The Melanoma Scare

Most studies on what can raise or lower the risk of cancer should probably never be publicized -- an impossible dream in the Internet age. However good the research, once it is treated as news the significance is blown far beyond proportion. Consider a paper, published last week in the journal Cancer, reporting that aspirin reduced the odds of older women getting melanoma by 21 percent, and by as much as 30 percent if the pills were taken for a longer time. That is far from implausible. Inflammation is intimately linked with cancer. Many of the same mechanisms normally employed to heal a wound—replacing diseased tissue with healthy new cells—are subverted to help generate a tumor. A number of studies have suggested that by reducing inflammation aspirin may muffle the effect, though any benefit would have to be weighed against the pills’ harmful side effects. It is always comforting when there is a reasonable mechanism behind a statistical correlation (as opposed to, say, cell phone signals and brain tumors). But the effects, if real, are almost always so much less meaningful than they appear, especially for readers wondering how they might be personally affected. Melanoma is one of the very few cancers whose occurrence is on the rise. (The reasons proposed range from the popularity of tanning beds to increased international travel, with fair-skinned people from the north flying south to bask in the warmth of high-frequency ultraviolet rays.) Even so, the overall incidence is about 21 cases per 100,000 people per year, or 0.021 percent. A 30 percent reduction would bring that down to 0.015 percent. In terms of public health that would be great. Six fewer annual cases per 100,000 people would be 6,000 for a population of 100 million. And for older people, who are more prone to the cancer, the effect might be more pronounced. But from the point of view of an individual, the risk either way is minuscule. And that is what gets lost in the news. That can be particularly true with a scary cancer like melanoma. If not caught early the chance of survival is extremely low. In the most advanced stages, even the new targeted therapies can only stave off death a month at a time. Hence all the admonitions to check suspicious moles, and hence a flood of false alarms that adds to the difficulty of getting an appointment with a dermatologist. I added to the problem last month when I became worried that a rough darkish spot on my skin was gradually changing, marking the beginning of the end. I imagined that it was also expanding inward and would soon, if it hadn’t already, set sail in my lymphatic system for new ground. I looked at the pictures on the Internet and learned about arcana like Breslow depth and Clark scale. Then began the frustrating and sometimes humiliating experience of trying to find a specialist who would see me while I was still alive. This was mid February and they were already booking for the end of March or even April and May. Two were not taking new patients, and the reaction of most office receptionists ranged from uncaring to rude. “I’m worried I might have melanoma” doesn’t cut it. Given the very low odds, they have good reason to be skeptical. But there was no such thing as triage -- a morning reserved each week for a quick glance to ensure that it is probably safe for a patient to wait a few months for a more thorough examination. This wasn’t even offered by the university’s skin cancer clinic, where the receptionist was especially brusque. Adding to the problem is a national shortage of new dermatologists. Some of the reasons are described in Dermatology Times. Where I live two of the remaining doctors are in their 80s, and the one with whom I finally got an appointment is retiring later this year. With an average starting salary of $325,000 (this is also from Dermatology Times), a young specialist could move to Santa Fe and make a fortune, especially if he or she takes Blue Cross/Blue Shield. Many here don’t. The first question asked, of course, is what insurance you have. Say the dreaded words “Blue Cross/Blue Shield” and the call is quickly terminated. I was lucky when there was a cancellation and my appointment was moved up. The spot I was worried about was benign (a keratosis, or overgrowth of keratin-producing cells), and two others that looked mildly suspect were cryogenically removed. Then I got home and noticed another funny looking spot. This one I’m going to ignore.