Advances in Skin Cancer Prevention, Diagnosis, and Treatment

Conclusions

• New sunscreen legislation and FDA action may soon improve access to better broad-spectrum UV protection in the United States.
• Nicotinamide appears to reduce overall skin cancer risk, especially when started after an initial skin cancer.
• High-risk cutaneous squamous cell carcinoma is rising, and gene-expression profiling can improve risk stratification beyond AJCC or BWH staging alone.
• The 40-gene expression profile can identify patients with cSCC who are most likely to benefit from closer surveillance, imaging, sentinel node evaluation, or adjuvant radiation.
• Advanced cSCC is increasingly treatable with immunotherapy, including adjuvant cemiplimab and newer agents like cosibelimab.
• Basal cell carcinoma incidence is increasing, and several non-surgical or less invasive approaches can be effective in appropriately selected patients.
• Curettage-based approaches, including curettage alone or followed by imiquimod, can achieve low recurrence rates in selected basal cell carcinomas with good cosmetic outcomes.
• For patients with advanced or hedgehog-inhibitor-refractory basal cell carcinoma, hedgehog inhibitors and PD-1 blockade remain important treatment options, with some evidence that sonidegib is better tolerated than vismodegib.
• Merkel cell carcinoma outcomes are improved with pembrolizumab, and polyomavirus antibody trends can help detect recurrence earlier and guide follow-up intensity.
• Melanoma incidence is rising in the U.S. and globally, making it an increasingly major public health problem.
• Dermatologists appear to reduce melanoma mortality, likely through improved access and earlier diagnosis.
• AI improves melanoma diagnostic performance as an augmentative tool, but the best results come from combining AI with clinician judgment rather than replacing dermatologists.
• Melanoma prognosis is better refined by gene-expression profiling, which adds independent prognostic value beyond Breslow thickness and other clinicopathologic features.
• Gene-expression profiling may also help identify which melanoma patients need sentinel lymph node biopsy and which low-risk patients may safely avoid it.
• For melanoma, wide local excision does not need to be delayed until after sentinel node biopsy, and margins for melanoma in situ—especially on the head and neck—often need to be wider than 5 mm.
• Neoadjuvant plus adjuvant immunotherapy appears superior to adjuvant-only therapy in advanced melanoma, and long-term survival with modern checkpoint inhibitors has improved enough that some advanced melanoma patients are surviving many years.
• Overall, modern diagnosis, risk stratification, and immunotherapy are substantially improving cutaneous malignancy care, but clinicians need to keep up with these advances to optimize patient outcomes.