Melanoma: thoughts from a dermatologist

You’ve already heard the message: melanoma is deadly. You probably also know that it is the fastest growing cancer in the United States and that an American dies every hour from melanoma. Millimeter by millimeter, it is the deadliest cancer. Rather than bore you with statistics on this horrible disease, let me share with you some fascinating background information that you may not have heard before.

There are few historical accounts of melanoma. It was not officially recognized as a disease until 1806 in France. Several years earlier, in 1787, a perplexed Scottish surgeon named John Hunter was faced with a large black growth on the jaw of a thirty-five-year-old man. He described it as a “cancerous fungus.” Not knowing what it was, he did what surgeons do: he cut it off. Surprisingly, it wasn’t until 1968 that someone first looked at it under a microscope and confirmed that it was melanoma. It had been kept all this time in the Hunterian Museum at the Royal College of Surgeons of England in London and can still be seen today, I was told. The patient evidently sought out Dr. Hunter a few years later for a growth recurrence in the same location. In a drunken fight he was beaten with a stick and the “soft black mass” returned. The fate of the patient is lost to history. But we do know that it was highly unlikely that her melanoma would return due to the beating she received.

Since then, there has been no shortage of melanoma. It may surprise you to learn that many of the leading melanoma researchers are based in Australia, not the U.S. In the 1870s, the British government established an Australian penal colony and sentenced criminals to live there for days with kangaroos. The forced emigration of pasty white English inmates to the sunny continent has sparked a melanoma epidemic several generations later. Australia has the distinction of being the melanoma capital of the world. However, we are not far behind. In 1935 it was estimated that only one in 1500-2000 Americans would develop melanoma. Several decades of bikinis and tanning salons later, the rate is now 1 in 65 and is getting worse every year. Now predictions are being made for 1 in 33 of us in the near future; a staggering increase.

Interestingly, melanoma is one of the few diseases that I can name that tends to disproportionately affect people from higher socioeconomic groups. This is believed to be because disposable income drives families to equatorial destinations for vacations. Cancun and Florida vacations equate to short but intense periods of sun exposure – exactly the same exposure you get from a tanning bed. All those high school girls who tanned for prom in the 80s and 90s are thought to explain the skyrocketing rates of melanoma we’re seeing in women under 40 today. Along with breast and thyroid cancer, melanoma is one of the most common cancers in young women. If you watch Grey’s Anatomy, you know that one of your favorite main characters (a blonde in her thirties) died of melanoma a few seasons ago. Although I don’t normally pay much attention to such shows, I applaud the writers’ efforts to raise awareness on this topic. Governor Brown just banned the use of tanning beds for those under the age of 18 in recognition of the link between ultraviolet light and melanoma.

However, tanning is not the only cause of melanoma. If only this horrible disease were that simple. Genetics play an equally sinister role in this story. We have known for a long time that if you have melanoma, your first degree relative is much more likely to get melanoma as well. Many of the new treatments specifically target various genetic mutations and genes associated with melanoma. Genes shared with pancreatic cancer and possibly even some forms of breast cancer are now being studied. But the tan is not resolved. If someone’s genetic makeup is dry cornfield, the tan is phosphorous and kerosene.

When it comes to mammalian skin, human skin in general is a mess. It offers practically no protection from the sun. Even very dark African American skin has only a natural SPF of around 13-20. Pigskin is the closest equivalent to human skin in its composition and organization. Surgical trainees usually begin their studies by operating and sewing pig’s feet and we still sometimes use pigskin grafts when necessary. It has been said: “Also like humans, pigs enjoy lying in the sun, tanning in response to the sun, and they enjoy drinking large amounts of beer.”

Now, to bore you with a little scientific training: the melanocyte is a cell in our skin that produces our color. Melanoma is the uncontrolled growth of melanocytes. One bad mutation begets two. So two beget four. Four begets sixteen, and so on. The normal melanocyte looks like an octopus and produces the pigment in our skin. Its long tentacles deliver the pigment (melanin) to the other cells of the skin. The purpose is to protect the other skin cells from sun damage by absorbing the sun’s rays. When you tan, the melanocytes speed up production to make more of this shield. When you see the tan, you know that DNA damage has occurred in skin cells. That is why I like to think of a tan as if the tears of the melanocytes were crying on their neighboring cells.

We are in the midst of a skin cancer epidemic with no end in sight. While most skin cancers are not life threatening, they can require extensive surgery and cause deformities that need surgical correction. However, melanoma is a different story. Fortunately, the northern state boasts a stellar collection of expert dermatologists and surgeons. While it is almost 100% curable if caught early, melanoma has a dismal survival rate once it spreads beyond the skin and into other organs. There is no definitive cure. (please read that last statement again)

Until recent years, we have fared no better in treating advanced melanoma than Dr. Hunter in 1787. The lack of progress in nearly 225 years embarrasses me as a dermatologist. Now the line of research is full of treatments to come. A melanoma vaccine paved the way and has been studied extensively, but has yet to live up to expectations. A recent revolutionary drug turns the immune system against melanoma cells. Unfortunately for the British, it has been rejected by England’s national health care panel as not being profitable for their society. The drug has a three-year survival rate of 20% (or in other words, 80% of people with metastatic melanoma who take it will die within three years). At $ 120,000 per patient per year, it certainly raises many philosophical and ethical dilemmas. Fortunately, there are many other promising new treatments on the horizon. Hopefully they are more reasonably priced.

If you or someone you know has metastatic melanoma, talk to your doctor about joining a study. Gone are the days when you will be randomly selected to receive the study drug or sentenced to unknowingly receiving the sham placebo treatment. I have several advanced melanoma patients who are doing quite well in some studies so far. It also gives his suffering meaning and a chance to fight back. While preparing this article, I realized that perhaps no other cell in the body has been responsible for more misery in humanity than the melanocyte. Historically, the functions of your melanocytes could doom you to a life of slavery, limit your martial prospects, curb your economic potential, or simply make you drink from a different water source.

In conclusion, I encourage everyone to see a dermatologist for a complete skin exam. You may say to yourself, “My moles look good. Nothing has changed.” To which he asked: “Would you bet your life on it?”