The most common cancer in the United States is skin cancer and the number one cause is the sun, something hard to avoid here in Florida. Dermatologist, Jill Waibel, M.D., medical director of the Multidisciplinary Skin Cancer Clinic at Miami Cancer Institute, joins host, Dr. Jonathan Fialkow to shed some light on the latest news in skin cancer diagnosis, treatment and prevention -- including the recent FDA warnings about the use of chemical sunscreens, in this episode of Baptist HealthTalk.
Want more expert advice on skin protection? Join Dr. Waibel and Drs. Naira Braghiroli and Roman Jimenez of Miami Cancer Institute for “Get Ahead of the Rays,” a virtual panel discussion, on Wednesday, July 29 at 6:00 p.m. Please register here.
The most common cancer in the United States is skin cancer and the number one cause is the sun, something hard to avoid here in Florida. Dermatologist, Jill Waibel, M.D., medical director of the Multidisciplinary Skin Cancer Clinic at Miami Cancer Institute, joins host, Dr. Jonathan Fialkow to shed some light on the latest news in skin cancer diagnosis, treatment and prevention -- including the recent FDA warnings about the use of chemical sunscreens, in this episode of Baptist HealthTalk.
Want more expert advice on skin protection? Join Dr. Waibel and Drs. Naira Braghiroli and Roman Jimenez of Miami Cancer Institute for “Get Ahead of the Rays,” a virtual panel discussion, on Wednesday, July 29 at 6:00 p.m. Please register here.
Announcer:
At Baptist Health, South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist Health Talk podcast, where our respected experts bring you timely, practical health and wellness information to improve your family's quality of life. It's the most common type of cancer in the country, and it may make you think twice before having fun in the sun. On this episode of Baptist Health Talk.
Dr. Jonathan Fialkow:
Hello, Baptist Health Talk podcast listeners, I'm your host, Dr. Jonathan Fialkow. I'm a practicing preventive cardiologist and lipidologist at the Miami Cardiac & Vascular Institute at Baptist Health, South Florida, as well as the chief population health officer at Baptist Health. When we talk about people's health concerns, cancer is always high on the list. You might be surprised to learn that the most common type of cancer is not lung cancer, breast cancer or colon cancer, it's skin cancer. More than 9,000 people are diagnosed with skin cancer every day in the United States of America. Today, I'm pleased to welcome dermatologist, Dr. Jill Waibel, the medical director of the Multidisciplinary Skin Cancer Clinic at the Miami Cancer Institute. Welcome to the podcast, Jill.
Dr. Jill Waibel:
Good morning. And thank you, Dr. Fialkow, pleasure to be here today.
Dr. Jonathan Fialkow:
Jill, we've known each other for a while, please call me Johnathan, okay? Jill, it's well known that sun exposure is a risk factor for developing skin cancer. We do live in the sunshine state and now in this COVID-19 environment we're specifically recommending people to go outside, both for the physical and psychological benefit. Let's start the conversation about the sun. What are the sun's effects on our skin, and then certainly how that pertains to skin cancer?
Dr. Jill Waibel:
So as you mentioned, skin cancer is the number one cancer in the human body. As a matter of fact, there are more skin cancers in the United States diagnosed here then all other cancers combined. Number one cause is sun. And what happens is that ultraviolet radiation changes our DNA and creates defects that will then enter into cancer. Now, is sun good for you? You'll be surprised your dermatologist say this, but I actually think sun has a lot of health benefits. We also know that here in South Florida we have one of the longest life expectancies in the United States. Naples in Miami live the longest. So I think it's all about common sense, prevention, and we can get into that as well.
Dr. Jonathan Fialkow:
So sun affects the skin, potentially a negative capacity, but you're recognizing there are benefits to being in the sun as well. So we don't want people to just necessarily be recluses to prevent skin cancer. But as you said, there are preventative things we can do to protect ourselves. So, what should that vigilant speak? What should people think when they are going to head outside or have the sun exposure? And again, South Florida and then the world in general.
Dr. Jill Waibel:
So, the first thing we tell everyone is sun protection. We want, and you as a cardiologist, want people out there running for an hour. What dermatologists don't want, we don't want you to go to the beach eight til five, laying out in front, that is very unhealthy. So some protective clothing, sun protection, sunscreens, physical blocks, we'll get into that, zinc and titanium, you want to reapply every two hours. There's no such thing as water resistant. So if you go swimming or in the pool, you need to come out and protect. Wear hats, wear sunglasses, great UPF protective clothing these days.
