Skin Cancer

Welcome to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health.

This week I sat down again with Dr. Joni Sago, whose background in both internal medicine and dermatology gives her a unique and practical perspective on skin health. Our conversation focused on skin cancer—the most common cancer—and the types I see far too often in my practice, from basal cell and squamous cell carcinoma to melanoma and the lesser-known but dangerous Merkel cell carcinoma. Dr. Sago helped explain what makes each of these skin cancers different, while also reminding us that risk is not shaped by sun exposure alone. Genetics, immune function, and certain health conditions can all play a role, which is why patients who are immunocompromised, including transplant patients and those with chronic lymphocytic leukemia, need to be especially vigilant. We also talked about prevention, including what we know about chemoprevention with niacinamide, the potential role of metformin, and the emerging hope that some diabetes drugs, including GLP-1s, may eventually play a part in cancer prevention.

We talked through practical treatment options for skin cancer and its precursors, from surgery to innovative topical therapies like 5-FU with calcipotriene. One of the most important takeaways was the need to tailor treatment to the patient, especially when caring for older or more vulnerable individuals, so we can treat effectively while minimizing harm. Dr. Sago also shared fascinating insight into melanoma and why it can be more genetically driven, which helps explain why even people without significant sun exposure can still be at risk. We wrapped up with the importance of smart screening, paying attention to unusual new bumps—even ones that look acne-like—and remembering that many skin cancers are highly curable when found early.

PODCAST NOTES 

• Basal cell carcinoma, while the most common type of skin cancer, is largely attributed to ultraviolet exposure, particularly on the head and neck. Dr. Sago pointed out that basal cells can appear as small pink or flesh-colored bumps, often mistaken for pimples but prone to bleeding and persistent growth. Although rarely fatal, if left untreated, they can cause significant local destruction, especially in sensitive areas like the nose, eyelids, and ears, impacting both function and quality of life.

• Squamous cell carcinoma presents a particularly serious risk in immunosuppressed patients, especially those who have received organ transplants or have chronic lymphocytic leukemia (CLL). Dr. Sago emphasized how transplant patients, due to necessary immunosuppressive medications, have dramatically higher rates of aggressive skin cancers, and are advised to maintain vigilant dermatology care. Patients with autoimmune diseases on immunosuppressive therapy and those with CLL also face heightened risks and can experience rapid and severe progression.

• Niacinamide (the amide form of vitamin B3), not to be confused with niacin, can lower the risk of developing non-melanoma skin cancers—especially squamous cell carcinomas—by as much as 25%. Dr. Sago explained that the evidence is strong when taken at a dose of 500 mg twice daily, though quality matters—a reliable source is needed to avoid poorly manufactured supplements. The benefits come without flushing or cholesterol effects, and the safety data has recently been reinforced for those at high risk.

• There is emerging and promising research showing that medications commonly used to treat metabolic conditions, such as metformin and GLP-1 receptor agonists, might play a role in reducing the risk of various cancers, including skin cancer. Both impact inflammation, metabolic signaling pathways, and immune surveillance, potentially lowering risk and even slowing cancer progression. These advances point toward a future where management of metabolic syndrome could also protect against cancer.

• The majority of basal and squamous cell carcinomas do not lead to death, but there are exceptions, especially among immunocompromised individuals. Dr. Sago shared that she has not lost any patient to basal cell carcinoma but has seen fatalities from squamous cell cancer, particularly in patients with CLL. This underscores the crucial importance of appropriate follow-up and increased screening in those who fall into higher risk categories.

• Melanoma stands apart from other skin cancers, as it is heavily influenced by genetic factors, and can appear in areas with little or no sun exposure. The most dangerous risk factor for melanoma is a history of severe, blistering sunburns during youth, not the chronic, mild exposure seen in other types. Melanomas on the legs, back, or even buttocks highlight a genetic and early-life environmental mechanism that differs notably from other skin cancers.

• Early detection cannot be overemphasized. While annual skin checks are not necessary for everyone, they are vital for people with risk factors—family or personal history of melanoma, abnormal-looking moles, or a concerning skin change. Self-exams are equally important, and any spot that doesn’t heal, bleeds, itches, or just looks different should be checked promptly, as early-stage skin cancers are much easier to cure.

• Merkel cell carcinoma, though rare, is extremely aggressive with a high rate of fatality, often associated with a common virus. It tends to appear as a rapidly growing, painless, dome-shaped red or purple bump on sun-exposed skin in older adults. Despite advances in immunotherapy, survival rates remain low, making awareness and prompt recognition absolutely critical.

Skin health is something we can actively protect with knowledge, vigilance, and action. If you’re over 40, have a family history, take immunosuppressants, or simply notice a new spot that doesn’t go away—don’t brush it off. Regular skin checks, smart prevention (sunscreen, hats, niacinamide), and modern treatments can make all the difference. Take care of your skin, trust your instincts, and don’t hesitate to get a dermatology opinion—early intervention saves lives. Take a moment this week to check yourself, talk to a loved one, or make that overdue appointment. You’ll be glad you did.

Stay educated. Stay healthy. 

Till next week.