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Alert Number 42

CLL and Basal Cell Carcinoma

Date: September 15, 2004

We have discussed several times the connection between CLL and suppression of the immune system. While the CLL itself can do a serious number on the effective functioning of the immune system, many of the therapies that are important in keeping the CLL at bay are themselves immune suppressive. Even monoclonal antibody therapies such as Rituxan and Campath are immune suppressive. Rituxan kills all B-cells, not just the CLL B-cells, and Campath kills many cell lines of the immune system including B-cells, T-cells, NK cells etc. The issue is therefore how to limit the level of immune suppression, of how to manage the gentle art of balancing between therapy necessary to control the CLL and not going overboard in terms of weakening the immune system more than is necessary.

There is now pretty strong evidence that skin cancers of several varieties (melanoma, basal cell carcinoma, squamous cell carcinoma, Kaposi's sarcoma, etc.) are not only more frequent in immune compromised patients, they are also likely to be more dangerous when they do occur. The problem with skin cancer is that you may not really see any overt signs of it unless you are vigilant. The results of deep immune suppression today may not be obvious right away, but you may be left holding a ticking time bomb that declares itself only a couple of years down the road, perhaps as skin cancer. We have discussed squamous cell carcinoma in prior articles on the website: see Dying to Get a Tan?. Here is a Reuters health report that specifically links CLL to basal cell carcinoma. The standard treatment for BCC is Mohs surgery to remove the cancerous tissue. The new research points out "patients with CLL were 14 times more likely than control patients to have recurrent BCC" after standard Mohs therapy. The moral of the story is that in the case of CLL patients, the surgeons should be more suspicious than otherwise. They should remove more of the surrounding tissue than they would in patients without CLL, to try and limit the rate of recurrence.

Of course, the best thing to do is not get skin cancer in the first place. Sun avoidance is a must, there are no ifs, ands or buts about it folks. True, sun exposure is one of the ways in which our bodies make the very important vitamin D3, and we have discussed in previous articles the almost epidemic levels of vitamin D3 deficiency in large parts of western populations. But here is one situation where it is possible to achieve both healthy levels of vitamin D3 and still avoid the clearly established UV-exposure-linked risk of skin cancer. It consists of swallowing a cheap, over-the-counter capsule of vitamin D3. But do read the detailed article on Vitamin D3. It is not at all a good idea to overdose on this particular vitamin, and therefore medical supervision and monitoring are essential.

To do list:

  • Stay out of the sun. Period.
  • Make sure you get enough vitamin D3 by way of supplements. But for heaven's sake do not overdose on it! Do read the detailed article on the subject and talk to your doctor.
  • Get frequent and regular skin exams to spot problems right away. Early detection is the name of the game in combating skin cancer.
  • Try to avoid immune suppressive drugs, if that is compatible with taking good care of your CLL. You may not always have that choice, unfortunately.
  • Be particularly careful to avoid skin cancer risk right after therapy of any sort, especially if involves heavily immune suppressive drug combinations.
  • If you do get skin cancer, be very sure your doctor treating the skin cancer is quite aware of your CLL status, and your CLL oncologist is aware of the skin cancer issue.
  • Be prepared for more aggressive Mohs surgery, if you do develop BCC; it is not pleasant to have a larger chunk of you dug out, but it sure beats the alternative.

Be well,

Chaya
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Press Report

Leukemia Patients Have High Basal Cell Carcinoma Recurrence Rate

By Will Boggs, MD

NEW YORK (Reuters Health) Sept 03 - Patients with chronic lymphocytic leukemia (CLL) face high recurrence rates of basal cell carcinoma (BCC) after Mohs surgery, according to a report in the August issue of the Archives of Dermatology.

"Given that recurrences appear to be more common in CLL patients, I think it is important for Mohs surgeons and any other surgeons who manage skin cancer in immunosuppressed patients to have a high index of suspicion when reading histologic slides from skin cancer surgery and a lower threshold for removing more tissue if there is any question of the significance of any indeterminate histologic finding," Dr. Clark C. Otley from Mayo Clinic, Rochester, Minnesota told Reuters Health.

Dr. Otley and colleagues compared the recurrence rates for BCC after Mohs surgery among 24 patients with CLL and 66 matched controls. The estimated cumulative recurrence in the CLL group was 3% at 1 year, 12% at 3 years, and 22% at 5 years, compared with 0% at 1 year and 3 years and 2% at 5 years in the control group. Overall, the researchers note, patients with CLL were 14 times more likely than control patients to have recurrent BCC.

"Patients with CLL may have immunologic impairment from their disease that renders them more susceptible to recurrences of BCC after even the gold standard technique for removal," Dr. Otley said. "Thus, physicians should identify this patient population as special and in need of the most thorough removal of their cancers to avoid recurrence."

"Specific examination of the surgical site by a skilled dermatologist over a period of 5 years...following surgery would be warranted," Dr. Otley continued. "Also, it may be wise to have a lower threshold for biopsy of any unusual changes around a previous surgical site in these patients."

"We are pursuing research on the outcome of cutaneous squamous cell carcinoma in CLL patients," Dr. Otley added, "and the results of that research are forthcoming."

Arch Dermatol 2004;140:985-988.
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