Archive for December, 2010

Skin Cancer Explodes

Tuesday, December 21st, 2010

3,5000,000! That is 3,500,000 new cases of skin cancer in the US in 2011.While the numbers are discouraging, the population, especially young people, continue to ignore warnings of unhealthy sun exposure and more importantly dangerous exposure to UVA and UVB radiation in tanning salons. This number also belies 40,000 new cases of malignant melanoma and more than 8,000 deaths from skin cancer in 2011.
There are many consequences of the escalation in incidence of skin cancer. Most obvious is the injury to the skin and subsequent necessity for surgery. Another is the huge cost incurred for diagnosing and treating skin cancer. Lastly there are the cottage industries which have arisen from inappropriate fears of the public. Many physicians have found a lucrative income in performing biopsies and removal of lesions that are not and have little chance of being malignant. Another, or the same? set of physicians make a handsome living removing lesions they “suspect” may become malignant in patients who have already had skin cancer. Many patients return to their physicians month after month and year after year for needless procedures and the track records of these physicians is somewhere between elected officials and the prognostic accuracy of weathermen. The cosmeceutical industry has reaped huge rewards for promoting herbs, vitamins, and proteins for the prevention of skin cancer. None of them, except for vitamin A, have demonstrated conclusive evidence of efficacy.
It is easy for me to become discouraged when I review the indifference of the public to this dynamic problem and the readiness for the medical and cosmeceutical industry to exploit it for profit. I remember the parable of the cave in Plato’s Republic. Plato tells us of a civilization of men and women living in a cave and chained to its walls. Each day light entered the cave from the outside and was reflected down the cave by a series of mirrors so that the perception of reality that the people experienced was a literal reflection of time and light, and not the real thing. Ultimately one of the inhabitants broke free and wandered through the cave to the outside where he saw the sun actually rise and set and observed the subterfuge that had been foisted upon the cave’s inhabitants. Breathlessly he hurried back through the cave to tell his people of the reality that awaited them in the outside world. As he told his story the inhabitants overwhelmed him; chained him again to the wall; and, ignoring his advice continued on with their labors as if nothing had happened.
And then I remembered the campaign against smoking which we have waged over the past 50 years. I remember when people argued over whether cigarette smoke could cause lung cancer. I remember the Marlboro man with his version of macho and his appeal to my generation. And I remember the cost to individuals and to society as we battled what was then the number one cancer and cancer killer. Yet today, smoking in the United States is less frequent; many cities and states ban smoking in public places and restaurants; and no one debates the health hazards of smoking.
Therefore I will once again reiterate that the World Health Organizaiton has found sun tan parlors to be the single biggest cause for the increase in malignant melanoma and skin cancer death. Also, people who have had skin cancer can prevent new cancers with judicious use of topical vitamin A and systemic administration of vitamin A analogues. Lasers combined with photosensitizing chemicals can treat some skin cancers and prevent many others; and neoadjuvant therapy in the form of application of topical chemotherapeutic agents can prevent others. Lastly, there is no proven benefit to constantly destroying lesions that might become cancerous. At the very least patients can request a second opinion before undergoing repeated procedures. And at a bare minimum, all patients should obtain a copy of their records and even more important, read and retain a copy of all pathology reports from removal of lesions of their skin.
Your physician is not the repository of responsibility of your skin health. Like it or not, the buck stops with each of us. 

Choosing a Cosmetic Surgeon

Sunday, December 12th, 2010

“He who can swim can get pearls from the bottom of the sea; but he who cannot swim goes under. Hence only he should dive for pearls who is practiced in swimming.”
Translated from German: Abraham Joshua Heschel ‘s Maimonides
As one might guess I am reading Heschel’s Maimonides and I am surprised and pleased at how much I have learned about the Jewish people and about myself. The quotation above somehow contradicts the aphorism: It is better to be a jack-of-all-trades than a master of none. Which of the 2 do you desire in a cosmetic surgeon?
On a trip to Manhattan last week, walking on the Upper East Side, my wife commented that many of the women walking past us had “the same face”. Translation: their cosmetic enhancements looked alike. As we passed a variety of department stores I noticed that many of the display windows, the entire windows, were devoted to marketing a given cosmetic surgeon and his formulas for facial rejuvenation success.
On reviewing a book of facial rejuvenation this weekend I noted that the authors, each seemingly expert in his area of discourse, extolled the virtue of a technique with little mention of what led to the need for the technique or how to evaluate when that technique was suitable. Further, each author promoted his technique as safe and effective, ignoring decades of literature to the contrary.
These seemingly disparate experiences over the past 10 days have again led me to contemplate what differentiates cosmetic surgeons who usually produce excellent results from the majority of cosmetic practitioners and medi-spas. The answer may be that the majority of facilities have a goal of selling a technique or product, sort of one size fits all; and the more exceptional practitioners insist on evaluating the cause of the patient’s concerns. Notice I said patient and not consumer. It is just too much wishful thinking that I accept that a consumer understands the etiology of their concern or that a commercial operation in or out of a doctor-office cares.
I once lectured at an international dermatology forum where I joined 4 experts in demonstrating how to treat a patient for facial rejuvenation. It happened to my advantage that I sat last in the row. The session was ostensibly on the use of facial fillers and each expert in turn looked at a patient across the stage and described how he/she would use a facial-filler with the patient. When I was asked how I would treat the patient I requested to be allowed to examine the patient and describe my findings. The chair of the session dismissed my request saying that I already knew what I was going to do and further discussion was superfluous. The session ended with me refusing to participate.
In answer to my wife’s observation I find the cosmetic surgeons in Manhattan to be skillful and erudite and deservedly experts in their fields. What I think has happened is that the business of selling techniques and products has superceded interpersonal relations and the similarity of the faces of our passersby reflects patient acceptance of the predictable if not the mundane.
Stepford wives anyone?
Mirror mirror on the wall
Who’s the fairest of them all?
Why you my dear, and you and you and you.