Most skin cancer patients are motivated to learn and understand their health problems. There have been many instances in which a patient has come into the author's office requesting a second opinion for a possibly cancerous growth that concerns the patient, when the patient's previous doctor(s) thought the growth was benign. Although these patients requested biopsies from their original doctor(s), he/she/they declined to take the biopsy or talked these patients out of a biopsy. Fortunately, for some of these patients they continued to suspect cancer, although they were not sure. When the author biopsied these patients' spots of concern, a cancer or significant abnormality was found about one-quarter of the time.

How can this happen, that certain patients would be right when their doctors were wrong? First, not all doctors are equally intelligent or equally trained. Second, many doctors do not take the time to inspect the area thoroughly closely or under magnification (this point will be discussed at length). Many patients can recognize a doctor's failure to inspect thoroughly, thus easily prompting their search for a second-opinion doctor. Third, many doctors are in a rush, which is usually easily recognized by the patient. Fourth, many doctors suspect a tumor but make a "weighted" decision (take a calculated risk) without telling the patient. One weighted decision/rationalization might be, "it's so small, I'll get it when it gets bigger." Another doctor rationalization is, "It's so small that insurance won't pay much until it gets bigger. I'll get it then." Another doctor rationalization is "It's so small, if I biopsy it, I may leave a mark that looks as big as the spot and get sued." (A good biopsy does not have to take long to heal or be unsightly. See The All Important Skin Biopsy.) If your doctor is an HMO doctor, then the doctor has been "capitated" (fixed paid) whether or not any action is taken and thus the doctor may not want to spend any time that will not be reimbursed in treating the area. The doctor may simply tell you to wait, hoping you will see another doctor. As one can easily see from reading this website, the consequences of rationalizing when a patient has a cancer can be serious. Trust your own suspicions; get a second or even third opinion if necessary. Usually, the author recommends for that patients go so far as to seek a third opinion, and that they visit a university medical center or well-reputed health institution.

Doctor's examinations vary widely in quality. The first thing a patient should ask him/herself is, "Just how thoroughly do I want to be inspected and cared for?" A 20-year-old fashion model is likely to have different thoughts on this matter than an 88-year-old man. Another important question to be addressed is, "If the doctor looks carefully, and if a cancer is found, how thoroughly do I want or need it treated?" For hints on answering this question, see Just How Much Surgery Is Necessary?

Nonetheless, different doctors see and recommend different things. An examination by a dermatologist who has vision worse than 20/200 with extreme nearsightedness, NOT corrected by glasses, is probably the best exam anyone in the world could want. First of all, the vision is stereoscopic so the doctor can sense the finest vertical dimensions in the object. Doctors using magnifying glasses or loupes (eyeglasses with binoculars) do not have much stereoscopic appreciation. Doctors who use a single-lens, hand-held magnifier have absolutely no stereoscopic capabilities. Doctors who see 20/20 or wear glasses or contact lenses can conduct only a naked eye-examination. The failure to scrutinize or fully magnify a suspicious lesion is the main reason otherwise well-trained doctors may "miss" skin cancers during an exam. Another reason is that many skin cancers do not look classical and instead may masquerade as a pimple or hair-pore inflammation, etc.

A full-body examination is recommended sometime during the course of time that a dermatologist is treating a patient. The author's office offers a full-body exam to all patients but does not force them to have it, due to ethical considerations. Frequently, patients come in initially with so many skin precancers and cancers on the sun-exposed skin that it may be two or three visits before the covered skin can be inspected, let alone treated. All patients should have the right to request a full-body examination, and doctors should oblige if their schedule permits. If it does not, a separate appointment should be made for that purpose.

