What it means to be an Australian – with skin cancer

Each year on the 26th of January, Australia Day, Australians of all shapes, sizes and political persuasions are encouraged to reflect on what it means to be living in this big, brown, sunny land of ours.  It is a time to acknowledge past wrongs, honour outstanding Australians, welcome new citizens, and perhaps toss a lamb chop on the barbie (barbecue), enjoying the great Australian summer.  It is also a time to count our blessings.

We whinge a lot about our health system.  While I am certainly not suggesting the model we have is anywhere near perfect, it could be a whole lot worse.

Dr Justin Coleman recently shared this NY times article via Twitter @drjustincoleman

It talks about the astronomical and ever-rising health care costs in the US and suggests that this, at least sometimes, involves a lack of informed consent (re: costs and alternative treatment options).  The US is certainly not the “land of the free” when it comes to health care.

There are many factors involved, not least being the trend in the US to provide specialised care for conditions that are competently and cost-effectively dealt with in primary care (by GPs) in Australia.

The article gives examples such as a five minute consult conducted by a dermatologist, during which liquid nitrogen was applied to a wart, costing the patient $500.  In Australia, (if bulk billed by a GP) it would have cost the patient nothing and the taxpayer $16.60 (slightly higher if the patient was a pensioner).

It describes a benign mole shaved off by a nurse practitioner (with a scalpel, no stitches) costing the patient $914.56.  In Australia, it could be done for under $50.

The most staggering example of all was the description of the treatment of a small facial Basal Cell Carcinoma (BCC) which cost over $25000 (no, that is not a typo – twenty five THOUSAND dollars). In Australia, it would probably have cost the taxpayer less than $200 for its removal (depending on exact size, location and method of closure).  The patient interviewed for the article was sent for Mohs surgery (and claims she was not given a choice in the matter).

Mohs  (pronounced “Moe’s” as in Moe’s Tavern from The Simpsons) is a highly effective technique for treating skin cancer and minimises the loss of non-cancerous tissue (in traditional skin cancer surgery you deliberately remove some of the surrounding normal skin to ensure you’ve excised all of the cancerous cells) . Wikipedia entry on Mohs  This can be of great benefit in a small minority of cancers.  However, this super-specialised technique is very expensive and time/ labour intensive. Perhaps unsurprisingly, it has become extremely popular in the US.  ”Moh’s for everything” seems to be the new catch cry when it comes to skin cancer treatment in the US.

In the past two years, working very part time in skin cancer medicine in Australia, I have diagnosed literally hundreds of BCCs (Basal Cell Carcinomas).  The vast majority of these I successfully treated (ie cured) in our practice without needing any specialist help. A handful were referred to general or plastic surgeons and one, only one, was referred for Mohs surgery. The nearest Mohs surgeon being 200 kilometres away from our clinic may have something to do with the low referral rate, but the fact remains, most BCCs (facial or otherwise), can be cured and have a good cosmetic outcome, without the need for Mohs surgery.

To my mind, using Mohs on garden variety BCCs is like employing a team of chefs to come into your kitchen each morning to place bread in your toaster and then butter it for you. Overkill.

Those soaking up some fine Aussie sunshine on the beach or at a backyard barbie with friends this Australia Day, gifting their skin with perfect skin-cancer-growing conditions, may wish to give thanks that when their BCCs bloom, affordable (relative to costs in the US, at least) treatment is right under their cancerous noses.

Being the skin cancer capital of the world is perhaps not a title of which Australians should be proud, but the way we can treat them effectively, without breaking the bank, should be.

Happy Australia Day!

The Big C at Christmas

Cancer. The Big C. No one wants it as a Christmas gift.

Maybe it’s just coincidence, but in the lead-up to Christmas I seem to be delivering this bad news more frequently than usual.

Intriguingly, as with children’s toys, each year there seems to be a particular type that is all the rage. Three years ago, I diagnosed two leukaemias in the week before Christmas. Two years ago it was three breast cancers and, in 2012, it was two invasive melanomas.

Unlike my breast cancer and leukaemia patients, my melanoma patients took the news calmly. Too calmly. They were both unusually blasé, even for middle-aged country blokes.

The first wanted to postpone the treatment of his aggressive desmoplastic melanoma until February, as he wanted to have a knee arthroscopy first.

The second didn’t even want an excisional biopsy until the new year. I had diagnosed his melanoma, with its textbook dermoscopic appearance, clinically.

Understandably, I was keen to remove the little blighter before it got up to more mischief, but the patient had plans to swim at the beach and didn’t want an open wound.

I usually employ a softly-softly approach when breaking bad news, trying to not unduly scare my patients. Wrapped in comforting padding, the “this is serious” message was obviously not being absorbed through either of their thickened, sun-damaged skins.

I was pretty sure neither was in a state of terrified denial; they both seemed genuinely unconcerned.

With the first patient, I worked my way up the scary-statements ladder until he “got it”. It was quite a climb; I even needed to use the word “death”.

With the second, I took an easier route, bringing in his wife from the waiting room and re-explaining the situation. He didn’t stand a chance! The melanoma was excised the following day.

When I saw him after Christmas to do his wider excision, he told me: “You’re too touchy-feely, Doc. You should’ve just said first-up, ‘This mole is deadly. I don’t care what plans you have — it’s coming off right away’. I wouldn’t have argued if you’d put it like that.”

Minutes later, as I sat wondering whether I should be more like Dr House at times, I received a phone call from a very worried daughter of another patient.

“Mum has been beside herself all Christmas. She’s convinced she won’t live to see another one. Getting the cancer diagnosis has completely knocked her for six.”

Puzzled, I reviewed my notes. I’d seen her mother as a new patient a week before Christmas and found a small solid pigmented BCC on the skin overlying L2/3.

I told her that a biopsy would be a waste of time and recommended excision, briefly going through the risks of skin surgery. She didn’t have any questions and the procedure was booked for early January.

I like to think I’m particularly good at reading people but in this case I failed miserably. I had no inkling that what she’d heard was: “CANCER!! On the SPINE! Too urgent to biopsy! Risky surgery!”

I apologised profusely, feeling terrible that I’d wrecked their family Christmas with my careless tossing around of the C word.

The daughter replied, “Oh it wasn’t all bad. Mum finally made amends with her sister after 20 years of fighting, and decided to work through her bucket list, starting with learning how to surf. She loves it!”

So while I’d kept a patient out of the water over Christmas, it seems that I’d inadvertently encouraged another one in. I just hope she slip, slop, slapped.


First published in Australian Doctor on 17th January, 2013: On the Big C