Before You Remove That Mole, Read This

Cancer headlines dominate the lay press yet public response to this sometimes preventable and sometimes curable disease is muted if not downright self defeating. There are many reasons for a sluggish response to an obvious problem and I will mention just a few.

The government: Government funding of cancer research is at an all-time low relative to GDP, government spending, and the military budget to name a few. Legislators are most concerned with getting re-elected and a project as mundane as improving health simply doesn’t get their attention (unless it involves populist agenda like beating up on wealthy doctors).

Health Insurers: The bottom lines for these companies are increased growth and increasing shareholder value. Paying for valued treatments of prevention dilutes their bottom line yet how much more they would gain by effective prevention and early treatment of disease as opposed to surgical intervention might be a valid consideration.

Hospitals and Surgeons: Both earn far greater re-imbursement for cutting than they do for diagnosis, though they are the least troubling of the elements of care.

And all of this plays into consideration of when you should have a mole, albeit suspicious, biopsied and/or removed. During the past decade with mounting evidence of a skin cancer epidemic the medical community and the public have responded by removing untold “suspicious” moles in a misguided attempt to arrest the development of malignant melanoma. Yet the epidemic, and increasing incidence and death from the disease continue. And so, even more mole removal is recommended. (This reminds me of the Lyndon Johnson mud-slinging campaign against Barry Goldwater in the 1960’s. Referring to the Viet Nam war one supporter of Goldwater was to have said, “Well they told me a vote for Goldwater was a vote for war. I voted for Goldwater, and we went to war.”

Here are a few published facts in the peer-reviewed medical literature. The average dermatologist evaluation in successfully identifying moles that were converting to malignant melanoma has been 1 out of 18 cases. With dermoscopy (a tool to clinically improve detection) the successful identification of such moles was 1 out of 4. The statistics are much worse for non-dermatologists. In other words, dermatologists are batting 0.050 in correctly identifying these moles clinically. Whole body examinations, by identifying mole patterns, reveal between 72-94% of moles depending on age to be consistent in a given individual and not indicative of cancer. Patients under 50 who developed new moles were diagnosed with less than 1% of their lesions as malignant melanoma whereas patients older than 50 years of age had a 30% incidence of melanoma in new lesions.

What is a patient to do? You are between a rock and a hard place. When faced with a changing mole or lesion, seek a dermatologist for evaluation since his understanding far exceeds other specialists. Find a dermatologist, if possible, with known expertise in melanoma. Full body exams are essential in evaluating changing lesions (have you ever tried to look at a painting through a keyhole?). Get second opinions before letting someone hack away at your body because a “lesion” is suspicious. Most “dysplastic nevi” will never become malignant. The art of evaluating the degree of dysplasia requires intelligence and experience. Two disconcerting anecdotes that occurred in the last year: two different adult females each over 40 years of age came to me for a second opinion on wide excision of lesions. They had each been seen by unrelated dermatologists and each had had a lesion biopsied. In each case the pathologist reported the lesion was benign. In each case the treating physician recommended a wide excision of the lesion! Lastly, I never met a physicians’ assistant or nurse practitioner who had studied histology under the microscope and was therefore competent to evaluate a “suspicious” lesion. If you are not going to seek expertise in your care, why seek care at all? The moral: get a copy of all of your laboratory results, read them yourself, and get 2 opinions when you perceive a discrepancy between fact and opinion.

The marriage of art and science in health care requires the good services of the physician as well patients taking responsibility for their own welfare.

Appreciate Your Appearance

Some years ago I was traveling in Italy when I found a shirt that I decided to buy. It was a beautiful shirt, very classic, very sharp. It was so fine that I decided it was too wonderful to wear. Something might happen to it. It could get stained. It could be damaged in the wash. Who knows what might happen to it? And so it sat in my closet these 5 years. It looked very handsome on the hanger. Recently my wife and I were going out for dinner and I decided to wear the shirt. I anticipated looking good and my wife would enjoy seeing me wearing it. I put the shirt on and to my surprise I saw … it didn’t fit! The shirt had not changed. I did. I am bigger. Now I will donate the shirt to charity. I cherished a shirt I never wore and because I treasured it too much I never enjoyed it.