Dr. Jill Waibel:
Then there's also a population of people who work outside. We have a lot of people that work for FP&L, our migrant workers, our lifeguards. That's a little bit of a different strategy. Those patients we want to get into Miami Cancer Institute. We want to be doing more preventative exams. We want to start them on Retin-A. There's treatments such as photodynamic therapy, which actually prevents 80% of future skin cancer. And there's antioxidants, both healthy eating as well as some things you can apply to your skin to help prevent that breakdown of the DNA and causing cancer. So lots of great things we can do to prevent skin cancer.
Dr. Jonathan Fialkow:
So we talked about a couple of populations, but let's start with that as you may have alluded to the, what we can call the high risk population. People who are working outdoors on a regular basis. Again, recommendations both in terms of their protection, you went through things. These are people who should be screened. They should be coming to Miami Cancer Institute, or what would be the direct recommendation you would have to someone who's working as part of their occupation?
Dr. Jill Waibel:
Yeah, so it's been a struggle nationally as a board certified dermatologist, we actually don't have national guidelines for skin cancer screenings. However, we tend to recommend starting at the age of 40. If you don't have a significant family history of melanoma, or you haven't had skin cancer, we recommend people at the age of 40 starts to come to the Miami Cancer Institute or your board certified dermatologist to do a skin cancer screening, where we literally look from head to toe, and you need to make sure that exam encompasses looking in your mouth, looking in your scalp, looking in between your bottom, it's not pleasant. Looking in your toes, because melanoma doesn't just happen, it's unexposed places. And of course, we're also looking for basal cells, squamous cells. So once a year for the average patient. Now-
Dr. Jonathan Fialkow:
Once a year at the age of 40?
Dr. Jill Waibel:
40, unless you have had a skin cancer personally, and then we see you. If you have a skin cancer when you're 25, which is unusual, we would want to see you every year then. The other exception is, there's a lot of genetic tests and syndromes out there. There's basal cell nevus syndrome. There's things that people have in their families that put them at higher risk. There's starting to be some research emerging that women that get breast cancer with BRCA2 might be associated with melanoma. So we definitely have populations that we identify that we want to see more commonly. Transplant patients, big one. Transplant patients die, number one cause of squamous cell because they're on immunosuppressed medication. So whether you've had a heart transplant, a kidney transplant, a bone marrow transplant, we need to see those patients every six months. And again, we have procedures to prevent skin cancer.
Dr. Jonathan Fialkow:
So lots of high risk populations you've alluded to, but even the average person over the age of 40 should be aware and have that level of surveillance specifically with a board certified dermatologist, Miami Cancer Institute techniques as well. How about now sticking with screening and prevention if you will. What kind of things would you recommend to a parent to develop good habits for their children and good protective things early in life?
Dr. Jill Waibel:
Good topic. So, the first thing I tell people is, six months or younger, no son. Fetal and infants have very, very thin skin, so they can get sunburned very quickly, and it actually can cause a lot of damage. Early sunburns in childhood are a marker for melanoma. So if you have a baby, keep them out of the sun. You know, now once they get a little older, one, two, and you're going to go put them in a baby pool or swimming, get them on protective clothing. Get the hats on them, again, their skin has not seen sun and they are at higher risk for sunburn.
Dr. Jill Waibel:
And then for your more active, your young children, your teenagers, sunscreen. We're way behind Australia, I've lectured in Australia several times. In the Australian schools, they have all their sporting events are covered. They have to wear hats that protect 360 degrees around the kids. If they don't apply sunscreen or protective clothing, the parents are [inaudible 00:07:38] financially. So I really do feel like in the United States we do need to be better. Here in South Florida, our kids are out in the sun for hours a day. So it's a tough one. And if you're fair, redheads, but even our Latin populations have had triple increases in melanoma in the last three decades.
Dr. Jonathan Fialkow:
So definitely opportunity for more public health awareness and involvement. The average person say, "I just walk to my car and from my parking lot to the office and back, anything I should be concerned with in my normal daily activities, if I'm not getting significant sun exposure in my work?"
Dr. Jill Waibel:
Yes, great question again. So most people don't realize that the UVA rays, which are the most damaging, come right through your car window and right through windows. And we have sort of this famous picture in dermatology of a 85-year-old seamstress. And she sat by her window for 60 years, sewing, and her side by the window is wrinkled and has about five skin cancers. And her other cheek looks like a 20-year-old.
