When Rachel Yaull was diagnosed with stage 3 melanoma skin cancer in May 2019 at the age of 52, she was told had she been diagnosed 10 years earlier, she would have been advised to “get her affairs in order”.
However, the development of immunotherapy has revolutionised the treatment of advanced melanoma skin cancer and, today, three years on from her life-changing diagnosis, Rachel is cancer free.
Rachel was treated with surgery and immunotherapy which she took for 12 months, and while the side effects were gruelling at times she is now back at work and living a life that 10 years earlier she would almost certainly have been denied. “I am extremely thankful and feel so incredibly lucky that I was eligible for immunotherapy treatment which has given me my life back.”
Skin cancer is the most common form of cancer in Ireland, with more than 13,000 cases diagnosed every year. The number of people being diagnosed with skin cancer in Ireland is rising rapidly.
Skin cancer is generally classified into two groups: melanoma, which is the more aggressive form; and non-melanoma skin cancer (NMSC). Between 2020 and 2045, it is predicted the number of cases of melanoma a year among men and women will increase by 67 per cent and NMSC will increase by 110 per cent.
According to Dr Aoife Lally, a consultant dermatologist at St Vincent’s University Hospital in Dublin and associate professor at the School of Medicine at UCD, skin cancer rates are increasing in parallel with the ageing population. They are also increasing in younger patients based on sun behaviour patterns during their childhood or early adult life.
She says that, thanks to the increasing awareness of the dangers of the sun, children today are very well protected. Therefore, she hopes that in 30 years’ time our rates of skin cancer will reduce but it will take a couple of decades for that to take effect.
Types of cancer
Dr Lally says there are two types of NMSC or keratinocyte cancers: basal cell and squamous cell skin cancers. Of these, basal cell is the most common and there are about 11,500 cases of keratinocyte cancers diagnosed in Ireland every year.
Melanoma, which is the most serious type of skin cancer, is less common with about 1,100 cases diagnosed every year here.
Dr Lally says basal cell skin cancer “won’t take a day off your life”, however, when it is very advanced and at critical sites on the body like the face, it can cause difficulty. Squamous cell skin cancer, however, can cause harm for a small number of patients as it can travel to the lymph nodes.
She explains that standard initial treatment for both basal and squamous cell skin cancer is surgical excision and treatments are available for advanced basal cell cancers for the “tiny minority” of people who need it.
She says emerging immunotherapy treatment options for advanced squamous cell skin cancer will “revolutionise” the management of these advanced cancers when they spread to other parts of the body.
“A small number would do that but it’s a very nasty disease when it happens because these tumours are often on the head and neck and can cause really disfiguring and awful lymph node disease that is difficult to manage entirely with surgery and radiotherapy,” Dr Lally says.
Ten years ago if you had stage 4 melanoma, the five-year survival was 10 per cent; with treatment and immunotherapy treatment it can be over 50 per cent
Treatments for melanoma skin cancer like immunotherapy has emerged really in only the past 10 years and, in that time, it has made a radical difference to the survival rates from this disease.
According to Dr Lally, overall the prognosis for melanoma is excellent with a 90 per cent five-year survival rate. However, a significant number of patients develop advanced disease – stage 3 or 4 melanom – and this is where immunotherapy has made a radical difference.
“If I were to look at my patients now, compared with 10 years ago the prognosis for patients with that advanced disease has really improved significantly. Ten years ago if you had stage 4 melanoma, the five-year survival was 10 per cent; with treatment and immunotherapy treatment it can be over 50 per cent,” Dr Lally says.
“We have got patients who would be on treatment for a year or two and would have complete remission of their disease. So it really has stepped in where we had nothing before. We now have options for patients who have stage 3, which is where you have got lymph node involvement or advanced disease where there are other organs affected,” she said.
Dr Lally says that while the prognosis today for people with advanced melanoma is greatly improved, the sad reality is that people still die from this disease.
A campaign by the HSE's National Cancer Control Programme – in collaboration with Healthy Ireland and cross-sectoral partners – supports people to protect their skin from the sun. The aim of the SunSmart campaign is to increase awareness of the steps that can be taken to protect skin from the sun and reduce the risk of skin cancer in Ireland.
Unfortunately, like a number of other areas of the health service, Dr Lally notices a reduction in referrals as a result of the Covid-19 pandemic, particularly during the initial lockdown period last year.
I think it will take five years for us to really see the impact of Covid on delayed presentations
From March to May 2020, she says referrals to the service reduced by a fifth compared with the same time period in 2019.
While the service has now caught up and referrals for the rest of 2020 far exceeded what they would have been in the equivalent period the previous year, Dr Lally says there is a suggestion that as a result of people not seeking help for skin changes or being reluctant to contact their GP, they may present with later more advanced disease.
“I think it will take five years for us to really see the impact of Covid on delayed presentations so we can look at it properly, but there is a suggestion that more advanced tumours were presenting in the later, say, third quarter, fourth quarter of last year,” she says.
The Covid pandemic also led to innovations in healthcare and in July 2020 Dr Lally and her colleagues at SVUH, including consultant dermatologist Dr Bláithín Moriarty, established the St Vincent’s Healthcare Group (SVHG) strategic skin cancer network.
One of the first of its kind in Ireland, this is a multidisciplinary network with collaboration between all the specialties that manage skin cancer including, dermatology, plastic surgery, oncologic surgery, histopathology, radiology, medical oncology, radiation oncology, ENT and opthalmology. The network team also includes skin cancer clinical nurse specialists and a patient representative.
The network facilitates multidisciplinary clinics for patients with high-risk skin cancer so patients see all the specialists they need to on same day. This reduces the need for patients to come back to hospital to see other professionals involved in their care at another date, and has reduced hospital visits by 50 per cent.
The new service also offers same-day skin cancer surgery and patients referred within the new network pathway had their wait times to surgical treatment completion reduced by 75 per cent compared with the traditional referral pathway.
Dr Lally says the network has not received any funding to help the development of services, but is supported solely by the clinicians who manage skin cancer in SVUH and wish to improve patient care.
She urges people not to be afraid to seek help if they have concerns about their skin as the service at SVUH has been running safely and successfully throughout the Covid-19 pandemic.
Dr Lally advises the first port of call for anyone concerned about skin cancer is to contact their GP who will then refer them to a dermatologist or plastic surgeon if needed.
Cover up, wear a hat, seek shade, wear sunglasses, avoid the peak sun hours between 11am and 3pm, and put sun factor on the bits that are exposed
She says people need to look out for something new on their skin that looks different, also known as the ugly duckling sign, or something on their skin that is changing and continues to change or a cut that isn’t healing.
In relation to primary prevention of skin cancer, she says the most important thing is photo protection or sunscreen.
“The key thing is cover up, wear a hat, seek shade, wear sunglasses, avoid the peak sun hours between 11am and 3pm, not to get burnt, and put sun factor on the bits that are exposed. I recommend wearing sun factor all year round because then it becomes part of a daily habit – factor 30 or higher with a good star rating, something that you use regularly and reapply.
“Prevention is the best way to approach this but our rates of skin cancer are not going to reduce for a couple of decades unfortunately,” she says.