The author is extremely nearsighted, which makes his full-body examination appear rapid. But even with special lighting conditions, it takes the author about five minutes to conduct a full-body examination on someone with minimal skin problems. Scanning the body with eyeglass-corrected vision as well as focusing above the eyeglass lenses to see a suspicious area thoroughly is the technique the author uses. The exam can take much longer on patients with extensive sun damage. Note that nothing is etched in stone. There is always a range of patient care and examination. Everyone is special and that is what makes medicine an art. People are not Chevrolets; the pistons and valves were not made at the same factory. Genetics and environment make the differences. If you are not convinced that your doctor is adequately addressing suspicious areas, tell the doctor. If the response or action taken by the doctor is not satisfactory, then perhaps it is time for a second opinion. Additionally, some of the best doctors become too busy, a potential downside of success. When a doctor is too busy to look closely, even the brightest doctor cannot have enough information to make an intelligent decision.

Some doctors look at patients at a distance of two feet with 20/20 normal or corrected vision and tell them they have "nothing wrong." A statement closer to the truth would be "nothing wrong that I can see." Doctors are only human; there is always a chance a cancer will be missed. A cancer can hide in a fold or sit in a shadow on the patient, not showing up in a certain light. Unfortunately for skin examinations, make-up works very well and will hide many cancers from the view of your doctor. Wearing make-up makes a good examination almost impossible. Women who want a good exam must not wear make-up. If that is out of the question, patients should be offered a make-up remover to apply just before the examination, if the patient desires.

 

What about photography and special scanning computers? This appears to be the future. Every year, the resolution is even better than the year before. However, computer screens are two-dimensional and are made of pixels (tiny lights). Look at a Kodachrome® slide that is projected onto a quality screen and compare it to a digital camera photo that has been input into a computer/projector. Even with today's better digital technology the digital image is usually fuzzier, and appears composed of many dots (from the pixels) and has no depth. Today, digital photography and computer resolution still have room for improvement. There is currently a tremendous difference between a doctor's careful visual exam of the patient's body and an exam by photography and computers that will continue to narrow as technology improves. In the real world, skin growths grow in three dimensions. Present computer technology is unable to easily resolve completely the third vertical dimension. Because of resolution problems among other difficulties, it appears a safe bet today that an extremely well-trained, nearsighted dermatologist can outperform a supercomputer using today's best lesion-tracking software. In other words, the naked eye of this doctor can likely sense depth and see roots heading up or down at the edges of a colored lesion, as no present-day computer can.

Some doctors may comment negatively regarding other doctors who "see too many things." But the proof is in the biopsy. If the doctor who notices "so many things" happens to have biopsy proof of a skin cancer then it is fairly obvious who is right. The commenting doctors usually have average eyesight. Everything depends on the thoroughness of inspection and how much the patient wants found or treated. Patients' desires may be highly varied. Patient should tell their doctors about the desired level of examination (thoroughness), because sometimes it's the 90- year-old man who wants everything found, while the 20-year-old just wants to hear she's "okay," no matter what.

Some classical signs of skin cancer that patients should consider include any growth or mark that has changed, grown or looks suspicious, as it may indicate the presence of skin cancer. The following signs should be checked out promptly:

• A new skin growth that does not disappear within four weeks
• A skin growth that gets larger and turns pearly, translucent, brown, black or multicolored
• A mole, birthmark or beauty mark that increases in size, changes color or texture or becomes irregular in outline
• A skin spot, growth or bump that continues to itch, hurt, crust, scab, break down or bleed for more than two weeks
• An open sore or wound that does not heal, or lasts for more than a month before it heals over again and looks better
• See the A, B, C, D's of pigmented lesions in Warning Signs of Malignant Melanoma.

Here are some further hints for patient self-examination. Mark your next self-examination on a calendar so that you will not forget it. With a full-length mirror and a hand mirror in a well-lit room, inspect your chest and stomach area, then check your sides with your arms raised. Bend your elbows to check upper arms, forearms, palms and backs of the upper arms. Use the hand mirror to inspect the backs of the legs and feet, the upper and lower back, back of neck, buttocks and scalp. Finally, check the soles of the feet and the spaces between the toes. Mark yourself with a blue inked Sharpie marker on the areas of concern within 1 day of your appointment then present these spots especially to the office staff.