I can remember every detail of the first time a doctor told me I had cancer. I stood in my cluttered office, holding the phone and looking out the window as he explained that the mole on my back he had removed had proved malignant.
I remember standing in a strange suspension, momentarily detached from my life, wondering what questions to ask and waiting for the proper rush of emotion — like a wondering child wandering onto the inexplicably exposed tidal flats just before the arrival of the tidal wave.
But the second time I learned I had a new, malignant melanoma remains curiously fuzzy, as though I’d smudged out the memory with a bad eraser.
My transition from reporter to patient is full of incongruous details like that, a strange mixture of fear and elation, denial and clarity, logic and panic. I was lucky, and cursed. I was terrified, and fearless. My life was threatened, and remade.
All because two moles went bad.
They slumbered on my back for years, inconspicuous spots of pigmented cells, part of my body’s complex, multi-layered system for protecting my insides. Then, for some reason, one cell went quietly crazy. It shook off the restraints of the complex cascade of chemical signals that regulate cell growth and began spreading out of control — seized by the biologically insane idea that it would rule the world.
Chance of malignant melanoma is 1 in 105
So, I became a statistic — an anecdote — in the greatest cancer epidemic of our time. Malignant melanoma has managed an astonishing increase in recent decades. Today, an estimated 1 in 105 Americans will develop a malignant melanoma — compared to one in 1,500 in the 1930s.
Experts estimate that, at this rate, about one in 75 Americans will develop a malignant melanoma sometime during their lives. No one can account for the rise, but it probably reflects some combination of an affluent, sun-drenched lifestyle and perhaps contributing factors like a thinning ozone layer, toxins in the air, or hormone cascades.
The risk appears significantly higher if you’re blond or red-haired, have a history of blistering sunburns, have asymmetric, splotchy, “atypical” moles, or work as firemen, dentists or high-income, white-collar workers.
Actually, some studies suggest the problem may be twice as bad as the official numbers suggest — since only about half of the malignant moles sliced off in doctors’ offices end up noted in the official numbers. Melanoma remains the fastest growing of all cancers — easily curable if caught early, usually fatal after its questing tendrils reach the bloodstream and release squadrons of deranged, metastatic commando-colonists.
I knew all of this, before my doctor reached me that first time. But I don’t think I understood it.
After all, if I understood — would my wife have had to make the appointment that saved my life?
Melanoma has lingered at the very back of my mind for years. I’m blond, I burn readily and tan reluctantly, my father developed the much less scary basal cell carcinoma, I once worked as a lifeguard, and I suffered a dimly remembered succession of blistering, skin-peeling sunburns in the California summers of my youth. Also, I have lots of moles — little moles — like so many pigmented question marks. Only later did I discover that some of them have the irregular shape, varied color, faded edges and lack of symmetry that marks so-called atypical nevi. Studies suggest these atypical moles elevate your risk of developing a melanoma perhaps tenfold.
But I didn’t much worry about my moles — or about cancer.
You see, I’m a great believer in denial. It is the twin-edged sword of my nature — releasing me from routine worry, but leaving me unprepared for certain other things. Besides — it’s a guy thing. I have never liked mirrors — both out of a male disdain for vanity and a specific dissatisfaction with what the mirror reflects when I stare into it. So I never gave my body much thought, prided myself on avoiding doctors, and virtually never called in sick to work. Being sick, after all, is so — well — unmanly.
Not even the article I did about rising melanoma rates worried me, although I interviewed a guy with metastatic cancer almost certainly doomed by his delay in getting a suspicious mole examined. Fortunately, my wife read the article, and it worried her. Some weeks later when I was toweling off after a shower, she noted a mole on my back about the size of a nickel. She didn’t remember it being so large, or so dark.
“I don’t like the look of that one.”
I studied it briefly in the mirror. “Oh, that’s always been there,” I said.
“I don’t like it,” she repeated stubbornly — eyes narrowed. She made it sound so personal. “You should get it looked at,” she said.
“Yeah, I will,” I said.
Several weeks later, she asked if I’d called the doctor.
“I will,” I said, thinking I might even actually do it.
