Anderson Cancer Center in Houston, Texas.

Hi, Doctor Hwu.

Patrick Hwu, MD, Chair, Dept. of Melanoma, MD Anderson Cancer Center, Houston, TX

Hi, thanks for having me here today, Selma.

Selma Schimmel:

I’m very happy to have you here because the warm weather is approaching; it’s really time to raise awareness about melanoma. So let’s talk a bit about the disease itself.

Patrick Hwu, MD:

We do know what causes the majority of cases of melanoma and that is UV rays because that can damage DNA in a number of ways. Sunburns are the most detrimental we’ve found, so as the sun gets hotter, people should be more careful and utilize sun safety techniques which is using lots of sunscreen, but also between the time, 10am and 3pm, the hottest time; we always say when the shadow is shorter than you, you’ve got to be careful because that’s when the sun is directly overhead and try to seek shade – there’s nothing like shade or covering your body with additional clothes.

Selma Schimmel:

I have a question about sunscreen because is can go as low as 15, as high as 45, something like that. But realistically, what is the sunscreen content that is sufficient because I don’t know if when you get above a certain number if it really does make a difference.

Patrick Hwu, MD:

We’re just now getting the first data that using sunscreen is helpful in preventing melanoma. So I think if you try to use a SPF – sun protection factor – over 30, I think you’re fine. People sell 45, 50, 60 but I think you’re right; there’s little data showing those are better than anything over 30.

Selma Schimmel:

What about as low as 15? Is that too low?

Patrick Hwu, MD:

I think that would be good too. The major thing is you use enough sunscreen and to reapply often. The major thing I see is people don’t use enough of it and then they go swimming and when they get out of the water they don’t reapply it.

Selma Schimmel:

How do you address people’s concerns now when they say ‘no, no, no. They told us to stay out of the sun and they told us to use sunscreen but now I’ve got a vitamin D deficiency’?

Patrick Hwu, MD:

Vitamin D can be supplemented orally. So you can even check your vitamin D levels, so I actually personally take vitamin D because I have dark skin and people with dark skin sometimes have trouble boosting their levels. So I think you can easily supplement your vitamin D orally, vitamin D3, that’s the form to take, it’s cheap, you can buy it at the drug store. You don’t need to get in the sun to get your vitamin D.

Selma Schimmel:

And what is the range of vitamin D? People have asked this: if you’re going to take supplemental vitamin D – first you should get knowledge of what your vitamin D levels are – but then how do you know how much vitamin D you should be taking as a supplement?

Patrick Hwu, MD:

So that’s very controversial, to know what the actual level is. And so the data really isn’t very clean in terms of what your level should be; a lot of people could say that it’s higher than the typical normal levels that are considered today to be in the normal range. So we really don’t have the information to give.

Selma Schimmel:

So that’s a discussion between a patient and their internist.

Patrick Hwu, MD:

Yes, and hopefully more information can come as we get more data on this.

Selma Schimmel:

So one of the concerns that one is that it’s the exposure you have as a child that’s quite cumulative so the people in my age group – the exposure that we’ve had when we were little – plays a role in our skin health and risk as we get older.

Patrick Hwu, MD:

Exactly true. You can get a sunburn at childhood could then induce melanoma years later. At the same token at any age you should stay out of the sun and not get sunburns because it can still induce damage to the melanocytes which can cause melanoma. But we do have to really think about children and start some education programs and put up shelters in the parks…I’m horrified sometimes when I’m at parks in Texas where it’s sunny and sometimes I don’t see adequate shelters around to just shield kids from the sun.

Selma Schimmel:

What do we do with our young adults and their inclination to use tanning booths?

Patrick Hwu, MD:

It gets very important not to do that, and there are some spray tans that can work well now. Initially it would cause an orange glow but I think they greatly improved so spray tans can give you that coloration if that’s aesthetically pleasing. Tanning beds can be harmful, and can induce melanoma. There are more laws that are being passed now to try to prevent young people from going to tanning booths and I think that’s going to be very important to try to decrease that behavior.

Selma Schimmel:

Let’s talk about the common sights and not-so-common sights for melanoma.

Patrick Hwu, MD:

Melanoma is normally found on sun-exposed skin because it’s the sun can that cause the majority of the cases. So anywhere that have sun exposure, for a trunk for a male – men often go shirtless in the beach – I put on a sunshirt, I don’t go shirtless for many reasons but – the most common sight for a man is between the skeepula in the back, the middle of the back. And for women, it’s on their extremities but I think that anywhere there’s sun exposure you have them check for moles or anything that’s changing. So that’s what we say, anything that looks like it’s changing, that’s probably the most important sign that we should have checked out by a dermatologist. I think people should consider having a dermatological evaluation at least once a year.

Selma Schimmel:

The mole, what does a melanoma mole look like? How does it present differently than other moles that we may see on our body?

Patrick Hwu, MD:

It’s challenging to tell, but there’s asymmetry where the left half doesn’t look the same as the right half, also the border is irregular so ABC – asymmetry, border, and C is color. So often it’s got variable colors in it, and D is for diameter so if it’s over 6mm we’re a little more concerned. That’s about the size of a pencil head eraser, and so if it’s larger than that we should be concerned and E is evolution or how it changes. That’s probably the most important sign, if a mole that’s changing should be brought to the attention of a dermatologist. So dermatology can do a wonderful screening once a year but still people can self-screen and find moles that are suspicious and get them cut out early that can really have better outcomes – that’s important.

