Key Points

• Everyone is at risk of skin cancer, regardless of skin color.

• Skin cancer usually, but not always, develops where repeated exposure to UV radiation has caused damage or where a chronic sore or inflamed area occurs.

Seventeen years ago, I submitted my first article for Massage & Bodywork magazine, and it was about skin cancer. And except for a column on squamous cell carcinoma and perineural invasion that appeared in the March/April 2018 issue, I haven’t returned to that topic since.

And since it’s been so long, we thought this would be a good time to take another look at the topic through this article, the accompanying Pathology Perspectives column, “Skin Cancer and Skin of Color,” and a new continuing education course offered through the ABMP Education Center called “Skin Cancer: Beyond the Basics.” 

Massage therapists are skin observers. It’s safe to suggest we see more of our clients’ skin than they do. We must do what we can to ensure our work is safe, and that includes being watchful of skin changes: color, texture, undiagnosed lesions, or any other situation that draws our attention. Then we must communicate what we observe to our clients in a way that is non-alarmist and that respects our scope of practice. That takes some skill and nuance.

In this article, we’ll look at what we understand about skin cancer. We’ll consider who is at risk (spoiler alert: it’s everyone, regardless of skin color), and who is most likely to have serious cases (spoiler alert: it’s not the people who get skin cancer most often). We will discuss the three major types: basal cell carcinoma (BCC), cutaneous squamous cell carcinoma (cSCC), and melanoma. We will provide a rich collection of photographs of several types of skin cancer in early and late stages, and on varying skin tones. And we will conclude with a discussion of how—carefully and respectfully—to bring our clients’ attention to what we notice about their skin.

Pathophysiology 

Skin cells have a special property that is not shared by most tissues in the body: They are labile, which means they can grow and reproduce throughout our lifetime. This is an effective protective device, because it means that even though skin is relatively delicate, it heals quickly.

However, lability comes with a cost. Every time skin is damaged and heals, cell production accelerates, and this raises the risk of genetic mutations that may become malignant. Consequently, skin cancer usually develops in one of two areas: where repeated exposure to ultraviolet (UV) radiation has caused damage, or where a chronic sore or inflamed area occurs—this could be a burn, pressure sore, or any other kind of prolonged, inflamed lesion. Some evidence even suggests skin cancer may occur more commonly than average where lesions connected to psoriasis, lupus, eczema, or other skin conditions linger.

Other factors that contribute to skin cancer risk include toxic exposures, especially to arsenic (but some petroleum products, pesticides, and other chemicals are also possible carcinogens), and immune suppression. This can be in the form of age, an immune-suppressing disease like HIV, or immune-suppressing drugs like chemotherapy or anti-rejection drugs used by organ-transplant recipients. An increased risk of skin cancer is an underappreciated complication of this kind of treatment. 

Most cases of skin cancer occur in older adults in areas exposed to sunlight: the face, scalp, ears, and whatever parts of the torso and extremities are exposed while working or relaxing in the sunshine. But both nonmelanoma skin cancer (NMSC) and melanoma occasionally appear in places that are not exposed to the sun: between the toes, on the bottom of the foot, inside the digestive or reproductive tracts, or in the groin. When that happens, it is most likely related to genetics, chronic injury and inflammation, suppressed immunity, and other non-UV light-related factors.

Statistics and Surprises

Skin cancer is the most common type of cancer in humans, although it’s not the leading cause of death by cancer. Your chance of developing skin cancer, if you haven’t had it already, is about 1 in 5. If you have had skin cancer before, your chance of having it again, especially a more aggressive or threatening type, is substantially higher.

If you have light-colored skin and blue or green eyes, your risk of skin cancer is higher than if you have darker skin and brown eyes. However, people with skin of color (a term that is defined in the column “Skin Cancer and Skin of Color,” on page 70) have a much higher risk of death from skin cancer than others. This isn’t meant to be alarmist; it’s meant to point out the importance of knowledge and vigilance against this highly treatable, highly survivable disease. 