Dr. Jonathan Fialkow:
Wow.
Dr. Jill Waibel:
And she was from Germany I think. So we really have to understand that just the transient son, your car window, your windows, you're not safe from the sun at all. And so you've got to keep up that protection.
Dr. Jonathan Fialkow:
So facial sunscreen, and maybe on your arms and hands would be something that people should basically be doing every day if they plan to leave their house?
Dr. Jill Waibel:
Yeah. Sun exposed areas and sunny places or snowy places. That's another one-
Dr. Jonathan Fialkow:
Yeah, good point.
Dr. Jill Waibel:
... that reflects a lot of sun. And also remember that shirt people is like, "Oh, I'm covered." A regular white T-shirt only as a sun protective factor of two, which is you might as well be walking around without a shirt. So, you've got to make sure if you're in the sun going to a game and going to the boat, you want to really have a preparation plan in mind. But we want you to enjoy life. We want people to be out exercising, having a great time. It's just, common sense goes a long way.
Dr. Jonathan Fialkow:
So proper precautions starting at a young age, over 40, regular screenings. High risk populations, those working outside, those with family histories of skin cancer, those who've had an early skin cancer and maybe some other medical conditions which might be associated like immunosuppressive therapies or certain breast cancers. Broad population out there who would be at risk at skin cancer, I guess, which is consistent with the frequency and the prevalence of skin cancer. Let's talk a little bit about sunscreens, then we'll get into a little bit more medical science about the different kinds of cancers and then what the great work you're leading at the Miami Cancer Institute. So what would be recommendations for sunscreens? What should people look for in sunscreens? Again, broad topic. I'm sure you'll simplify it for us.
Dr. Jill Waibel:
A lot going on in sunscreens in 2020. Last fall the FDA issued a pretty strong warning based on some clinical trials done that chemical sunscreens and things with oxybenzone, azobenzene, these names you don't necessarily have to remember, but there's an absorption threshold that they consider safe at the FDA. And again, nobody needs to know this, but it's 0.5 nanograms per milliliter. They had several studies where they took healthy volunteers and put them in a house for two weeks. And they had them apply sunscreen with chemicals three times a day. And then they did a series of blood draws.
Dr. Jill Waibel:
And scarily what we found was that there were toxic levels of these chemicals in the blood. And this is very relevant, because we know that migrant workers that pick oranges that have pesticides and fertilizers and chemicals have a much higher rate of leukemias and lymphomas and other cancers. So any chemical exposures as we're learning every day are probably not a healthy thing for the human body, which is why we try to be as organic as possible most of the time. So the FDA is doing more studies, but at this point most dermatologists are recommending physical sunscreen. So those ingredients are either zinc or titanium dioxide. And you want to, it needs to say physical block, and those do not penetrate through your skin, they actually stay on top of your skin and reflect the sunlight. And so this is a very big emerging story to keep people healthier and safer.
Dr. Jonathan Fialkow:
Well, you know I'm going to go right out and check my sunscreens after this and check the ingredients, although I guess I think I'm safe. Because it's the thick white stuff that kind of leaves kind of impression, maybe is that bad?
Dr. Jill Waibel:
And for a lot of the women out there, there's sun protective things that you can do. We have, our number one selling product is a compact that has makeup. It's actually a wonderful sun protection. So we try to simplify life, but yes, you should not be white and pasty.
Dr. Jonathan Fialkow:
That is good news. But again, the zinc, the titanium, the physical barriers as you're saying, those are the ones I want to look for. And again, the goal of the podcast is to bring information and resources, not to scare people. So certainly that's something they could look to. So, we use the term skin cancer. It's broad, there are different kinds of skin cancers. If you could speak to again the different kinds of the more common skin cancers and what the differences are, both in terms of prognosis and the treatments.
Dr. Jill Waibel:
Okay, so I'm going to do the big three we call them. The most common cancer in the human body is the basal cell carcinoma. Basal cell is almost completely due to ultraviolet radiation, sun and tanning beds. Basal cells are probably the best cancer to get if you can say that, because they're easily treated, they're easily preventable. The cure rate is in the high 90s. Very few people will ever die from basal cell, although it has happened. Basal cells are red and bleedy. So I always tell patients, "If you have a growth more than one month, it's growing, changing, bleeding, burning, or itching, you want to go to MCI to see a dermatologist, because that's a real danger sign."
