Is It Cancer Yet?

It took me a while to catch on.

My first hint came at a free skin cancer screening years ago at our city hall. I noticed that not all the patients who came were the uninsured with no medical access. Many had dermatologists. Many had me.

"What about this dark spot, Doctor?"

"It's a seborrheic keratosis, Mrs. Jacobs. Completely benign."

"That's what you said at my last visit. I just wanted to see if it's still OK."

Fast forward to last Thursday. Dale is worried about some spots on her face.

"The ones on your chin are keratoses," I explain. "They're fine. And the flat ones on your cheeks are also no problem. If they don't bother you, they can stay."

Dale expresses relief. We chat for a few minutes, catch up on things. Then her eyes narrow. "Ah, tell me, Doctor … these spots could never become … cancerous, could they?"

Here then is another instance of how patients view and categorize the world in ways that can't be translated into the way we do. Simply put, to us a lesion is either benign or malignant. To patients a spot is either malignant, or not yet malignant.

Perhaps we're suspicious about a lesion and perform a biopsy. The biopsy is benign. We delightedly report the good news. The patient is happy, too, but just provisionally. Sure it's not cancer—today. Tomorrow, who knows?

Of course even in our scheme benign nevi can sometimes turn cancerous, but that uncommon transformation is not what worries patients. After all, every day we see things that never, ever turn bad, which can't do so even in theory—seborrheic keratoses, dermal nevi, dermatofibromas. For our patients, however, even these are potential malefactors who got off on a technicality. Better be vigilant; they could come back.

The difference between the way we look at things and the way our patients do is the difference between a thing and a process. To us, a lesion is a collection of cells—melanocytes, keratinocytes, and so forth. Each collection has an identity and an expected biologic fate. We look at all diseases that way too, and call them "entities."

To patients, a lesion is not a thing in itself but a deviation from what used to be—an instability. The skin used to be clear; now there's something there. Something is going on. Once that starts to happen, who's to say it won't keep happening, leading finally to the ultimate instability—cancer.

No need to take my word for any of this. The next time (in 10 minutes?) you see a patient worried about a benign spot, try saying something like: "We call this a dermal nevus, Mr. Perkins. It's completely benign." Then pause for effect and add, "and it will always be benign."

Watch his eyes widen in surprise. This is indeed news. "You mean it will always be nothing to worry about? I had no idea."

Of course, some people are more anxious about instability than are others. But if you look for this reaction, it shouldn't take long to recognize that many people with ordinary moles, keratoses, and skin tags are just not assuaged by a bland reassurance that all is well. Like Dale, quoted earlier, they retain a level of unresolved suspicion.

What to do? A few suggestions:

▸ Avoid advising patients to "Keep an eye on it." That implies you, too, have your doubts. If you do, either keep an eye on it yourself or take it off.

▸ Assure people that trauma—bra or neck chain rubbing, sun exposure—doesn't make benign things malignant. (This widespread conviction flows from the fact that swelling and bleeding imply even more dangerous instability.)

▸ Sometimes the expressed anxiety of a spouse or primary physician makes it impossible to reassure someone about a specific spot. Unless logistics dictate otherwise, it's often better in such cases to just take the damned thing off and be done with it.

Then call to say it's benign. And now that it's out, it will always stay that way.

It took me a while to catch on.

My first hint came at a free skin cancer screening years ago at our city hall. I noticed that not all the patients who came were the uninsured with no medical access. Many had dermatologists. Many had me.

"What about this dark spot, Doctor?"

"It's a seborrheic keratosis, Mrs. Jacobs. Completely benign."

"That's what you said at my last visit. I just wanted to see if it's still OK."

Fast forward to last Thursday. Dale is worried about some spots on her face.

"The ones on your chin are keratoses," I explain. "They're fine. And the flat ones on your cheeks are also no problem. If they don't bother you, they can stay."

Dale expresses relief. We chat for a few minutes, catch up on things. Then her eyes narrow. "Ah, tell me, Doctor … these spots could never become … cancerous, could they?"

Here then is another instance of how patients view and categorize the world in ways that can't be translated into the way we do. Simply put, to us a lesion is either benign or malignant. To patients a spot is either malignant, or not yet malignant.

Perhaps we're suspicious about a lesion and perform a biopsy. The biopsy is benign. We delightedly report the good news. The patient is happy, too, but just provisionally. Sure it's not cancer—today. Tomorrow, who knows?

Of course even in our scheme benign nevi can sometimes turn cancerous, but that uncommon transformation is not what worries patients. After all, every day we see things that never, ever turn bad, which can't do so even in theory—seborrheic keratoses, dermal nevi, dermatofibromas. For our patients, however, even these are potential malefactors who got off on a technicality. Better be vigilant; they could come back.

