Three years ago, on one cold March afternoon, James Costello slipped on black ice. He hit his head hard enough that he expected the worst: a concussion.
Although he was feeling a bit off, he continued his usual duties—trekking eight miles a day as a mail carrier in South Jersey. Two weeks later, Costello and his wife traveled to Florida to surprise his parents; he hadn’t seen them since Christmas.
It was Costello’s father, finally, who convinced him to see a doctor. What he’d eventually learn at the emergency room in Naples would forever change his life.
“The doctor came in and said, ‘Jim, you don’t have a concussion, you have a brain tumor the size of a walnut in your head,’” recalls Costello, who was 50 years old at the time.
He flew back home for surgery at Penn. Pathology determined the tumor stage 4 melanoma, and he began treatment with ipilimumab, an immunotherapy. Less than a month later, a second brain tumor grew.
Melanoma, though the least common of skin cancers, is by far the most dangerous. It’s been estimated that in the U.S. this year, about 91,270 new melanomas will be diagnosed, and about 9,320 people will die from the disease.
“We worry about melanoma because unlike some of the more common skin cancers, it can travel from the skin to affect other parts of the body,” explains Emily Chu, an assistant professor of dermatology, pathology, and laboratory medicine at the Perelman School of Medicine. “Melanomas metastasize more frequently than do, for instance, squamous cell carcinomas and basal cell carcinomas.”
From its Melanoma Program in the Abramson Cancer Center to its Department of Dermatology and beyond, researchers and practitioners at Penn and its health system work every day to educate and treat patients—just like Costello—while also uncovering and testing novel therapies.
Today, after treatment with pembrolizumab, a newer FDA-approved immunotherapy, Costello is thriving. An avid runner, this past April he completed his third Boston Marathon.
“I just had to do this race one more time and get it in,” he says. “This was my last marathon. My wife says, ‘We’ll believe it when we see it.’”
High priority
Talking in her office, Chu, who specializes in melanoma, says the mainstay of thinking about the disease is to “try to avoid getting one in the first place.” With such a strong correlation of sun exposure to skin cancer, that means—for the most part—monitoring time in the sun.
Sunlight consists primarily of two types of ultraviolet light: UVA, which contributes to premature aging of the skin, and UVB, which typically causes sunburn.
“Both UVA and UVB can create DNA damage in the skin that really increases your risk for skin cancer,” says Katherine Steele, an assistant professor of dermatology at Penn.
Avoiding sun exposure, especially between 10 a.m. and 2 p.m., is the most effective way to protect skin, Steele says. Other strategies to employ are the use of sun-protective clothing, first, and sunscreen, second.
“Sun-protective clothing is clothing that has ultraviolet protection factor, or UPF,” Steele explains. “As opposed to a regular T-shirt, which blocks about 80 percent of the sun’s rays, UPF 50 clothing can block up to 98 percent of the sun’s rays. It is definitely a worthwhile investment.”
Better yet, Steele adds, UPF clothing proves more beneficial than sunscreen because it starts working as soon as it’s on and won’t wear off during the day. It’s not messy, oily, or greasy, and it won’t get into your eyes. It’s also non-allergenic. Being that it’s washable, too, there could be cost savings.
But for those body parts clothes don’t cover—sunscreen is a person’s best bet, even if it’s foggy or hazy, or you’re under an umbrella. The best sunscreen, Steele insists, “is the one that you will use.”
Typically, dermatologists recommend a sunscreen that’s broad spectrum—blocking UVA and UVB—and is at least SPF 30. It should be applied 15 to 30 minutes before going outside, with re-application every two hours, or after swimming or sweating. It’s also important, Steele says, to choose a sunscreen that’s water resistant (the FDA has banned the terms “waterproof” or “sweat proof”).
Studies show most people only apply about 25 to 50 percent of the recommended amount of sunscreen, Steele notes. In fact, every time sunscreen is applied, at least one ounce—enough to fill a shot glass—should be used.
“That should be enough to cover the majority of your sun-exposed skin,” Steele says. “And it’s definitely more than most of us are using.”
Early detection
Earlier this month, while addressing a crowd at Penn’s 16th Annual Focus on Melanoma event, a program designed for patients and caregivers dealing with the disease, Phillies legend Mike Schmidt shared his story.
The Hall-of-Famer began his battle with melanoma in 2013, after a spontaneous skin check by his dermatologist. He was in Boston when he got the call: He had stage 3 melanoma—the cancer had spread from his skin cells to his lymph nodes.
“Professional athletes feel a sense of invincibility,” Schmidt says. “The sense of invincibility went away just like that, with one phone call.”
Schmidt, adding that he’s “one of the lucky ones,” received treatment, and is doing well with what he calls his “new normal.” Though, to this day, he still wishes he had found it earlier.
“We all have two things we can control,” says Chris Miller, director of the Penn Dermatology Oncology Center. “How well we prevent these skin cancers by how well we protect our skin from the sun, and how early we detect them by how active we are in examining our own skin and getting help from the doctor when we need it.”