Dr. Jill Waibel:
And basal cells are real, we call it, friable, like they break down, they bleed. People don't tend to miss those, but they're flesh colored or red, they're pink, they're not a brown color. Second most common cancer is squamous cell. Now our listeners might be going, "Well, I've heard squamous cell." Squamous cell can happen for many different organs. So there's a squamous cell in the lung, but the skin squamous cell is somewhat more dangerous on the head and neck. If it's not treated, there could be about a 7% death rate of head and neck squamous cell, and there are certain areas that we are very concerned about, like the lip, the ear, that you can have a higher rate of the cancer spreading. Squamous cell also is a high likelihood due to sun. But there's other things that can affect squamous cell. If anyone's had radiation for treatment of cancer, it can actually make you a little more prone to squamous cell.
Dr. Jill Waibel:
Burn patients, trauma areas are a little more prone. And then people on immunosuppressed medications for any disease, whether it's lupus, whether it's transplant, those patients have a higher rate of squamous cell. Easily preventable, easily treated. Again, early detection is the name of the game. Now the deadliest skin cancer is malignant melanoma. Malignant melanoma happens when a mole turns into cancer. 50% of melanomas come from a mole people have had on their body their whole life. So I have a lot of patients that come in, they'll be like, "I've had this my whole life." And I'll be like, "Well, that's melanoma." If it's changing, and we'll talk about the ABCDEs in a minute, but-
Dr. Jonathan Fialkow:
Let me just do a, it's 50% of melanomas come from a mole you've had your whole life. Is that what you're saying?
Dr. Jill Waibel:
Yes, and the other 50% show up de novo, like you wake up one day and boom, a new mole. That's a bad sign. You get moles from the time you were born until you're 40. So if you're over the ... Again, that magic age of 40 in dermatology and you get a new brown spot, that's a little more concerning than if you get a new mole when you're 20. Now there's other fun things you get that I call wisdom spots. But, if you're 55 and wake up with a really black mole, that could be a melanoma.
Dr. Jonathan Fialkow:
So the key to all three remain early detection and early assessment and early treatment. Is that what you say?
Dr. Jill Waibel:
That is a 100% true. We have a higher survival. The earlier detected, the higher survival. And much less morbidities, smaller surgeries, easier cures.
Dr. Jonathan Fialkow:
Okay. So now let's talk about the great stuff that's being done at the Miami Cancer Institute's Multidisciplinary Skin Cancer Clinic. Tell us a little bit about some of the advanced technologies that are available at the Miami Cancer Institute?
Dr. Jill Waibel:
Well, MCI is one of my favorite, it's an honor to be part of MCIs Cancer Multidisciplinary Clinic. And we have eight physicians that span from surgical oncologist, the radiation oncologist, the medical oncologist, the dermatologist, and we all work together. We literally spend about four hours per patient, from prep to seeing the patient together, to discussing the patient and making a plan.
Dr. Jill Waibel:
So Miami Cancer Institute is the only place that I know of in the world that has three cutting edge imaging technologies to detect skin cancer. The first one is called the Vector360. This is an imaging device where you step into a 92 camera device and it takes photos of every part of your body. And it can detect cancers and melanomas that we can't see with the human eye. It creates an avatar. Do you remember the movie Avatar? We literally create an avatar of you and we can hone in and analyze. I can type in, put moles from the biggest to the smallest, and I get a printout on the screen. And I could press that mole and it will go to that mole on your arm. And I can then go look at your arm a little closer and make sure I didn't miss anything.
Dr. Jill Waibel:
I found a patient on an eyelid cancer, a basal cell on an eyelid that I couldn't see visibly, but the Vector picked up. So the Vector, there's about four in the United States right now, there's about 18 in the world. It's a wonderful early detection tool. It's used for people that are high risk. If you've had more than five cancers, if you've had melanoma, Dr. Braghiroli works side by side with me at MCI. We have found lots of melanomas or moderate to severely dysplastic moles and prevented melanomas or treated them early.
Dr. Jill Waibel:
So that device has been absolutely a game changer. And it's great for everyone to go and get a check there. Now, the two other devices we have, and again, I think we're the only center of the world that has all three of these. We have an Optical Coherence Tomography, OCT. You might have had done it, your ophthalmologist, if they ever take a picture and you can see the different levels of your retina. The OCT is one of my areas of expertise and one of my favorite tools. You can do a 30 second bedside, it's like an ultrasound, but no gel. You just apply a probe to the skin and you can see right then and there basal cell, squamous cell, some melanomas without a biopsy.