Then you asked about other sights. There are sights that don’t have sun exposure that can also have melanomas, and we don’t understand those quite as well but even inside the mouth, in the rectum, the vaginal mucosal areas and the retina of the eye, wherever there are melanocytes – there can be other unusual sights as well.

Selma Schimmel:

What about how African Americans – I understand that they may be at risk for melanoma on their feet or their toes?

Patrick Hwu, MD:

Yes, I would call that acral lentiginous melanoma. That is a melanoma that starts on your palms, the surface, which there really isn’t a lot of sun exposure, or the soles of your feet. And then if someone has a darker colored skin that’s the kind of melanoma they tend to have. Sometimes it’ll go under the nails.

Selma Schimmel:

Is there any genetic predisposition for melanoma in addition to sun exposure?

Patrick Hwu, MD:

There certain familial syndromes, certainly if you have melanoma in the family you’re more likely to get that but that’s probably mostly linked with skin tone. So if you have a fair skin tone you’re much more likely to get sunburned and much more likely to get melanoma. There are some rare familial cases, and then there is a syndrome called neo-dysplasia syndrome where people just have a lot of moles and you have to be closely watched by a dermatologist.

Selma Schimmel:

When it’s removed and diagnosed early do you look at depth to understand the degree of tumor?

Patrick Hwu, MD:

Yes, that is the most important indicator is how thick it is. But melanoma is scary because even at 1mm thick it has a decent chance of spreading to other places. So that’s why we often look at lymph nodes to try to get some more information, whether it spread or not. So that is the case and that’s why we have to be so careful about melanoma. Now if you see spread in lymph nodes then we think about therapy called adjuvant therapy to try to prevent recurrence.

Selma Schimmel:

The spread of melanoma, the metastatic course, where does it spread to?

Patrick Hwu, MD:

It can spread to the draining lymph node but then it can spread to almost any place in the body. There’s not an organ or sight in the body anatomically that I haven’t seen melanoma go to in my career. It can go anywhere, so that’s why it’s something that we really need to try and catch early, prevent it in the first place by not getting sunburns and then catching early by screening, and then if the patient does have some spread to try to treat with some of these new agents that we have.

Selma Schimmel:

Doctor Hwu, how many people die a year from metastatic melanoma in the United States?

Patrick Hwu, MD:

In this country it’s about 8,000.

Selma Schimmel:

Who is the fastest growing patient population of melanoma patients?

Patrick Hwu, MD:

I haven’t seen the latest statistics but I think it’s women, actually.

Selma Schimmel:

Between what age group?

Patrick Hwu, MD:

Young women, I think, and I don’t know why that is; it’s not my area of expertise but I’m not sure why that is. But hopefully it’s not because people are going to tanning salons or…

Selma Schimmel:

It’s not so different from the Cybarate (sp?) issue where it was portrayed as something glamorous, in this case being tanned is portrayed as something beautiful and sexy and it’s a similar kind of social orientation to warrant what we think – good looking, when it really puts us at risk.

Patrick Hwu, MD:

Absolutely. They should change that so we go back to the days when being light-skinned and pale is okay.

Selma Schimmel:

In the old days if you were very fair skin, you were considered an aristocrat, if you didn’t tan your skin.

Patrick Hwu, MD:
Well there are parts of China that are like that today so women will go around with umbrellas just because they really don’t want that sun exposure, don’t want that dark skin. And that’s a good practice so I think whatever the aesthetic, the key is UV light can cause damage to your melanocytes can cause melanoma so if you like dark skin, great, but get it with a spray tan.

Selma Schimmel:

And if you are already dark-skinned, do you need to wear sunscreen?

Patrick Hwu, MD:

Yes, I wear sunscreen and I have dark skin.

Selma Schimmel:

But much dark skin…if you’re Hispanic, if you’re African American, does the darker complexion in that area still need to wear sunscreen?

Patrick Hwu, MD:

You have lower case of melanoma if you have dark skin, that’s clear but you should still wear sunscreen. Not only does it decrease your potential wrinkles as you get older but also it can prevent the other kinds of skin cancers, which can be disfiguring, less deadly but can be disfiguring – squamous cell cancer and basil cell cancer of the skin. Those two are associated with life-long exposure to the sun; melanoma’s more associated with episodic exposure to sunburns.

Selma Schimmel:

So if you’re black or Hispanic you should still be wearing sunscreen.

Patrick Hwu, MD:

Yes, in my opinion you should.

Selma Schimmel:

Well that’s important because I think people have a tendency to think ‘well I’m very dark-complected, I don’t have to worry’. Thank you very much, Doctor Patrick Hwu, Department Chair, Department of Melanoma Medical Oncology, Division of Cancer Medicine at the University of Texas, MD Anderson Cancer Center in Houston, Texas.

Patrick Hwu, MD:

Thank you for inviting me.

Selma Schimmel:

My pleasure.

END OF VIDEO

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