I have many examples in myself and others of cherishing things too much and losing the opportunity to derive pleasure. Think about it: how often do women look in the mirror, examining their face for hidden flaws or their clothed figures for imperfections that no one else will notice. How many times do men look in the mirror, fantasizing that Schwarzenegger in his prime is reflected back at them. I see it every day in the gym locker room and have certainly been guilty myself. I saw two beautiful women last week, one aged 25, the other 50, who complained about imperfections in their skin. What imperfections? Does anyone believe that when they appear in public the rest of us stare and examine them looking for their hidden flaws? Is there a problem with enjoying one’s appearance and having fun because you appreciate how you look.

This is often the case with cosmetic surgery and especially the medi-spa industry. You should use a moisturizer because even if you are not dry you may be at some time in the future. You should treat wrinkles because even if you have none you may in the future. You should wear sunscreen during the winter in Chicago to protect you from the sun. What sun??! Are we now going to tout visible light as causing skin cancer while we let the sun tan industry run amok with UV lamps that poison the skin? You should wear foundation to cover blemishes or wrinkles. Foundation that fills your pores and cakes your skin and makes you look older.

Here’s an idea. I will wear new shirts and enjoy them immediately after I buy them and we can all groom ourselves nicely and go into the world with a smile on our face, a greeting in our heart, and the confidence that comes from feeling good about ourselves.

You didn’t choose to get cancer. You can choose to fight cancer... NOT

The sign above the corner of Irving Park and Lincoln Avenue, an otherwise non-descript corner in Chicago reads: “You didn’t choose to get cancer. You can choose to fight cancer”.

Good sound bite. Lousy message. For the naive, for the unsophisticated, for the panicked patients and families alike it sounds so good to fight cancer. I must ask, “How successful has anyone you know been in “fighting” taxes and death". A survey of those I have known or know of is a perfect zero. If there was one remedy for cancer, one cure, why does anyone think there are so many choices? If one treatment plan would serve would anyone need to choose between two or three? Would there be a need for clinical trials? Would parents of children with leukemia, lymphoma, bone cancer and so on spend so much time in prayer if all they had to do was fight?

This is a wake-up call. The needed emotion is acceptance. Acceptance and not fighting. Acceptance that this is a part of life. Some of us celebrate remission. Some of us celebrate life and sharing and companions and love for some precious and measured time. Cancer is not a death sentence. Cancer is a life sentence. It is a time of awareness and an ability to plan how we shall spend the balance of our lives and with whom. Hopefully it is a time where we marshal our resources and get the best help that medical care can provide. It is in God’s hands, it is in fate’s hands, it is in luck’s hands. And, oh, we can help by celebrating the gifts we have received and co-operating with our doctors who are doing their best to help us.

We can participate in clinical trials which can increase survival by up to 400%. Kids do it. Why don’t adults? When I had pancreatic cancer I opted for a clinical trial and 9 years later not only have I survived but the remission rate in all patients who received this treatment across the United States increased from 15% to 35% as a result of the clinical trial in which we participated. Most patients won’t co-operate with a clinical trial. My cohorts and I did, and the only thing most of us wanted was that someone would be helped by our experience and if by chance it was us so much the better. We were not saints. We were pragmatists. We had nothing to lose and if not us, someone else might be helped.

At a time when so little makes sense in our social culture, we can choose to value our lives, our good fortune, and our friends and family. We can choose acceptance and appreciation and if by chance more blessings shall come we can receive them with humility. Fight? Leave it to the self-deceived.

LIPEDEMA: You know it when you see it

'Tis but thy name that is my enemy;
What's in a name? that which we call a rose
By any other name would smell as sweet;

-Shakespeare

Would that I had written those famous lines. Yet often have I quoted them, even as I have indulged myself in fanciful daydreams.

So it is no great surprise that in my recent travel to Vienna I learned that that which I have often called “God’s curse” euphemistically is really LIPEDEMA. Not infrequently over the past 20 years I have consulted with women who are relatively thin or at least appropriately proportioned everywhere but in their hips, or their thighs, or their calves and invariably these body distortions are reported to have begun in puberty without any inappropriate weight gain. Patient’s euphemistically call these distortions thunder thighs or thunder hips and go to great lengths to hide them with loose clothing. What we usually don’t discuss is the embarrassment that these disproportions have caused and the self consciousness that follows.

