Physician Spotlight: Désirée Ratner, MD

One in five Americans will develop skin cancer by the age of 70, and more than two people die of skin cancer in the US every hour, according to the Skin Cancer Foundation. The good news is that increased awareness, earlier detection, and the development of novel treatments are helping to turn the tide on skin cancer, shares Désirée Ratner, MD, a dermatologist in New York City and editor-in-chief of Carcinomas & Keratoses. Dr. Ratner talked to Practical Dermatology® about all things skin cancer from the use neoadjuvant theory for melanoma and AI-aided detection to the potential downstream effects of sunscreen ingredients on the coral reef, plus more.

How are we doing in terms of skin cancer prevention? Is the message being heard?

Désirée Ratner, MD: Skin cancer incidence, including melanoma and non-melanoma skin cancer, has been on the rise. The good news, however, is that deaths related to melanoma has been on the decline with an expected decrease of 5.3 percent in 2020. An increase in prevention measures and overall skin cancer awareness and education have helped play a part in this dip. More brands have been incorporating SPF into their products, such as moisturizers and foundations, and sunscreen sales have gone up over the years, which shows that people are taking sun protection much more seriously.

What’s new in treating skin cancer?

Dr. Ratner: The oral Hedgehog inhibitors, vismodegib and sonedegib, have revolutionized our ability to treat locally advanced basal cell carcinomas. There is now a topical Hedgehog inhibitor that is under investigation for the treatment of patients with Gorlin’s syndrome with multiple facial BCCs. Since these patients undergo numerous procedures for BCCs over their lifetime, having a topical agent available to decrease the numbers of tumors that they develop would change their lives. The other big area of research is in PD-1 inhibitors. Cemiplimab was recently approved for the treatment of patients with locally advanced or metastatic squamous cell carcinoma with about 50 percent of patients responding. The question now is how long those responses will last, as some patients still have no evidence of disease a couple of years after treatment. These agents are also being looked at for melanoma. Right now a randomized study of neoadjuvant pembrolizumab (Keytruda) vs. adjuvant pembrolizumab in patients with high-risk stage III to IV resectable melanoma is being conducted to figure out if PD-1 inhibitors are more effective before or after surgical resection. Researchers are also working to determine the optimal combination of therapies to combine with PD-1 blockers to minimize toxicity while maximizing effectiveness of these treatments for patients with metastatic melanoma.

What barriers to prevention exist in special populations such as skin of color patients?

Dr. Ratner: Skin cancer can affect anyone, regardless of race, ethnicity or skin tone. Although people with dark skin are not at as high a risk for developing skin cancer as those with light skin, when they do develop skin cancer, it tends to be found at a later, more dangerous stage. Therefore, it’s important for people of color to practice sun safe behaviors, which includes wearing sunscreen, covering up with clothing, and seeking shade. Education and inclusivity are key to ensuring all people have the tools, knowledge, and medical attention they need. It has been reported that people of color are less likely to wear sunscreen every day, if at all. People with darker skin tones may be wary of using physical sunscreens, especially titanium-based products, because they can look chalky and white on the skin. However, many physical sunscreens have been formulated with nanoparticles. The small particles help the product go on the skin without leaving a white cast sometimes associated with physical sunscreens. People of color may want to try chemical sunscreens, which are usually more cosmetically elegant than physical sunscreens.

People of color are also less likely to practice self-exams or get a professional skin check once a year because of the misconception that they can’t get skin cancer. When people of color develop melanomas, they often occur in places that are rarely or never exposed to the sun. Up to 60 to 75 percent of tumors in people of color arise on the palms, soles of the feet, mucous membranes and nail regions. That’s why it’s so important for everyone to check their skin regularly and see a dermatologist at least once a year so they can examine your skin from head to toe and go over areas that are often missed.

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Are you concerned about fallout from the studies regarding active ingredients in sunscreen reaching the bloodstream or affecting the coral reef?

Dr. Ratner: Hawaii and Key West, Florida have banned the sale and use of sunscreens containing oxybenzone and octinoxateas it’s believed these ingredients contribute to the bleaching of coral reefs. This does not consider other factors of reef degradation such as pollution and climate change and more research is needed. By removing access to a significant number of products, this ban will give people another excuse to skip sun protection, putting them at greater risk for skin cancer. Additionally, a recent study found that chemical sunscreens are absorbed into our bloodstream. It’s important to note that absorption does not equal toxicity. Furthermore, we already know that organic ultraviolet (UV) filters, otherwise known as chemical sunscreen ingredients, may be absorbed into the body to some degree. Chemical sunscreen ingredients, like oxybenzone, work by absorbing into the skin, versus sitting on top of the skin to block the sun’s rays, which is how physical sunscreens work. The chemicals are then excreted in breast milk and urine, making significant buildup virtually impossible. Oxybenzone is FDA-approved for human use based on exhaustive review. The Skin Cancer Foundation’s Photobiology Committee reviewed the studies as well, finding no basis for concern about the use of sunscreens containing oxybenzone.

Thoughts on the use of AI in skin cancer detection?

Dr. Ratner: In today’s digital world, we as doctors understand the need for advances in all forms of medical practice. However, with dermatology, and specifically skin cancer detection, it’s very visual and therefore seeing a dermatologist in person is always going to be best. The use of AI can certainly help diagnose and monitor skin cancers, but I would not recommend AI in place of an actual doctor. The two working together is what is going to be the most productive and accurate.

Are you planning to use telemedicine services to see skin cancer patients during COVID-19 pandemic?

Dr. Ratner: Telemedicine can be helpful under circumstances such as we have now, with patients not being able to come into the office. I am currently using telemedicine visits to evaluate patients who have already been diagnosed with skin cancer to do consultations prior to surgery. I am also using them to follow up with my patients who have undergone surgery. However, nothing can replace an in-person visit. As COVID-19 continues to develop, if you see anything on your skin that is new, changing or unusual, you should try to see if your dermatologist is able to see you in person. Early detection saves lives and a suspicious spot should not be put off completely during this time. Similarly, if you have a medical emergency, you should call your doctor and schedule an appointment to be seen in person as soon as possible.