Several weeks later she told me she’d made an appointment.
The doctor reassured me as he studied the mole which Elissa had circled with a ball-point pen.
“It doesn’t look like anything much,” he said.
“I know, but my wife’s all worried,” I confided, in that just-between-us-men tone.
So he injected some anesthetic into my back, sliced off the mole, dropped it into a little vial, and stitched up the small hole in my back. I pulled on my shirt, and dismissed the whole idea of cancer.
So I was almost startled three days later when my doctor called me at work. The nurse came on the line first — and told me to hold for the doctor. I remember thinking that this didn’t sound good.
And it wasn’t.
Well, actually — it was — if you read the fine print.
It was a superficial spreading malignant melanoma, which had penetrated the surface of the skin by just .45 millimeters. It was in the earliest stage when removed — which means a five-year survival rate of at least 95 percent. I’d had the mole for years, but it had probably rebelled against its biological controls and gone malignant sometime in the past year. Superficial spreading melanomas can creep outward across the surface of the skin for months, or even years, before making a dive for the bloodstream. As long as you catch them before they hit the bloodstream, or the immune system-marshaling lymphatic system, they’re easily removed and rarely recur.
The doctor referred me to a plastic surgeon, since it seemed prudent to remove a chunk of flesh all around the mole to make sure that no stray cancer cells had escaped removal. The plastic surgeon surgeon said that he thought he should take about a two-inch margin all around the site of the now-missing mole.
I said that he should take as much as he wanted.
So he cut out a chunk of me, put in a drainage tube, and sent me home. The wound opened up again after they pulled the drainage tube, which left a most remarkable scar for which I have been trying to fashion an interesting cover story.
Of course, I had not learned my lesson.
A couple of years later, Elissa took a dislike to another mole on my back.
I rolled my eyes — having learned, as it turned out, very little. I had been undergoing regular checkups by dermatologists. They had removed a couple of suspects, which the pathologists duly declared benign.
This time Elissa waited only a week before she made an appointment with our new doctor. She circled two moles in ball-point.
This time, I got the wake-up call at home. The doctor broke the news gently. I walked quickly into the bathroom with the cordless phone, wondering how I would tell Elissa.
So I studied up on melanoma — so that I could name the possibility that stalked me, moving from mole to mole like a leopard through the jungle.
The increase in melanoma rates remains a frightening mystery. The official statistics say doctors diagnose about 38,300 new cases of melanoma annually, and report about 7,300 deaths — but one detailed survey of dermatologists suggests that there are actually 80,000 new cases annually. Men account for two thirds of the deaths — perhaps because they’re slow about going to the doctor. The incidence is rising 4 percent annually — much more quickly than the much less fatal forms of skin cancer, basal and squamous cell carcinoma.
The melanoma epidemic appears connected to some combination of genetics and lifestyle, especially sun exposure on weekends and vacations.
For instance, one study presented at the American Cancer Society’s National Conference on Skin Cancers in Phoenix found the highest melanoma rates among firefighters and corporate executives. Waitresses and plumbers had the lowest rates. Risk rose with income, peaking among electricians, lawyers, doctors, pharmacists, bankers, dentists, engineers, executives, dentists, architects, pilots, judges and veterinarians.
These high-income jobs came with six times the risk as even the low-income jobs that involved a lot of daily sun exposure like fishermen, dock workers, oil field workers, loggers or construction workers. The researchers attributed most of the difference to leisure time activities that produce episodic sunburns.
The federal Environmental Protection Agency predicts a 4- to 6-percent increase in skin cancer for every 1-percent decrease in ozone layer as a result of pollutants in the upper atmosphere. The EPA estimates suggest that without a stabilization of the ozone layer, increased UV light could trigger an additional 163 to 310 million non-melanoma skin cancers and an additional 1.4 million melanomas. That could kill an additional 3.2 million people by 2075.
“We had a big change in the population’s view about sun exposure,” observed Dr. Suzanne Connolly, of the Mayo Clinic in Scottsdale. “We’ve got a good percentage of the population out tanning by poolside.”