The statistics about skin cancer are surprisingly difficult to gather, especially about NMSC, which is to say, basal and cutaneous squamous cell carcinoma. This is at least partly because we have no national reporting guidelines, and it is impossible to guess how many of the skin lesions that are removed or burned off “just in case” may or may not have been cancerous. One of the consequences of this is that different organizations report different numbers about NMSC diagnoses and deaths.   

These statistics get even more complicated when we consider sex and ethnicity. For instance, men get skin cancer more often than women, probably because, as a whole, they spend more time working outside.¹ But cases of NMSC among affluent Black women are rising—possibly because they are likely to engage in more outdoor activities like tennis, golf, and gardening. 

Here is a summary of what we know (or think we know) about how common and how threatening various types of skin cancer are. First, the risk of skin cancer is not evenly distributed across populations. It accounts for about: 

• 45 percent of cancers in White people

• 5 percent of cancers in Hispanic people

• 4 percent of cancers in Asian people

• 2 percent of cancers in Black people

However, it is more likely to be found after significant growth or metastasis in people of color, compared to non-Hispanic White people.

Basal Cell Carcinoma (BCC)

BCC is the most common kind of skin cancer among White, Hispanic, and East Asian people. It’s hard to determine how many cases of BCC are identified each year in this country, but some estimates suggest about 5.4 million cases of NMSC are treated annually, and about 80 percent of those are BCC: over 4 million cases.² BCC almost never metastasizes, so its survival rate is very high.

Cutaneous Squamous Cell Carcinoma (cSCC)

Statistics for cSCC vary by skin tone. It is the most common kind of skin cancer for people with darker skin, especially for African Americans and people of East Indian descent, and the second most common kind for light-skinned people, specifically Whites, Hispanics, and Asian Americans.

This type of cancer accounts for about 20 percent of all NMSC, with an estimated 1 million diagnoses every year in this country. And while organizations vary on the mortality rate of cSCC, at least one reputable source suggests that over 15,000 people die of this disease in the US each year. Many of these patients are elderly, and many may be immune compromised; immune suppression is a contributing factor for cSCC. But it’s also relevant to point out that cSCC is 10 times more likely to metastasize in Black people compared to White people.³ That’s not because it’s more aggressive in Black people; it’s because delays in diagnosis and treatment lead to poorer outcomes. 

The mortality rate of cSCC is a surprising statistic—if the estimate of 15,000 deaths per year is accurate, then cSCC takes twice as many lives each year as melanoma.

Melanoma

Melanoma is the least common form of skin cancer, but it metastasizes easier than all other types. Statistics suggest that anywhere from 100,000 to 200,000 cases are treated, and about 7,500 deaths are attributed to melanoma each year in the US.⁴

If it’s found early, melanoma is highly treatable and has an excellent survival rate—if the patient is White. The five-year survival rate for melanoma in White people is 93 percent; in Black people it’s 71 percent.   

The Pathology Perspectives column “Skin Cancer and Skin of Color” (page 70) offers more discussion of disparities in skin cancer diagnoses and outcomes.

Skin Cancer Gallery

Basal Cell Carcinoma 

BCC begins in the basal layer of the epidermis and causes slow-growing tumors in areas with a history of UV radiation damage. BCC almost never metastasizes to other parts of the body, but it can erode into healthy tissue, which can be dangerous. We will look at four subtypes of BCC.

Nodular BCC:

This is the most common version of BCC. On a light-skinned person it usually looks like a small ulceration with a raised pink, shiny border, sometimes with visible telangiectasias (tiny capillaries) around the borders. It is painless, but the scab may itch, fall off, and grow back without ever healing (Image 1).

On darker skin, nodular BCC may be harder to identify. A raised area with shiny skin around an ulceration can sometimes be seen, but not in the example we have here. However, close inspection shows a raised nodule on the left side of the discoloration (Image 2).