Although everyone is at some risk for skin cancer, those who are at most risk typically have light skin, light hair, and light eyes. Risk increases with age, as well as for those with a family history of skin cancer. Remember any blistering sunburns as a child? Those especially increase risk, too.
Thuzar Shin, an assistant professor of dermatology, emphasizes the “big problem” that are indoor tanning salons, as well: “They are a huge risk factor for both melanoma and non-melanoma skin cancers.”
“If you have several of those risk factors,” says Miller, “make sure you are seeing your dermatologist regularly.”
Basal cell carcinoma is the most common skin cancer, producing a small, pink bump with a shiny texture that bleeds easily. It doesn’t spread, except in rare cases, but it can grow when left untreated—destroying surrounding tissue.
Like basal cell, squamous cell carcinoma is often seen on areas of the body that have been exposed to excessive sun. Commonly, squamous cell looks like a scaly, red patch, and will feel rough in some areas. It can become life threatening if allowed to grow, as it has the ability to spread to local lymph nodes, distant tissues, and organs.
Melanomas often resemble moles, with the majority being black or brown, but they can also be skin-colored, pink, red, purple, blue, or white. When detecting a melanoma, dermatologists typically look for specific characteristics—the ABCDEs, which constitutes: asymmetry, irregular border, varying colors, larger diameter, evolving.
A melanoma is usually, Miller adds, “an ugly duckling”—it’s different from any other moles on a person’s body.
But, there are always exceptions, notes Lynn Schuchter, the C. Willard Robinson Professor of Hematology-Oncology.
“To catch those exceptions, it’s important to know your skin so you can recognize change,” she says, adding that the earlier a melanoma is caught, the better.
“We want to catch them when they’re flat and asymptomatic, you might not even know it was there,” Miller says. “If we do that, we can cure 90 percent of melanomas if removed from your skin in time.”
Many melanomas are actually detected by patients and their partners, and throughout the past several years, in-the-works smartphone apps are beginning to make the monitoring process easier.
One app in particular, MelaSight, developed by recent Penn Medicine graduate Andrew Marek and tested at the Melanoma and Pigmented Lesion Clinic, stores professional photos of a patient—head to toe—on a password-protected mobile site. A recent study, published in February in the Journal of the American Academy of Dermatology, shows that the app not only helped melanoma patients with difficult skin exams, but it also allowed for better patient satisfaction than traditional methods, which, instead, include printed photographs.
“It can help us with early detection of skin cancer, and also helps us to monitor other lesions that may not need to be biopsied,” says Chu, an author on the study. “If someone comes in with lots of moles, they all might look at bit atypical at first glance. We’ll watch them, and if they haven’t changed in a period of time, we’ll worry a lot less.”
Getting personal
Knowing a person’s stage of melanoma is the first step in crafting a treatment plan, says Schuchter, who’s head of the Abramson Cancer Center Melanoma Program.
For the most part, stage 1 and 2 requires a simple surgery, she says, with continuous monitoring: the melanoma was just localized to the skin, and there hasn’t been any evidence it’s traveled to other parts of the body.
Stage 3 melanoma has traveled to the lymph nodes, detected through a sentinel lymph node procedure or through a scan. Stage 4 melanoma is if the disease has traveled through the blood stream to the lungs, liver, bones, or other sites.
Fortunately, throughout the past few years, treatments have vastly improved to aid later stage melanoma. Two approaches in particular—targeted therapy and immunotherapy—have “completely changed how we treat melanoma, and have completely changed the outcome,” Schuchter says. “It’s unbelievable progress, something I never thought I would see in my lifetime.”
And, better yet, a new world of tumor surveillance is being developed right at Penn with liquid biopsies, as well as better practices for surgeons—think: “glowing tumors.”
Since melanoma is an aggressive cancer, after a tumor, for instance, is removed, targeted therapy and immunotherapy can help to make sure it won’t recur.
Targeted therapy is taken in pill form, and is for someone who has a broken BRAF gene. If doctors don’t find a BRAF mutation, then immunotherapy is the main approach to treatment.
“How we treat melanoma is very personalized,” says Schuchter. “The characteristics of the patient and of their tumor are going to determine how we best treat them.”
‘A new person’
It was Schuchter who visited Costello after he had his second brain tumor removed. She suggested Costello try Keytruda, or pembrolizumab, which was approved by the FDA just a few months before. An immunotherapy, Keytruda blocks the PD-1 pathway and helps prevent cancer cells from hiding. It makes sure the immune system can do what it is meant to do: detect and fight cancer cells.
“Every three weeks, on Fridays for two straight years, I’d go to the Perelman Center for Advanced Medicine for treatment,” says Costello, recalling fondly his nurse practitioner Suzanne McGettigan.
“When I qualified for this year’s Boston Marathon, I told Suzanne, ‘You just gotta give me 17 months,’” he says.
Aside from regular skin checks and monitoring, Costello’s life today is back to normal. He’s still a familiar face on his mail route, and he runs every day.
“Because of Penn, I’m a new person, running is fun again,” he says. “I have my third Boston Marathon jacket; there’s one for all three of my kids to have now. They can tell their own kids some day: ‘This is what your grandfather did, he was a runner.’”
