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 It's OK to question your doctor
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1 Posts

Posted - 10/04/2007 :  14:51:56  Show Profile  Reply with Quote
About a year ago I noticed am unusual spot on the tip of my nose. I went on the Internet and researched skin cancer, found an exact description and photo that matched - shiny, blister-like but firm with tiny speck of blood on occasion. Went to skin clinic, saw a P.A. who said it was actinic keratosis and froze it off. I went home happy. Went for follow-up appt 30 days later, saw a dermatologist this time and he said it looked normal to him and to come back in a year. Again went home happy. 2 months later I noticed same look - shiny, tiny speck of blood - and went back. Saw plastic surgeon this time. He said looked normal to him. I said .... "humor an old lady, do a biopsy." Although obviously very angry that I questioned his authority and knowledge, he did the biopsy. It came back positive for basal cell carcinoma. Am I wrong to be angry that an old woman with no medical training or knowledge but with the help of the Internet was able to make an accurate diagnosis when a P.A., a Dermatologist AND a Plastic Surgeon were unable to do the same? Later I realize that this is a practice that favors doing cosmetic treatments (botox, breast augmentation, etc.) over skin cancer.

Edited by - anivoc on 10/30/2007 08:45:48


637 Posts

Posted - 10/30/2007 :  08:52:01  Show Profile  Reply with Quote
Hi Lola,

I felt this topic deserved sticky status.

Here's a link to an interesting web page by a Dermatologist. The topic is False treatments and identifies that most Derms don't follow the letter of the law in treatment. I can sure attest to that with cryo I have had with multiple Derms.

Though dated on the laser information,It's a good read. My favorite line in this is the question "What do they call the person that graduates with the lowest grade in medical school? The answer is: "Doctor!"

Here's the text "just in case" the link goes bad at some point:
The fact that a doctor gives a patient a particular treatment does not mean that the treatment was performed properly. With skin cancer, an improper attempt at removal can cause a worse outcome than not treating the problem at all. For our purposes, a false treatment may be fake or inadequate treatment or a treatment performed by a fake or an impostor to the profession. Improperly trained doctors may provide false treatments inadvertently. Other false treatments may occur when a doctor does a standard and true treatment based upon a false need. We will address this issue first.

An early October, 1998, an ABC News 20/20 Special showed a New York dermatologist who was using ultraviolet photography to make pictures of patients, mostly younger women. Ultraviolet photography shows mostly pigment and pigment cell irregularities and is absolutely no substitute for a good old-fashioned clinical skin examination with nearsightedness or magnification. Ultraviolet photography rarely can identify precancers or even basal-cell or squamous-cell cancers, but it does show pigment irregularities. Yes, sun damage does cause pigment irregularities which can result from sun damage. Many times these cannot be seen with the naked eye. In patients who do not show much sun damage to a dermatologist's trained naked eye, this pigment irregularity is mostly meaningless and not harmful at all.

Nonetheless, ultraviolet photographs of mostly fair-skinned women who went in the sun even just a bit showed tremendous gross disfiguring black speckling of their faces. The patients and the TV viewers were shocked to know "they had this much sun damage." Even though the photography seemed like a waste of patient's time and money, the website author thought if it encouraged patients to use more sunscreen, then maybe it was a good idea. However, following the commercial break, ABC News showed the lady dermatologist using LASER surgery to treat the patients who had "bad" ultraviolet photographs. After the laser treatment, the patients were photographed by ultraviolet camera, which of course look improved. The ultraviolet photos show only the most superficial problems in the most superficial epidermis which is removed by the treatment. What the treating doctor did not mention is that abnormal cells hidden in the hair pores come to repopulate the surface tissues over a period of months and that without much sunscreen, skin bleaching agents and sun avoidance the "spots" come back and would provide a similar photographic result.

Why was this particular LASER surgery in combination with the promotion by ultraviolet photography "suspect"?

First, most practicing dermatologists and university professors of dermatology will agree that ultraviolet photography is not a good screening tool either for skin cancer or for precancer. Ultraviolet photography is just a tool for showing whether there has been some past sun exposure. It is merely a teaching tool to encourage the patient to be more careful in the sun. The "damage" does not even have to be significant to show up in the photo.

Second, laser surgery is not currently a first line, nor even second line, treatment for precancers. This is because precancer cells can hide deeper in hair pores than the laser reaches. Precancer cells frequently return following laser surgery, growing out of pores or even out of some wrinkles. Precancers and the cells that really count in our health exist, in part, much deeper in the skin than even a deep carbon-dioxide laser can reach, which is why precancers frequently return soon after even deep laser surgery.

Third, because even the deep penetrating carbon-dioxide lasers are somewhat ineffective on precancers while probably the most expensive treatment of all those available, this dermatologist is doubly "ripping off" her patients. This is especially true if the laser is used under false pretenses to treat the "damage" seen on the ultraviolet photos.

Fourth, anything but the mildest laser risks scarring and causing even more pigment abnormalities. Consider that even a mild, superficial, mostly surface laser treatment, which is even less effective in treating precancer, wrinkling and anything more than mild pigment irregularities, places a patient at risk for scarring to treat a "problem" that is not even a true medical problem.

