Squamous Cell Skin Cancers Can Kill

Skin CancerAs part of my office visits, I routinely question patients about health checkups and benchmarking. We talk about eye exams and glaucoma. We talk about women’s health issues and gynecologic exams plus mammograms and bone densitometry.  We talk about colon cancer screening and colonoscopies and immunochemical fecal occult blood slides.  We always ask about skin and whole body checkups with a dermatologist or a primary care physician.

Patients often ask me why I am constantly harping on looking at these issues. “I am old and have survived quite well without these checkups until now.”  

Florida is my home state and it is in the extreme Sun Belt and one of the skin cancer capitals of the world. MedPage Today, the University of Pennsylvania online journal justified my questions about skin cancer and skin exams by publishing a synopsis of Chrysalyne D. Schmults, MD and associates at Harvard University publication in the May issue of JAMA Dermatology.  They reviewed the pathology reports of skin cancer from Brigham and Women’s Hospital in Boston from 2000 through 2009 identifying 1,832 tumors in 985 patients. More than half of the patients were men, most were Caucasian and a suppressed immune system was present in almost 15%. Tumor diameter was less than 2cm (2.54 cm equal an inch) in 85%, was well differentiated in 66% and the tumor was limited to the upper skin level or dermis in 89.5%. The most common locations were the head and neck (28.7%), the legs or feet ( 23.7%), and the hands or arms in 21.6%. Treatment included standard excision in 69.5% and Moths Surgery in 20.2%

Analysis for spread to the lymph nodes, local recurrence, or death due to the disease directly or indirectly seemed to be related to certain factors.  Age over 70, male sex, poor tumor differentiation and perineural invasion all were considered poor risk factors. The death rate from the squamous cell skin cancer approached 3%

The data reviewed in this study will allow researchers to design evaluation and surveillance protocols for high risk skin cancer patients. Until now, no study actually defined what characteristics comprised a high risk skin cancer patient.  

As we head into the summer season it is a reminder of the need for us to use SPF 30 or greater sunscreen on all exposed areas and reapply liberally. Wear wide brimmed hats and clothing with a tight weave to protect your skin. Above all, see your board certified dermatologist for a whole body skin checkup regularly to prevent the growth and spread of a preventable killer disease.

There is no Way to Control the Cost of Care in the Last Few Months of Life

Sun and Wispy Clouds Over Mountains“J.T.” is 92 and clearly a soul who lives to the beat of a different drummer. She has no children and her closest relative is a niece who she despises. Despite this the niece oversees her care, sending in a full time aide and her personnel assistant to run the household. J.T. will not come to the office for a visit. If I call and make an appointment to see her in her home she at times will not permit me into her home. Despite her abrasive nature she is legally competent to make decisions and remains thin and frail but with no major acute medical problems. She is cognitively impaired to a moderate degree but legally competent to make decisions.  She too has executed a living will and has a large “Do Not Resuscitate” form posted on her refrigerator door.

Several months ago the niece called me to say her aunt was failing. She claimed she was ungroomed and refusing to bathe or eat. She said her hair was unkempt and nails long and filthy. She said she wasn’t eating.  She asked me to make a home visit.  I went out to the home with my nurse.

Upon arrival the patient at first did not want to let me in. I pleaded with her and she opened the door and invited us in. She was in a clean house coat. Her hair was wet having just gotten out of the shower. She was clean. The home was spotless. I asked her if I could have a cold drink so that I could get a look at the inside of her refrigerator. It was full of fresh food and beverages and was spotless. I asked to use the bathroom which was clean and spotless. The patient remarked that she had been under the weather the week before and had cancelled her weekly appointment at her nail salon.  I took a history, reviewed her medicines in their original pill bottles in the closet to check for accuracy and performed a brief but thorough exam. I pronounced her fit. We reviewed her end of life issues and choices with her and the aide. She said that if she got ill she would prefer not to go to the hospital unless I needed to send her to relieve pain and suffering.

Last month my office received a call from a new aide saying that the patient had fainted at the dining room table and was uninjured. By the time she got over to check on her she was up and coherent. The patient had no chest pain or breathing problems. She had no neurologic deficits. She had no visible seizure activity.  The aide called 911 before calling my office and the paramedics were there and were transporting her to the ER.  The patient did not want to go but the niece, who has power of attorney insisted that she go.  Upon arrival in the ER she was fine. A CT of the brain was performed upon arrival and was non-diagnostic as were her EKG and blood chemistries and electrolytes. This was all completed before my arrival. 

Upon my arrival I met the new aide.  She was quite glib and forceful. She told me she had been the caregiver for the niece’s mother. When the mother passed on several weeks ago, the niece had fired her aunt’s longtime aide and replaced her with her mother’s former care giver.

We kept the patient in the hospital overnight for observation. She was seen by a neurologist and by her own clinical cardiologist who had not seen her in three years since she became a recluse. By the next morning the patient was fine with all tests and scans normal.  I wrote discharge orders.   Two hours later I received a phone call from the floor nurse telling me that prior to discharge her heart rate had dropped to below 40 beats per minute without her suffering any symptoms of illness. The cardiologist suggested we keep the patient and have her seen by an electro physiologist for evaluation for a pacemaker. I called the niece to explain the change in plans and she actually accused me of keeping her aunt and suggesting a pacemaker to generate a higher bill.  I suggested we ask her aunt if she would consent to a pacemaker if she needed one. She said she would. 

The EPS physician did an evaluation and determined that the patient did not in fact need a pacemaker. We then planned to send her home again.  I set up a phone conference with the niece and caregiver and suggested that we return to the original plan of only calling 911 or moving the patient to the ER or hospital if we needed to for the relief of pain and suffering as originally planned.  The niece refused to follow that plan. She told me the aide didn’t want to stay in the house with a dying individual and she instructed the aide to call 911 whenever she felt it was appropriate. “I can’t have my aide watching my aunt die at home. “

The decision of the niece clearly is contrary to the wishes of her aunt. It is one more example of the public being unwilling to provide comfort measures at home and follow the guidelines outlined by their senior relatives when they were competent and able to make their choices. It is one more example of why we cannot keep the costs of end of life care in a reasonable range.