It turns out that a number of clinical researchers in Europe have been studying these problems for a number of years and have found that the enlarged body parts are not a result of obesity (which we knew) but of a proliferation of fat cells usually beginning in puberty. Little is known of their cause but the “disease” appears to be confined to women and onset is usually at puberty. The problem usually involves a portion of a limb such as a forearm or arm or thigh, but can involve the calves and hips. Interestingly it rarely if ever involves the feet. The latter is important because patients suffering from a reduction of lymph vessels called lymphedema have swelling of their hands or their feet. Lastly the affected limbs tend to be tender to squeezing and that patients have become so used to the discomfort that they forget to complain or rarely notice their problem until it is resolved and they no longer have the pain.

Another interesting fact is that lipedema responds especially well to liposuction. While the tissue removed with liposuction contains much fat, recent research indicates it contains abnormal metabolites not routinely identified in liposuctioned material. The treatment results appear to be permanent and patients resume a normal lifestyle with much less self-consciousness.

So if a thing by any other name is still a thing I will choose to call this condition lipedema and assure patients that rather than a curse this is another genetic alteration that can be corrected. Look it up on Google. You may be surprised you know someone with this condition.

Take Responsibility for Your Own Care or Pay the Consequences

The 19 year old sophomore sat on the exam table looking at the floor. A college student with obvious charm and kindness, she appeared withdrawn and shy. Covering her face were pustules , redness, and several cysts. Her mother was in tears fearing her child could not continue college because of depression concerning her appearance. They had been to a “doctor”, at a dermatologist’s office for the past 6 weeks and after taking several ineffective oral antibiotics and 6 different topical medications; having spent hundreds of dollars this family could ill afford to lose; after having hopes for a resolution dashed by failure to respond; her “doctor” recommended Acutane – a drug known to cause depression in students. This is to ignore also the potential for injury to eyes, liver, and cholesterol. A drug that causes depression is being recommended for a depressed college student. I looked at the different medicines and out of curiosity, if nothing else, gazed at the prescribing doctor’s name on the bottle. The doctor was a name unfamiliar to me with the suffix “PA” after her name. “PA: Physician Assistant”. The child was not being treated by a doctor but by a “doctor” i.e. “PA”. The doctor was a dermatologist who saw the patient once and referred her to his employee “doctor” with a diploma as a “PA” and this “doctor” with 2 years of education diagnosing everything from brain tumors to acne was going to give a depressed student a drug that might induce depression!

A 65 year old female patient had progressive shortness of breath and acute anxiety. She and her husband went to a University affiliated hospital emergency room where the doctor noted no evidence of heart disease and omitted a chest Xray or scan. He sent her home for a cardiac stress test. Her primary care physician, noting the absence of cardiac symptoms ordered a chest scan and found a pulmonary embolism. The patient survived and will never trust an emergency room doctor again.

A patient saw an advertisement for a new form of ultrasound to reduce fat in her abdomen. She called our office and told the receptionist, “Don’t give me smartlipo or slim lipo, or cool lipo. I don’t want Velashape or Zeltique or Zerona. I just want the new ultrasound so if you don’t have it I will go somewhere else.” The patient never considered the value of examination or diagnosis.

Noted physician experts in plastic surgery and dermatology have published their opinion that the often promoted “stem cell face lift” is at this time hyperbole and does not exist as a separate procedure. Nevertheless, judging from its popularity in the lay and medical press, many patients seek this “new break-through”.

From seeking help for disease to addressing cosmetic concerns, many patients fail to follow minimal procedures for assuring responsible care for themselves and their loved ones. As examples:

· Interview physicians when there is time.

· Look at before and after results

· Check physician credentials at least using Google and hospital references

· Seek second opinions when care does not appear effective or when an elective medical/surgical path is recommended

· Use resources like Mayo Clinic and John’s Hopkins websites

· Maintain objectivity

It is nice to remember 50 years ago when a physician sat at your side and held your hand. Today we have much better diagnostic and therapeutic aides with which to intervene; but… they will only be available for those who take responsibility for their own care.

U.S. vs. Europe: Health Care

As I have tried to make abundantly clear the United States is the only country in the industrialized world that does not provide universal health care for its citizens. We have preferred crisis management to preventive medicine and we use emergency rooms of hospitals as triage units and primary care offices for the poor. In my judgment the reason for the lack of consensus on the need for universal coverage is the self centered attitude of patients. They want what they want and they want it now! Anecdotally this is nowhere more evident than the selfish and immature attitude of senior citizens.

Two vignettes, please.

