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.

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 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.

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