Skin Cancer Treatment: Surgery, Radiation, Immunotherapy

Skin cancer is not a single disease. The term covers several conditions that behave very differently: the non-melanoma types, mainly basal cell carcinoma and squamous cell carcinoma, and melanoma, the most serious form. Because these cancers grow at different speeds and differ in how likely they are to spread, there is no single treatment that fits all of them. What is recommended depends on the type of tumor, its size and depth, where it sits on the body, and a person's overall health. A great deal has changed in recent years, especially for melanoma. Surgery is still the most important treatment. Alongside it, doctors now use radiation therapy, several local treatments, and modern medicines that act directly on tumor growth or on the immune system. In advanced disease, these building blocks are often combined. At many cancer centers, a multidisciplinary tumor board decides on the treatment plan, bringing together specialists in dermatology, surgery, oncology, and radiation therapy. This helps tailor the approach to each person. This article gives an overview of the common options. It is not a substitute for a conversation with your own doctor, where your personal situation comes first.

For most skin cancers, surgery is the first and often decisive step. The goal is to remove the tumor completely. The surgeon takes out not only the visible tumor but also a rim of healthy-looking skin around it, known as the margin. This is meant to make sure no tumor cells are left behind. How wide the margin is depends on the type of skin cancer and, for melanoma, mainly on how deeply it has grown. The removed tissue is then examined under the microscope. This examination confirms exactly which tumor it is and whether it was removed with a clear margin. If the tumor reaches the edge of the sample, a second procedure may be needed. Small, easy-to-reach tumors can often be removed under local anesthesia in the office. In tricky areas such as the face, nose, ears, or eyelids, a particularly tissue-sparing technique may be used, called Mohs micrographic surgery. The tumor is removed in stages, and the edge is checked completely under the microscope until no tumor tissue remains. This helps preserve as much healthy skin as possible. For melanoma above a certain thickness, the sentinel lymph node is often examined as well, through a sentinel node biopsy. This is the first lymph node in the tumor's drainage area. If no cancer is found there, that is a good sign. The procedure is mainly used to determine the stage of the disease more precisely and to help plan further treatment.

Not every skin cancer can be removed by surgery, and surgery is not always the best route. This is where radiation therapy comes in. It uses high-energy radiation to damage tumor cells and stop them from growing. The treatment itself is painless and is usually spread over several sessions. Radiation therapy can make sense, for example, when a tumor sits in an awkward spot and surgery would leave a very large or disfiguring result, or when older or frail people prefer to avoid a bigger operation. It can also be added when a tumor could not be removed completely. In some situations, it follows surgery to lower the risk of the cancer coming back, which doctors call adjuvant radiation. In advanced melanoma, radiation therapy has a somewhat different role. Here it is used, among other things, to treat individual deposits or to ease symptoms, for instance from spread to the bones or the brain. As with any treatment, the team weighs the likely benefit against possible side effects and involves you in the decision.

Non-melanoma skin cancer, particularly basal cell carcinoma, usually grows slowly and only rarely spreads to other parts of the body. For superficial forms and for pre-cancerous changes such as actinic keratosis, gentle local treatments that do not require a scalpel are available alongside surgery. These include creams applied over several weeks that either stimulate the skin's own defenses or slow cell growth. In photodynamic therapy, a light-sensitive substance is applied and the area is then treated with a special light, destroying the abnormal cells. Other options are freezing the tissue, known as cryotherapy, and scraping away the affected skin, known as curettage. Which method works best depends on the type of tumor, its extent, and its location. Local treatments have the advantage that they can cover larger areas and often leave little scarring. Their drawback is that, unlike surgery, they do not provide tissue for microscopic examination. That is why a reliable diagnosis beforehand and good follow-up afterward are especially important.

Perhaps the greatest advances of recent years have come in treating advanced melanoma, and immunotherapy has been at the center of them. The idea behind it is simple: the immune system is the body's own defense against abnormal cells, but tumor cells can slow this system down and hide from it. Immunotherapy targets exactly this weak point. The most important group of medicines are the immune checkpoint inhibitors. Checkpoints act like brakes on the immune system, normally keeping it from attacking healthy tissue. Tumors exploit these brakes for their own benefit. Checkpoint inhibitors release them, so the body's defense cells can recognize and attack the tumor again. The brake points targeted include the molecules known as PD-1 and CTLA-4. Immunotherapy is usually given as an infusion. It can also be used after a melanoma with a higher risk of recurrence has been fully removed, to lower the chance of the cancer returning. Because the treatment activates the immune system, it can affect healthy tissue too. Possible side effects range from skin rash and bowel problems to inflammation of organs such as the thyroid. They are monitored closely and can often be managed well. It is worth knowing that immunotherapy does not work the same for everyone, and its success cannot be predicted with certainty in an individual case. According to the American Cancer Society, these treatments have nonetheless clearly improved the outlook for advanced melanoma. Whether and how they fit your case is something the treatment team works out with you.

Alongside immunotherapy, a second modern approach has become established for advanced melanoma: targeted therapy. Rather than acting on the immune system, it works directly on specific switches inside the tumor cell that drive its growth. The condition for using it is that the tumor carries a matching change in its genetic material. In a portion of melanomas, for example, there is a change in the so-called BRAF gene that keeps cell growth permanently switched on. Medicines that act on this switch and on a further one, called MEK, can slow the growth of such tumors. Whether targeted therapy is possible is therefore determined by testing the tumor tissue for these changes, known as mutation testing. Targeted medicines are usually taken as pills. They often work quickly but can lose effect over time if the tumor finds ways around the blockade. They too have side effects, such as fever, joint pain, or skin changes. Which sequence and combination of immunotherapy and targeted therapy makes sense in a given case is a matter for medical advice and depends on your individual situation.

Once the main treatment ends, the illness is usually not fully behind you yet. Follow-up care accompanies people for years. Its purpose is to catch a recurrence or a new skin cancer early, keep an eye on side effects, and answer open questions. How closely the checks are spaced depends on the type and stage of the tumor. Anyone who has had skin cancer carries a higher risk of developing it again. That makes regular skin checks with a dermatologist and your own careful observation of your skin all the more important. Self-examination using the ABCDE rule and consistent sun protection become a fixed part of everyday life after treatment for many people. Beyond the physical side, the emotional side matters too. A cancer diagnosis and its treatment can be a heavy load. Many cancer centers and support organizations offer counseling and psychological support. Do not hesitate to use it and to raise your questions openly at follow-up visits.

This article offers general, carefully researched information about the treatment of skin cancer. It cannot and is not meant to replace a personal conversation with a doctor. Which treatment is right in a given case can only be judged after a thorough examination and by taking your whole situation into account. If you notice a suspicious change on your skin or feel unsure, do not wait. Have it checked by a doctor. The earlier skin cancer is found, the more gently it can often be treated.