May is Melanoma Awareness Month. Why might you ask does melanoma need an entire month for awareness? Well, even with all the recent improvements in the treatment of advanced melanoma this cancer still kills over nine thousand Americans a year. Compare this to what routinely makes national headlines, brain eating amoebas, flesh-eating bacteria, shark attacks; yet in contrast with these headliners you are a 1000 times more likely to die from melanoma in your lifetime than these leading stories. Melanoma only makes the news if a celebrity or politician is stricken; yet it is a real event for every 1 out of 50 Americans. So if sharks can have shark week, then I think it’s entirely appropriate for melanoma to deserve a full month.
With the scores of medical students that have completed dermatology rotations with me the subject of melanoma is always forefront. I try to emphasize four critical take-home messages regarding melanoma.
The three keys to successful treatment of melanoma are early detection, early detection, and early detection. The good news is that now 91 percent of all melanomas diagnosed in the United States are caught in time and have a survival rate beyond five years and are cured. Sadly, with the other almost 10 percent that succumbs to the disease the majority could have been saved if detected earlier. You can’t diagnose a melanoma if you don’t look. Every dermatologist out there has a story of a rash that saved a person’s life. The patient comes in for a skin eruption; the dermatologist discovers the melanoma the patient didn’t realize he/she had and saved the person’s life. However, this only happens if you examine the patient.
If you cut a lesion off the skin always biopsy it. No matter how good a diagnostician you think you are, you are far from perfect, and all dermatologists understand this fact. Studies show when testing dermatologists they have about an 80 percent success rate in the clinical diagnosis of melanoma, and if you are in another specialty, the rate is much worse. Even when your clinical diagnosis is correct, you may still run afoul. Sometimes cancers grow at the same site as a benign growth. These collision tumors can clinically appear as benign, but on the histologic exam, a small cancer is found hidden within or adjacent to the benign tumor.
If you do not send the specimen for a histopathologic exam, medically-legally you can run into serious problems, even being correct in your diagnosis. For example, you evaluate a benign seborrheic keratosis that the patient wants removed cosmetically. He emphatically expresses his desire not to pay to have a biopsy done especially since you have already said the growth is harmless. Trying to be a nice person and to save him money you acquiesce to his wish and toss the specimen, but appropriately document the removal of a benign growth. Four years later the patient has a routine chest x-ray, and they discover metastatic melanoma throughout the lungs. A skin exam reveals no melanoma. The lawyers review all medical records and discover you removed a growth and did not have it tested. Guess who gets sued. Sometimes melanomas will involute on the skin or arise outside of the skin. If you have no histologic documentation of what you excised, you will be blamed for a missed diagnosis even though inaccurate. You will not see a dermatologist cutting off “benign lesions” and throwing them in the trash.
Melanoma survivors need periodic total body skin exams for life. Once you have experienced a melanoma, you are five times the risk of getting a second melanoma. Current guidelines for melanoma survivors recommend a complete total body skin exam every six months for five years and then annually for the rest of their life. With melanoma-in-situ, the recommendations are exams every six months for two years and then annually for life.
My experience with melanoma patients is I catch the second melanomas in time if they follow the guidelines. For those that have meticulously followed the guidelines, I have yet to lose a patient to a second melanoma. Sadly, in the last three decades, I have had four patients with second melanomas that did not follow up for exams until years later. The standard excuse was “because they were too busy”. These folks did not survive their second melanoma, but possibly could have. I share this story with my new melanoma patients to emphasize the importance of long-term follow up with full skin exams.
Don’t let your kids get sunburned. One of the major risk factors in the development of melanoma is childhood sunburns. We now know its not just childhood sunburns that increase risk, but all sunburns throughout life. Although just like smoking, it is never too late to quit, it is never too late to start using sunscreens. However, you are never going to completely undue the damage that has already been done. The best way to deal with solar damage that may contribute to a future melanoma is to prevent it in the first place. Now having raised three boys, I will tell you, if one of the twelve labors of Hercules were getting a good application of sunscreen over an entire six years olds body, he would have failed. Consider adding UV protective swim shirts to your anti-burn armamentarium. Your kids won’t care, and you will have much less skin surface to address when applying sunscreen to a wiggling, squirming, screaming, subhuman. Please remember to have them exit the water and reapply sunscreen every 45 minutes, yeah right, good luck Hercules.
By John “Lucky” Meisenheimer, M.D.
Lucky Meisenheimer, M.D. is a board-certified dermatologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic – Dermatology and Mohs Surgery. He is a former chairman of the Division of Dermatology at ORHS.