The difference between the way we look at things and the way our patients do is the difference between a thing and a process. To us, a lesion is a collection of cells—melanocytes, keratinocytes, and so forth. Each collection has an identity and an expected biologic fate. We look at all diseases that way too, and call them "entities."

To patients, a lesion is not a thing in itself but a deviation from what used to be—an instability. The skin used to be clear; now there's something there. Something is going on. Once that starts to happen, who's to say it won't keep happening, leading finally to the ultimate instability—cancer.

No need to take my word for any of this. The next time (in 10 minutes?) you see a patient worried about a benign spot, try saying something like: "We call this a dermal nevus, Mr. Perkins. It's completely benign." Then pause for effect and add, "and it will always be benign."

Watch his eyes widen in surprise. This is indeed news. "You mean it will always be nothing to worry about? I had no idea."

Of course, some people are more anxious about instability than are others. But if you look for this reaction, it shouldn't take long to recognize that many people with ordinary moles, keratoses, and skin tags are just not assuaged by a bland reassurance that all is well. Like Dale, quoted earlier, they retain a level of unresolved suspicion.

What to do? A few suggestions:

▸ Avoid advising patients to "Keep an eye on it." That implies you, too, have your doubts. If you do, either keep an eye on it yourself or take it off.

▸ Assure people that trauma—bra or neck chain rubbing, sun exposure—doesn't make benign things malignant. (This widespread conviction flows from the fact that swelling and bleeding imply even more dangerous instability.)

▸ Sometimes the expressed anxiety of a spouse or primary physician makes it impossible to reassure someone about a specific spot. Unless logistics dictate otherwise, it's often better in such cases to just take the damned thing off and be done with it.

Then call to say it's benign. And now that it's out, it will always stay that way.

It took me a while to catch on.

My first hint came at a free skin cancer screening years ago at our city hall. I noticed that not all the patients who came were the uninsured with no medical access. Many had dermatologists. Many had me.

"What about this dark spot, Doctor?"

"It's a seborrheic keratosis, Mrs. Jacobs. Completely benign."

"That's what you said at my last visit. I just wanted to see if it's still OK."

Fast forward to last Thursday. Dale is worried about some spots on her face.

"The ones on your chin are keratoses," I explain. "They're fine. And the flat ones on your cheeks are also no problem. If they don't bother you, they can stay."

Dale expresses relief. We chat for a few minutes, catch up on things. Then her eyes narrow. "Ah, tell me, Doctor … these spots could never become … cancerous, could they?"

Here then is another instance of how patients view and categorize the world in ways that can't be translated into the way we do. Simply put, to us a lesion is either benign or malignant. To patients a spot is either malignant, or not yet malignant.

Perhaps we're suspicious about a lesion and perform a biopsy. The biopsy is benign. We delightedly report the good news. The patient is happy, too, but just provisionally. Sure it's not cancer—today. Tomorrow, who knows?

Of course even in our scheme benign nevi can sometimes turn cancerous, but that uncommon transformation is not what worries patients. After all, every day we see things that never, ever turn bad, which can't do so even in theory—seborrheic keratoses, dermal nevi, dermatofibromas. For our patients, however, even these are potential malefactors who got off on a technicality. Better be vigilant; they could come back.

The difference between the way we look at things and the way our patients do is the difference between a thing and a process. To us, a lesion is a collection of cells—melanocytes, keratinocytes, and so forth. Each collection has an identity and an expected biologic fate. We look at all diseases that way too, and call them "entities."

To patients, a lesion is not a thing in itself but a deviation from what used to be—an instability. The skin used to be clear; now there's something there. Something is going on. Once that starts to happen, who's to say it won't keep happening, leading finally to the ultimate instability—cancer.

No need to take my word for any of this. The next time (in 10 minutes?) you see a patient worried about a benign spot, try saying something like: "We call this a dermal nevus, Mr. Perkins. It's completely benign." Then pause for effect and add, "and it will always be benign."

Watch his eyes widen in surprise. This is indeed news. "You mean it will always be nothing to worry about? I had no idea."

Of course, some people are more anxious about instability than are others. But if you look for this reaction, it shouldn't take long to recognize that many people with ordinary moles, keratoses, and skin tags are just not assuaged by a bland reassurance that all is well. Like Dale, quoted earlier, they retain a level of unresolved suspicion.

What to do? A few suggestions:

▸ Avoid advising patients to "Keep an eye on it." That implies you, too, have your doubts. If you do, either keep an eye on it yourself or take it off.

▸ Assure people that trauma—bra or neck chain rubbing, sun exposure—doesn't make benign things malignant. (This widespread conviction flows from the fact that swelling and bleeding imply even more dangerous instability.)

▸ Sometimes the expressed anxiety of a spouse or primary physician makes it impossible to reassure someone about a specific spot. Unless logistics dictate otherwise, it's often better in such cases to just take the damned thing off and be done with it.

Then call to say it's benign. And now that it's out, it will always stay that way.