Pigmented BCC:

Pigmented BCC is the most common type of BCC seen in people with skin of color. Ironically, it was not possible to find a photograph of this on a dark-skinned person to share in this article, but the resource “Galleries of Images” (page 40) lists several collections where this may be seen. The example we have here is on light skin, where the darkened, pigmented lesion is easy to see, but it has a variety of colors and textures. Without a biopsy to check, this looks like it could be melanoma—a much more dangerous situation (Image 3).

Superficial BCC:

Superficial BCC, as its name implies, is flat and thin. It can look like psoriasis, eczema, actinic keratosis, or Bowen disease—all types of cSCC. It’s easy to miss on light skin (Image 4). On darker skin, superficial BCC looks darker than the surrounding area. This example also demonstrates a more advanced case in a person with skin of color (Image 5).

Morpheaform BCC:

Morpheaform BCC is the most invasive type of BCC. Its name comes from its resemblance to a type of lupus called morphea. Its growth on the surface of the skin is often slow and subtle, but it sends projections deep into the tissues to invade muscles, bones, and nerve tissue (Images 6 and 7).

Excision or burning off with liquid nitrogen are the preferred treatment options for BCC. If a lesion is not fully excised, it can recur. For morpheaform BCC, this can sometimes mean extensive plastic surgery to remove the growth and rebuild the affected part of the face or other part of the body.

Cutaneous Squamous Cell Carcinoma

Cancer that starts in the layer superficial to the basal cells is called squamous cell carcinoma. We add the qualifier cutaneous to denote that this is a type of skin cancer, because many organs have a squamous layer of epithelium, so it is possible to find many types of squamous cell carcinoma. 

Usually affecting areas with a history of repeated sunburns, cSCC also arises from skin injuries with chronic or repeating inflammation. People who use tobacco may develop a type of cSCC inside the mouth called leukoplakia, but we won’t look at that here. 

CSCC is more concerning than BCC because, although it happens relatively rarely, it is more likely to metastasize. Metastasis can happen through the lymphatic or cardiovascular systems, but cSCC is also capable of perineural invasion: Cancerous cells travel from the skin toward the central nervous system along the nerves. This pattern requires more aggressive treatment than most cases of cSCC. We will look at three types of cSCC.

Actinic Keratosis, Actinic Cheilitis:

Actinic keratosis (AK), or solar keratosis, is sometimes called a precancerous condition. But if AK lesions are not removed, they often go on to become more typical versions of cSCC, so some experts now refer to them as simply an early presentation of cancer.

These growths often look like dry patches: flaky reddish or brownish areas on sun-exposed parts of the skin (the face, ears, extremities). The forehead is a common site for AK: A close look shows varying skin colors and textures where these flaky patches grow (Image 8).

Actinic cheilitis is essentially the same as AK, but it appears on the lips. It can look like chapped lips, but it doesn’t heal. This condition can become aggressive, and may require plastic surgery to remove the growths and reshape the lips (Image 9).

Cutaneous Squamous Cell Carcinoma:

The typical presentation of cSCC is a lesion that looks more painful, or inflamed, or alarming than BCC, although it is not necessarily painful. It usually appears on the head or face, or parts of the body exposed to sunlight, but it can also develop at sites of chronic injury and inflammation. 

This type of skin cancer is the most common one for people with dark skin. This example shows an advanced cSCC lesion on the scalp of a Black man. This might have been difficult to identify in early growth because it would be covered by hair (Image 10). On light skin, cSCC often looks red and aggressive, as on the shoulder of the person shown here (Image 11).

Bowen Disease:

Bowen disease is sometimes called in situ cSCC, because it is usually localized and shallow. It is associated with previous exposure to human papilloma virus 16, which can also cause genital warts with a high risk of becoming malignant. It often appears on the trunk, but this photograph shows it on a finger, where it could be mistaken for eczema, psoriasis, or even an allergic reaction (Image 12).

Treatment for cSCC ranges from removing early lesions with liquid nitrogen, to surgical excision, to full courses of radiation and chemotherapy. People who get repeating lesions may be prescribed a type of topical chemotherapy, which can leave the skin raw and vulnerable to infection for several days or weeks (Image 13).

