A 34-year-old woman presents to her primary care provider to “have her moles checked.” She is motivated by a family history of sun-caused skin cancers, as well as her own history of multiple sunburns as a child.
Noting the patient’s fair, freckled skin, red hair, and blue eyes, the primary care provider agrees with the patient’s assessment of her risk. One lesion stands out from the rest: a 1.5-cm dark, irregularly bordered, and pigmented maculopapular lesion on the patient’s right triceps. The primary care provider arranges for a timely referral to dermatology.
The dermatology clinicians know immediately that the triceps lesion is highly suspicious, and tell the patient so while setting up for biopsy. Before that procedure is carried out, a careful examination of all exposed skin is conducted. The patient’s fair, sun-damaged skin is again noted, but no other suspicious lesions are found. There are no palpable nodes detected on her right axilla.
Under local anesthesia (1% lidocaine with epinephrine), the right triceps lesion is removed by deep saucerization (through the deep dermis into the upper adipose layer) using a double-edged razor. Minor bleeding is controlled with light cautery.
The pathology report, received three days later, confirms the malignant nature of the lesion, with a diagnosis of invasive melanoma (nodular, with no horizontal growth phase), measuring 1.7 mm. Fortunately, no other ominous signs—such as a high mitotic rate or vascular invasion—are reported.
The patient is immediately contacted by phone and notified of the results. The potential danger of this diagnosis is reiterated, along with information regarding the next steps in the process. These include consultation with a surgeon for consideration of re-excision and possible lymph node dissection. Evaluation by an oncologist will likely follow.
The patient’s response to this news is puzzling, to say the least. Though she appears to understand what she is being told, she sounds blissfully unconcerned, saying she is “not that worried” and is sure she will “be just fine.”
There are patients newly diagnosed with melanoma who overreact. I’ve had patients hop on the next plane to the Mayo Clinic, or, as in one notable case, to Tijuana, which, as we all know, is the home of such questionable practices as coffee-ground enemas and chemically modified amygdalin.
But then there are melanoma patients who go to the other extreme, making us wonder if they really understand the potential seriousness of the situation. It’s not that we want to see any particular “angst” as a reaction, but an appropriate indication or two is reassuring as feedback to the announcement. Questions— “What does this mean?” “What’s going to happen now?” “How serious is this?”— are good to hear in this regard. The answers allow us to convey the sense of where the patient stands, both for the present and in the long term, and help us to get a sense of how well the patient perceives the situation.
This patient had no questions, at all, as if she was totally unconcerned. That concerned me. It left me with a number of questions: “Does she really understand what’s going on?” “Will she follow our instructions and see the specialists we advise her to see?” Over the years, I’ve had several patients like this who went on their merry way, doing nothing we suggested. Some even survived.
This lack of appropriate reaction has been termed la belle indifference. It’s a way of pretending nothing is happening, and represents a way of showing one’s paralysis to others by manipulating their judgment through an attitude of indifference. One doesn’t want to frighten these patients (“Don’t you know this could be fatal?”), so what I do is keep close tabs on them—calling them regularly, making sure they’re following our advice, and documenting our calls and the patient’s responses. When family members can be enlisted to help, so much the better.
So far, this patient is complying with our advice, but it’s early in the process yet. We’ll see. Our job—and her ordeal—is far from done.
Any melanoma over 1 mm in thickness (based on the Breslow scale) is associated with an uncertain prognosis, and nodular melanomas are associated with a relatively poor prognosis. Besides re-excision (probably with 1-cm margins), this patient will probably be a candidate for elective lymph node dissection in the right axilla. PET scans, blood tests, and a visit to the oncologist will most likely follow. The surgeon usually acts as decision-maker in terms of what the patient needs and in what sequence.
Even if she survives all that, this patient will still need to see us every three months or so for a year, then regularly thereafter, to monitor this cancer and watch for new ones.
• Deep-shave biopsy (sometimes called saucerization) is an appropriate technique for possible melanoma.
• About 75% to 80% of all melanomas are superficial, spreading types, (essentially flat), while 10% or so have only a vertical phase of growth (ie, present as a nodule or mass).
• Survival rates for melanoma are closely tied to tumor thickness, which is most commonly measured (by the pathologist) in millimeters; this staging system is called the Breslow scale. The older system of staging melanoma by the anatomical depth (called the Clark’s level I-V) has fallen into disuse.
• Underreaction to the diagnosis of melanoma (la belle indifference) can be as problematic as overreaction. Consistent monitoring of patients for compliance is often necessary.