Is It Cancer Yet?
When it's hard to take "yes" for an answer
Posted Jun 22, 2014
A common visit in my office:
“What’s that bump on my back, Doc?”
“It’s a cyst. Just a ball of tissue under the skin, nothing to worry about. You can remove it if it bothers you.”
“Can it ever turn into something bad?”
“No. It can never become cancerous.”
“No, it can never become cancer.”
I examine the rest of the body, we talk about this and that. Just before it’s time to go, the patient frowns. “Just one thing, Doc.”
“Sure. What is it?”
“That cyst on my back. It can’t ever turn into cancer, can it?”
I hear questions like this all the time: about cysts, moles, and any number of spots, bumps, and blemishes that skin develops over time, starting with birth. Most of these are not dangerous and won’t ever become dangerous. So why do patients keep asking over and over whether these spots are safe? Why is it so hard to take “Yes” for an answer?
Here too, patients and doctors think differently about the same things. Doctors divide the world of growths into “benign” or “malignant,” but to patients, growths are either “malignant” or “not yet malignant.” In other words, reassurance that a mole or a cyst is OK is fine, but only provisional. It’s OK now. But what about tomorrow or the week after next?
This is a tricky point. It’s true that in some cases—like certain moles—it’s hard to say with total certainty that they might not change some day. But that’s a rare situation Everybody has moles, ranging from a few to many dozen. Then there are cysts, keratoses (those ugly barnacles that come with age), fibromas, blood vessel collections—any number of blemishes we collect over a lifetime. Doctors have to be able to declare the vast majority of these benign—permanently. We can’t very well take them all off just to be sure.
Yet patients sometimes think we should, especially if they are nervous types, or if family members have had cancer, or they just heard a horror story about somebody’s mole that broke bad. (Such stories, by the way, are often distorted—the “mole” that supposedly “turned” might have been a cancer all along.)
To patients, every spot is a sign of instability. Babies start life with clear, even skin. Then imperfections show up. These weren’t there before and now they are—that’s a change, isn’t it? And isn’t a “changing mole” something we should be careful about?
The challenge for doctors is to be prudent but not paranoid. So when a patient asks whether a worrisome spot is OK—for a skin doctor that happens many times every working day—I say, “Your mole (or cyst, or whatever) is fine.” Then I pause, for effect, and add, “And it will always be fine.”
The patient often stops a moment to let this sink in. Then his eyes widen, and he says, “Oh! I didn’t know that!”
And then, just to be sure, he asks again….