Melanoma

Melanoma is a cancer that affects melanocytes, those cells deep in the epidermis that produce melanin, our skin’s pigment. This is what creates the changes in color we see with skin tumors. But melanoma can metastasize easily, usually to the liver, bones, or central nervous system.

Melanoma usually affects skin that has a history of sunburns, but it can also be found in the eye, reproductive tract, gastrointestinal tract, and sun-protected parts of the extremities. In situations where it is not related to sun exposure, the assumption is that the melanoma is caused by other factors like genetics and toxic exposures.

Melanoma is threatening, but it is also highly treatable, if it is found early. The main predictive factor is the depth of lesions at the time of diagnosis. If they are less than 0.8 millimeters deep (about ¹∕³ inches), the prognosis is good. But if a lesion is deeper, the risk of metastasis is higher. We will look at four types of melanoma.

Superficial Spreading Melanoma:

Superficial spreading melanoma is the most common form of this disease. This version tends to spread along the surface of the skin before penetrating to deeper tissues or lymph nodes. Its appearance varies. On light skin, it might be multicolored and textured (Image 14). A very close-up view shows how the color seems to move across the lesion, with feeder capillaries (Image 15). On darker skin, this may look like an ordinary mole. As is often true for people with skin of color, the person in this image was diagnosed with a more advanced case than we usually see with light-skinned people (Image 16). Early superficial melanoma on brown skin could easily be missed. Only keen observation found this lesion before it became more threatening. (Image 17).

Lentigo Melanoma:

Lentigo melanoma usually appears on the face among older people, and it resembles a lentigo: an ordinary age spot. However, while age spots are typically round or oval, lentigo melanoma often shows a notched, uneven border (Image 18). In a more advanced stage, lentigo melanoma can penetrate more deeply and disrupt the texture of the skin. The lesion on the patient in this picture began on her lip (Image 19).

Acral Lentiginous Melanoma:

Acral lentiginous melanoma grows on the extremities. This form, which accounts for about 10 percent of melanoma cases overall, but up to 50 percent of cases in Black people, usually starts on the hand or the foot.⁵ It can be on the sole or the palm, between the fingers or toes, or under the nails (Images 20 and 21).

Acral lentiginous melanoma has some unique patterns among skin cancers. It is not necessarily associated with sun exposure, since it occurs in places that are usually not sunburned. It is not associated with advanced age: Reggae singer, songwriter, and activist Bob Marley died from this disease at 36. And it is the most common form of melanoma seen in people of color. It also has a high rate of recurrence. 

Nodular Melanoma:

Nodular melanoma creates an elevated nodule-like tumor, but it also penetrates deeply into the skin. Its prognosis may be serious because it is often aggressive and metastasizes quickly. In the example shown here, this tumor probably started as a mole, but over the course of 14 months it evolved into a much more threatening problem (Image 22).

Treatment for melanoma varies, depending on the subtype, the stage at which it is found, and its location. Topical treatments along with surgical excision and lymph node dissection to look for signs of metastasis are common. Other possible therapies include biologics that help the immune system become more aggressive against cancer cells, photodynamic therapy that fills cells with a chemical that kills them when exposed to a certain kind of light, and radiation. 

Signs and Symptoms 

The shorthand for signs and symptoms of NMSC is “a sore that doesn’t heal,” which is appropriately vague; as we’ve seen, these lesions can look like flaky spots, pimples, mosquito bites, and so on. And the mnemonic for melanoma signs and symptoms is ABCDE, for asymmetry, indistinct borders, mixed colors, large diameter, and evolving.

In the interest of saving space, we excerpted the signs and symptoms sections of the continuing education class “Skin Cancer: Beyond the Basics” as a video to accompany this article, and it explores these patterns in more detail. (Scan the QR code on page 35.)

Massage Therapy Risks, Benefits

What are some of the risks related to massage of a person in any stage of dealing with skin cancer—from the appearance of a suspicious lesion to post-treatment? 

