Overeager Surgeon Does His Melanoma Patient No Favor

For many people, the word “melanoma” often prompts the same response as the word “snake”- fear and, if announced as a personal warning, panic.

Indeed, the worst form of skin cancer can be deadly if ignored or treated improperly. Several years ago we sued a dermatologist whose dereliction in treating a patient with moles led to his death. But like so many other kinds of cancer, many people are harmed because their symptoms or their disease is overtreated by fear-mongering surgeons. This was the case in a story published in the Archives of Internal Medicine called “What the Surgeon Should Have Said to My Patient with Thin Malignant Melanoma.”
The writers, two medical doctors, explained how the patient presented with a colored lesion on his shoulder. A simple biopsy revealed a stage 1A malignant melanoma which, on a relative scale, is a small, early-stage cancer. This one was 0.5 mm deep. It had no ulceration nor evidence of palpable lymph nodes, either of which should have raised more questions. The surgeon, who specialized in oncology, played the fear card in encouraging the patient to have a procedure known as a sentinel node biopsy.

According to the authors, he said, “It is up to you, but you have a risk that there is spread into your lymph nodes. It has been shown that patients with nodal disease operated on at an early stage do better than those having total lymph node resection at a later stage when an enlarged lymph node is palpable. By doing this procedure, I could save your life.”

A sentinel node biopsy involves injecting a radioactive substance, dye or both near the tumor. Then the surgeon uses a probe to locate the lymph node(s) containing the injected marker-that’s the “sentinel.” The affected nodes are removed and analyzed for the presence of cancer cells. The point is to see where cancer cells are likely to spread from the primary tumor.

As noted in a companion story in the same publication, performing sentinel node biopsy on patients with early-stage melanomas is not considered best practice. But nearly 1 in 10 such melanomas are overtreated with such invasive procedures. About 30,000 of these melanomas are diagnosed every year, so thousands are overtreated in this way.

The risks of sentinel node biopsy include:

• infection;
• hematoma (swelling of clotted blood caused by a break in a blood vessel wall);
• nerve damage.

In addition, the procedure can cost about $15,000.

Patients in the only scientifically sound study on sentinel lymph node biopsy had lesions that measured at least 1.2 mm. The death rate from malignant melanoma was nearly identical in the group with sentinel lymph node biopsies compared with those whose lymph nodes were biopsied only if enlarged. But patients with microscopic disease did better than those with lymph nodes that were enlarged and palpable.

The journal writers note that it’s wrong to compare outcomes of patients with palpable nodes with those who have normal-sized lymph nodes, because the latter group’s disease is at an earlier stage, and when it’s discovered incidentally is usually less aggressive. In short, it’s possible that their positive sentinel nodes might not progress because of the body’s natural immunity. “The unambiguous finding of this trial,” the writers reported, “is that there was no advantage of sentinel node biopsy over observation.”

The surgeon in this case not only was too eager to practice his skills, he was malfeasant; he neglected to discuss treatment options with his patient and their possible side effects weighed against their benefits.

According to the journal authors, the surgeon should have said, “A wide excision alone [cutting around the lesion] gives you an excellent chance of cure. No studies have shown that sentinel node biopsy will improve your chances, and we do not know if you would benefit from the discovery of microscopic lymph node disease.”

If you want to more about melanoma and how to assess the value of treatment options, link to the website LifeMath.net, which tries to make sense of “the enormous number of fundamentally discrete events that occur among the many molecules, genes, and cells of which we are comprised.” Click on the cancer and melanoma tabs.

Here’s a discussion on our firm’s web site about the vital issue of “informed consent” in medicine.