Dr. Jill Waibel:
And not only has this been a game changer for diagnosis, but we work closely with the radiation oncologist and we mark out the area and tell them how deep to go. And one of the emerging things that we're working with our oncology colleagues is, we think perhaps we're putting the radiation too deep, because a lot of these basal cells don't go very deep in the skin, but the radiation is penetrating deeper, so possibly more side effects. So we're really learning a lot.
Dr. Jill Waibel:
And then the third technology is called reflectance confocal microscopy. And that you can literally diagnose a melanoma and map out the margins of a basal or squamous. So the surgeons come into the room and we mark out the cancer and then they go and use those margins for surgery and we're increasing our accuracy. So we have all these, it's an artificial intelligence world out there and we're using these imaging for patient care and we're really pushing treatments forward.
Dr. Jonathan Fialkow:
So that seems to what really separates the approach that you and your colleagues take in this multidisciplinary approach. And the technology I guess it's very unusual to have all these technologies in one place, no less have them at all. And I guess the benefit of the patient as well is not just the detection, but the least ... The treatment which would have the least side effects or negative consequences, which as you said, radiation therapy, surgery. Other therapies that are being done for skin cancer that's kind of innovative at the Miami Cancer Institute?
Dr. Jill Waibel:
Yeah, we have, and of course, not all of these are for every patient, but we often as you know have to get creative in medicine. So there's new immunotherapies and we have one of the best immunotherapy, Dr. Rabinowitz came from Harvard and he's brilliant. So we now have immunotherapies like pembrolizumab for melanomas, for our stage three and above. We've got a systemic therapies for squamous and basal cell. So now there's a pill you can take if you have an inoperable or a metastatic. We didn't have those even five years ago.
Dr. Jill Waibel:
I do some technologies with lasers, our laser assisted delivery of chemotherapy. When we have patients that have 30 or 40 cancers, I use a laser and then we put different chemotherapies down those channels. Sometimes some of us team together and we're doing multiple therapies on patients, but we really work hard for every single patient. And especially for the complicated cancer patients that are high risk to come up with very good solutions for each patient that had both cured their cancer, number one. But we also are very cognizant of cosmetic trying to keep the best cosmetic outcomes as possible.
Dr. Jonathan Fialkow:
So in a sense, unfortunate that there's a great need for these services because of the prevalence of skin cancer in our country. But it's reassuring to know we have these means of detection and treatments for those that would benefit from it. And let's not forget the preventive strategies starting at a young age, which I think we pounded home at the beginning of the podcast. A quick promo. I understand you're presenting a virtual panel discussion about skin protection later this month. Can you give us a little preview of what's going to be covered in that? And for the listeners, we will have a registration link for that program in our notes.
Dr. Jill Waibel:
Yes, absolutely. So we have Dr. Ramon Jimenez, who's our wonderful surgical oncologist and Dr. Braghiroli, my partner in crime dermatologist. And we are going through skin cancer, what to look for, how do I identify it? And then treatment options and prevention options. So a lot of what we talked about today, but we'll of course have the visuals to go along with it. And so it's great for the listeners, especially during these summer months to learn a little bit about skin cancer.
Dr. Jonathan Fialkow:
Well, I look forward to having my family attend and I certainly will watch it as well. This is great, Jill. Fantastic information, very timely. Again, specially everything can be related to the COVID-19 pandemic, which we recognize, but again, the concern about people being outside, which we want them to do with the proper prevention and precautions can go a long way towards decreasing their risks of problems down the road leading to skin cancer. Anything you'd like to add or anything we missed or anything you want to iterate for the listeners before we sign off?
Dr. Jill Waibel:
No, the only thing that I guess I would final is make sure that everyone over the age of 40 is getting skin cancer screening. And we know that men actually die 10 years younger than women, because they don't go to the doctor as frequent as women. So let's get those men in there and thank you for having me, it's been a pleasure everybody.
Dr. Jonathan Fialkow:
Last I checked I'm over 40, so I'll make my appointment. Okay, thank you, Dr. Jill Waibel, the medical director of the Multidisciplinary Skin Cancer clinic at Miami Cancer Institute. Thanks to our podcast listeners. As always, if you have any ideas, thoughts, requests for future topics, please email us at Baptist Health Talk at baptisthealth.net. Stay safe. Remember, skin protection.
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