• A massage therapist might miss an early sign that needs attention.

• A massage therapist might share their observation of a suspicious lesion with careless language. This could be a breach of scope of practice, and it could cause unnecessary alarm for the client. 

• A massage therapist might, through not paying attention or recognizing signs and symptoms, rub directly on a tumor. Whether that actively promotes metastasis or not is impossible to predict, but it’s still not a good idea. 

• Some cases of skin cancer are treated with topical chemotherapy or surgical excision. Both at least locally contraindicate massage while the skin is compromised and vulnerable to infection.

• Other side effects of cancer treatment require advanced education in oncology massage therapy for best safety practices. 

This is not to suggest that massage therapy has no benefits for people who are dealing with skin cancer. Our work can be helpful in several ways: 

• We can be an early warning system. This is especially true with clients we see over time, because we can take notes and track changes in what we observe.

• Skilled massage therapy can improve sleep, ease anxiety, reduce pain, and offer support during a challenging time. Again, this requires advanced education to be safe and effective.

• Clients who have successfully treated their skin cancer are usually good candidates for massage. Some follow-up questions about lymph node involvement, surgical scarring, or other lingering effects of their cancer and treatment are called for, of course.

Communication Guidelines

How best to communicate our findings or observations to our clients without creating unnecessary fear is a nuanced skill. There are many good ways to do this, and a few bad ones. Waking up a dozing client with, “Ew, that’s a nasty basal cell carcinoma you’ve got there!” or, “Wow, look at that. That could be a melanoma!” are examples of messages that miss the mark.

The first step in communicating what you observe is to choose your timing. If your client is awake, alert, and chatting with you, then it’s probably fine to mention what you see during the session (with careful language), especially if it means you want to change plans in your massage. But if your client is in one of those gorgeous transcendental states that only massage can induce, or even just having a lovely catnap, then it is best to wait until your post-session conversation to bring up what you noticed.

This can be done with a simple construction: State your observation, using descriptive, non-alarmist language. “I see a bump here that I haven’t noticed before.” “Tell me about this brown mark.” “Have you ever noticed this spot on your foot?” Other non-scary descriptors might include “raised area,” “blemish,” “different texture,” and so on. 

Inevitably, clients will ask, “What do you think it is?” and this is where we must refer them firmly to their primary care physician or dermatologist. As we saw in the photographs, sometimes BCC looks like melanoma. Sometimes melanoma is almost invisible but needs attention. We are not capable of making that call. So, it is appropriate to say something like, “I can’t say what this is, but I do think it would be great to ask your doctor about it.”

This must be followed by a plan of some kind: You will make a note in their chart; the client will consult their doctor; or maybe you can take a picture of what you see (using the client’s phone, not yours) so they can track any changes over time. 

A Call to Action

Skin cancer kills thousands of Americans each year, and every one of those deaths could be avoided. As massage therapists, we can participate in early detection of skin cancer growths, empower our clients with good information, and make appropriate referrals to other professionals. 

I have provided some links to resources to find free early screening events and for low-cost skin cancer care cancer care in the list of resources on page 40. Our health-care system creates many barriers, but massage therapists can help reduce some of those hurdles through observation, careful language, and appropriate referrals. 

Notes

1. American Academy of Dermatology Association, “Skin Cancer,” accessed December 26, 2022, www.aad.org/media/stats-skin-cancer.

2. Skin Cancer Foundation, “Skin Cancer: Facts & Statistics,” accessed December 27, 2022, www.skincancer.org/skin-cancer-information/skin-cancer-facts.

3. Maryann Mikhail, “Skin Cancer in People of Color: Statistics, Pictures, and Prevention,” GoodRx Health, updated September 1, 2022, www.goodrx.com/conditions/skin-cancer/skin-cancer-people-of-color-pictures-prevention.

4. Skin Cancer Foundation, “Skin Cancer: Facts & Statistics,” accessed December 27, 2022, www.skincancer.org/skin-cancer-information/skin-cancer-facts; American Academy of Dermatology Association, “Skin Cancer,” accessed December 26, 2022, www.aad.org/media/stats-skin-cancer.