Sometimes seeking the most modern treatment or experience succeeds only in exposing oneself to the most modern scam. Even intelligent reporters from the media can easily be misled. Unfortunately, some doctors will do anything for money, and they can even be legitimized on national TV. Caveat emptor, let the buyer beware!

The next example of a false treatment features a middle aged lady came to the website author saying that she had had Mohs Surgery of the nose performed by the respected head of a northern U.S. University. The website author took a biopsy and found that the cancer had returned (another way of saying it was not cured the first time) in the middle of a scar on her nose. She was extremely unhappy with the cosmetic result of the surgery performed at the northern university. She at first refused to believe that the tumor had recurred (come back), because her doctor had used Mohs Surgery and was head of the department of this particular northern university. The website author immediately showed the patient the annual American College of Mohs Surgery membership catalogue and the patient discovered that this northern doctor was not and had never been a member. She then agreed that she could not say that true Mohs Surgery had failed since the doctor may never have been sufficiently trained to do the Mohs procedure.

In Broward County, Florida there are only about five certified Mohs Surgeons of the American College of Mohs Micrographic Surgery and Cutaneous Oncology; however more than 20 other doctors in the county are billing for performing Mohs Surgery. Many of these doctors are, of course, not performing the procedure up to proper standards, because they were not properly trained. Unfortunately, the Florida Department of Professional Regulation is unable to stop the other 15 or so. When the tumors treated by the 15 or so impostors return, the Mohs procedure is blamed. But did these patients even have real Mohs Surgery? One thing is for sure. As of 1997, there are no Board Certified Plastic Surgeons officially trained in Mohs Surgery, which would give them membership in the American College of Mohs Micrographic Surgery and Cutaneous Oncology. This is one criterion that makes it easy to see if a patient received what he/she was "billed for."

Sometimes treatments don't work because unqualified doctors perform the treatments. Not every doctor can be good at everything. What do they call the person that graduates with the lowest grade in medical school? The answer is: "Doctor!"

Other false treatments occur when 5-fluorouracil is applied in a fashion different from the one that was tested for FDA approval, i.e., the one on the label for extensive precancers. Some doctors have modified the traditional approved 5-fluorouracil treatment without even comparing their new proposed treatment with the traditional tested treatments using simple standard scientific methods. See Treating Precancers.

A common improper or false treatment may occur when the doctor treating a skin cancer with the cryosurgery (liquid nitrogen) method does not also freeze a margin beyond the tumor to create an adequate ice ball time (freeze-thaw time which should be 90 seconds, in most instances). Many times, the doctor is afraid of producing a scar. However, in the case of liquid-nitrogen surgery for cancers, treating to the level recommended by the medical textbooks, almost always results in a scar. Another example of inadequate treatment is that a patient may not have received proper scraping and burning of a skin cancer if the treating doctor removes only the epidermis in the zone of the cancer.

False treatments can occur when some surgeons cut too close to the edge of a melanoma or mole without taking sufficient extra, buffer, or normal skin to obtain a good cure rate, in an effort to keep the scar small. Plastic Surgeons often make this mistake, possibly due to their more limited education regarding the biology and microscopy of skin cancer. Taking a proper 1cm (1/3 of an inch) margin (border of normal tissue) can cure 95%+ of thin melanoma patients, whereas taking only half that margin may produce only an 85% cure rate. That means too little margin kills three times as many patients (15% divided by 5%) within five years. No patient should like to be part of the 10% difference (85% subtracted from 95%) just because a surgeon who took too little tissue to have an easier job or to get a smaller scar which usually gets more referrals. To understand the logic of this statement, see Mole Biopsy & Removal, as well as Melanoma.

Edited by - anivoc on 10/01/2008 12:14:12
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5 Posts

Posted - 11/29/2007 :  09:23:20  Show Profile  Reply with Quote
I have a long history of BCC and mostly removed by Mohs. Lately I have had some removed by a plastic surgeon and I am looking for an alternate solution. The latest lesion is on my nose and was biop. and came back positive. I have been using efudex for a little over a week and see some action. I have used it before on other lesions but quit after only a couple of days. My question is how long should I use it and how can I tell if the cancer is gone. Help would be appreciated. Joart
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4 Posts

Posted - 08/21/2009 :  12:44:30  Show Profile  Reply with Quote
Lola, Good for you for insisting on a biopsy!!! I had a BCC scraped off my back for biopsy after the derm told me it was precancer and she was just going to freeze it off. I insisted on biopsy and she then scraped it off and sent it in. Called me two days later with results and told me "you were right my dear". Always insist, if you have to, and find a new doctor until you get the treatment that you deserve.
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Disclaimer: The three most common types of skin cancer are basal cell carcinoma, squamous cell carcinoma, and melanoma. While melanoma is the most dangerous type, keep in mind that any cancer and potentially some cancer treatments can cause injury or death. The various views expressed in these public forums should not be considered as medical advice. See your qualified health-care professional for medical attention, advice, diagnosis, and treatments.