I asked 10 female senior citizens a hypothetical question. Your husband needs a liver or he will die. A 4 year old child needs a liver or he will die. Only one liver is available. To whom will you reward the liver? In all cases the women chose to give the liver to a husband in his waning years rather than a child with the potential for a full life ahead of him.

A male senior citizen came to my office complaining of a benign growth on his face which he requested be removed. I told him I would comply but that since removal was not medically necessary the procedure would be considered cosmetic and he would have to pay for his care out of his own pocket. He responded with some anger saying that several years ago he had a similar growth and the dermatologist down the block charged Medicare. I explained that the doctor probably falsified the diagnosis to justify the procedure and questioned if his physician would lie to the government was he comfortable that the physician would not lie to him. He was not assuaged.

So we are in a deadlock where voters want everything for themselves and do not want to pay for it. At least they do not want to pay so that someone else can get care.

Another problem: State after state has voted down itemizing basic health care; that is, listing diagnoses that would be covered for all Americans. The presumed worry is what if my diagnosis is not on the list? This is the same sentiment that prevents tort reform in medicine. What if I have a medical injury? I want to collect the big bonanza too!

The conundrum: Technologically health care in the U.S. is superior to any in the world.

The last vignette: My wife’s was back in Sweden a few years ago and had a physical check-up. I advised her to request a routine colonoscopy. The doctor denied the request advising that the Swedish health care system only provides colonoscopy for patients who are bleeding. My wife had her colonoscopy paid for by our health insurance in the United States. Three years ago my wife’s best friend moved from Sweden to France. This year her French physician insisted she receive a routine colonoscopy. Her friend was found to have colon cancer! We believe successful surgery followed.

Conclusion: The health care system in the United States is technologically superior for those who can afford the system and know how to access care. The health care system in the United States in inequitable and even if you can afford it most patients have no idea how to evaluate care. The social care system in Europe is often inferior and inadequate given the knowledge we possess today. One would think it would be possible to merge the advantages of each.

Health care in the United States is schizophrenic; we have the best quality and poor distribution. Those of us on Medicare don’t have to worry. The politicians are too scared of us to change the system.

Fat Returns After Liposuction … NOT

A study appeared in a journal titled “Obesity” which was reported by a group from the University of Colorado. In a nutshell the study used sophisticated techniques to prove a doubtful if not unsubstantiated conclusion. More than 100 years ago Mark Twain wrote (quotations are used despite my paraphrasing) “There are three kinds of lies in the world. There are lies. There are worse lies. And then there are statistics.” I read the article and noted a number of background and design errors in the study and I would have forgotten about it except that a reporter called me for an interview regarding the study. The reporter told me that the article had been picked up and circulated by the press and was being taken seriously in the lay literature (magazines and newspapers). Now it is one thing for educated investigators to report their findings and argue their conclusions; it is quite another to publish these findings in the lay press where inadequacies and inconsistencies are taken for truths by unsophisticated readers.

So... here goes: my analysis of the data. First, the study was done on patients with “small volume liposuction”; a group which has previously been shown to have little metabolic changes after liposuction. Second, studies in which metabolic changes have been demonstrated are numerous in the diabetes literature and demonstrate at the least changes in insulin resistance and blood sugar. Much more important is the authors’ conclusion that there is a homeostasis in the human body which compels the body to hold a fixed amount of fat so if you take some away it naturally comes back. How many of us have lost weight on a diet. How many of us have gained it back? How many of us complained that we went off our diet and the fat came back. Do any of us think this happened by serendipity? How many overweight patients do you know that gained weight after losing it and were not eating more.

Lastly, fat is deposited according to hormone receptors that are present on adipocytes (fat cells).. Females in pubertal years deposit fat on hips, thighs, and buttocks; in reproductive years on hips and abdomen; in pre-menopausal years on arms , shoulders, breasts. You don’t have to believe me. Ask anyone who has been there. So when these investigators found increased fat in the abdomen a year after liposuction, I am not sure what they were thinking.

Twenty years ago cosmetic surgeons felt that women increased breast size after liposuction and you would not believe how many men came to my office in support of their wives having a liposuction procedure. Five years later we found it was not true and in my practice only 15% of female patients developed larger breasts. Yet the myth goes on. Now women who gain weight after liposuction will blame the liposuction and the self sustaining prophesy will continue.

Fat returns after low volume liposuction ? … NOT!