5. Deborah S. Sarnoff, “The Skin of Color Revolution in Dermatology: Crucial Lessons Learned,” Carcinomas and Keratoses 2, no. 3 (2020), accessed December 29, 2022, www.carcinomasandkeratoses.org/the-skin-of-color-revolution-in-dermatology-crucial-lessons-learned.

Resources

American Cancer Society. “Key Statistics for Basal and Squamous Cell Skin Cancers.” Accessed December 26, 2022. www.cancer.org/cancer/basal-and-squamous-cell-skin-cancer/about/key-statistics.html.

Butrón-Bris, B., E. Daudén, and P. Rodríguez-Jiménez. “Psoriasis Therapy and Skin Cancer: A Review.” Life 11, no. 10 (October 2021): 1,109. www.doi.org/10.3390/life11101109.

Green, A. C., and C. M. Olsen. “Cutaneous Squamous Cell Carcinoma: An Epidemiological Review.” The British Journal of Dermatology 177, no. 2 (August 2017): 373–81. www.doi.org/10.1111/bjd.15324.

McDaniel, B., T. Badri, and R. B. Steele. “Basal Cell Carcinoma.” StatPearls [Internet]. (Treasure Island: StatPearls Publishing, 2022) www.ncbi.nlm.nih.gov/books/NBK482439.

Marzuka, A. G., and S. E. Book. “Basal Cell Carcinoma: Pathogenesis, Epidemiology, Clinical Features, Diagnosis, Histopathology, and Management.” The Yale Journal of Biology and Medicine 88, no. 2 (June 1, 2015): 167–79. 

Skin Cancer Foundation. “Destination Healthy Skin.” Accessed December 16, 2022. www.skincancer.org/early-detection/destination-healthy-skin.

Skin Cancer Foundation. “Squamous Cell Carcinoma Overview.” Accessed December 13, 2022. www.skincancer.org/skin-cancer-information/squamous-cell-carcinoma.

Skin Cancer Foundation. “Squamous Cell Carcinoma Risk Factors.” Accessed December 25, 2022. www.skincancer.org/skin-cancer-information/squamous-cell-carcinoma/scc-causes-and-risk-factors.

Wells, J. W. “Cutaneous Squamous Cell Carcinoma.” Medscape. September 24, 2021. emedicine.medscape.com/article/1965430-overview#a3.

More Resources 

Screening and Self-Exams

American Academy of Dermatology. “Find a Free Skin Cancer Screening.” Accessed December 16, 2022. www.aad.org/public/public-health/skin-cancer-screenings/find-a-screening.

American Academy of Dermatology. “No Health Insurance? How to Follow-Up After a Skin Cancer Screening.” Accessed December 16, 2022. www.aad.org/public/public-health/skin-cancer-screenings/medical-care-without-health-insurance.

Scott, Julie. “Information on Free Skin Cancer Screenings and How to Perform a Self Exam.” Verywell Health. Updated June 26, 2022. Accessed December 16, 2022. www.verywellhealth.com/information-on-free-skin-cancer-screenings-514371.

Galleries of Images

(see also: “Skin Cancer and Skin of Color” in this issue of M&B)

American Cancer Society. “Skin Cancer Image Gallery.” Accessed December 13, 2022. www.cancer.org/cancer/skin-cancer/skin-cancer-image-gallery.html.

American Society for Dermatologic Surgery. “Skin Experts.” 2023. asds.net.

Magro, J. “Finding Medical Images.” NYU Dentistry. Updated November 17, 2021. Accessed December 16, 2022. www.hslguides.med.nyu.edu/medicalimages/openaccess.

Other Skin Issues for People of Color

Brown Skin Matters: www.brownskinmatters.com

Mind the Gap: www.blackandbrownskin.co.uk/mindthegap

Skin Deep: www.dftbskindeep.com/diagnoses-gallery