Researchers have made progress in the long-running effort to unravel the reasons certain cells go on such self-destructive rampages — abandoning the trillion-cell cooperation that makes life possible.
Some researchers have identified key genes whose mutation appears to clear the way for development of melanomas. National Institutes of Health researchers helped identify misfiring genes that regulate cell division in one group of melanoma-prone families with cancer risks hundreds of times above normal.
Such studies led researchers to basic discoveries about how the body normally regulates cell growth through the complex dance of proteins, hormones and neurotransmitters.
Sometimes the system breaks down — triggering cancer. Researchers have discovered that people who develop melanoma often have a defect in the gene that produces a protein called p16, which normally suppresses cell growth.
Researchers have helped lay bare a frightening process whereby the melanocytes, which give rise to melanoma, go bad. Melanocytes release a pigment called melanin that protects surrounding cells from sun damage — apparently by soaking up oxygen radicals. The melanin produces a nice tan when exposed to the sun, but some forms of melanin increase effects of sun damage. That might explain why blondes and redheads get more skin cancer.
Blondes like me.
Elissa circled about 13 odd-looking moles before I went into surgery for my second excision. The surgeon reluctantly agreed to remove them all. The second surgery was a lot easier — since doctors had discovered since my first operation that the cancer seemed no more likely to recur whether you took a 1 mm margin or a 5 mm margin.
None of the 13 moles the surgeon removed proved malignant, but the pathologist concluded that about four of them were “atypical” or “dysplastic” nevi — possible melanoma precursors.
The doctors assured me that the second mole was a second primary tumor, not a metestatic return of the first one. That’s good. The odds of survival after the early removal of a malignant mole are 95 percent, but drop off the cliff if the cancer reaches the bloodstream.
However, now that I’ve demonstrated my remarkable skill in growing malignant moles, I have a daunting 15-percent chance of spawning another one — compared to a less than 1-percent chance for a normal person.
I gained little comfort from interviewing an array of well-regarded dermatologists for this article. Some say that they always use magnification to look at moles, and think that any doctor who doesn’t is too lax. Some say they’re using a special scope that’s even better than magnification. Some say it’s a matter of a trained eye and good instincts.
They all describe suspect moles as being irregular in shape, asymmetric, variously colored, likely to change in size and outline, hairless, and sometimes scabbed or scaly.
Every time I get a doctor’s description, I subject myself to the mirror and find a couple of moles that seem to fit one or two of the criteria.
Of course, you can also get melanomas between your toes, in your inner ear, in your mouth, or other places never exposed to the sun.
Worse yet, some melanomas don’t have any pigment. And others begin at the surface, then fade away as they grope down into the skin — like the fin of a prowling shark only briefly rippling the surface.
I am not reassured.
I find myself staring at my arms sometimes, turning them over, studying the small brown dots of clustered melanocytes. Sometimes, they frighten me. Sometimes I expect them to ripple, like the victim’s chest the moment before the alien’s hideous head bursts out.
But more often, I marvel that cancer remains so rare. I watch in slow-motion amazement as cuts fade away, marveling at the precise coordination of trillions of cells.
And this is very twisted, but I sometimes catch myself admiring cancer cells. Imagine the audacity — to clutch at immortality, divide indefinitely, run rampant, ignore all the rules, and overwhelm all of the unimaginative, place-holding cells that surround you.
So now I live here at the uneasy boundary between vigilance and denial.
I do what I can: I wear a broad brimmed hat when I’m out in the desert, I’ve bought a long-sleeved watershirt made of parachute cloth for going in and out of the water, I slather on spf 15 sunscreen, I study my moles in the mirror, I heed Elissa’s gut instincts.
But it’s hard. I miss my denial — like the alcoholic his dark afternoons in a favorite bar.
So I live with it — amazed at my skin, grateful to my wife, and happy that I was given the gift of more time.
And this is odd — and probably not related. But my life is so much better since I got cancer.
I’m spending more time on the right things.
I’m much more clear about the reasons I love my wife.
And I cannot prove it — but it seems to me sunsets have more colors in them than before.
But then, perhaps it’s just me.