Sometimes, what’s always been done isn’t the right thing to do

“I did then what I knew how to do. Now that I know better, I do better”

Maya Angelou, author

The quote has face validity in life. In this case, it has a critical application in medicine.

The specific topic is Stage III melanoma, when skin cancer has spread to the lymph nodes. The traditional standard of care has been surgical removal of the lymph nodes. Unfortunately, as a new paper from researchers at the University of Colorado shows, that surgery doesn’t improve life expectancy over other treatments and often introduces complications.

Now that we have immunotherapy, patients with Stage III melanoma do better without the surgery than they do with it.(1) Not only can immunotherapy alone solve the immediate challenge from skin cancer but it also reduces the chance of recurrence more than lymph surgery does. In addition to the risk involved in normal surgeries (infections, incomplete cancer removal, etc.), removal of the lymph nodes “has a 20% to 30% risk of permanent lymphedema, potentially harmful tissue swelling caused by an accumulation of protein-rich fluid that’s usually drained through the body’s lymphatic system.”(2)

The basic point is that there is a relatively new and much easier and safer alternative to surgery that produces better results. Immunotherapy works for several types of cancers and is reportedly much easier to endure than either surgery or chemo.(3)

The problem is that a lot of doctors are wedded to the old ways.

“It takes years to change people’s practice patterns. I still have conversations with community surgeons who treat melanoma, asking me, ‘Should I be doing these regional node dissections?’ even though this data has been out for five to 10 years now,” McCarter continues. “They’re afraid to give up what they used to do, and they’re afraid that they are doing a disservice to the patients or not giving them the best chance, when in reality, our understanding of cancer biology has evolved. We now have effective immunotherapy, which is overcoming some of the limitations of surgery while improving outcomes.”

Martin McCarter, MD and professor of surgical oncology at the CU School of Medicine (2)

Bottom line: The burden is on the patient to seek out second, third and perhaps fourth opinions on the correct course of treatment. If one doctor automatically recommends surgery, you will want to talk to someone else.

While immunotherapy is a “tried and true” form of treatment, it’s only been around for a few years, and a lot of medical practitioners aren’t fully informed about it. Inevitably, there are also a few who are motivated by the fees they get for performing surgery. You need to be your own advocate.

I had a somewhat related experience from just before the Covid epidemic. I have a heart issue. Upon flunking an EEG and stress test, my doctor referred me to a heart specialist. I spoke to the doctor by phone and he instructed me to go to a hospital the following Monday so that he could place some stents in me.

He never examined me before ordering the surgery. His first time seeing me would be on the operating table.

I was suspicious that the problem had a different source, and started asking questions instead of following his instructions. When I asked questions, he stopped taking my phone calls.

That was four or five years ago. The surgery never happened and I’m still here, having survived a couple of intense rounds with Covid-19, both Alpha and Omicron versions.

Was I right not to follow the recommendation? Time will tell. But I don’t like being rushed into a surgery that’s clearly not a “time is of the essence” sort of thing. I want to know why something is recommended and the reasons why that is the best choice.

You need to know that as well.

If a doctor can’t or won’t explain his reasoning to you, you need a different doctor. Habit isn’t a valid answer.

And frankly, I saw my father endure a lingering death in a nursing home and I don’t want that for myself or my loved ones. If I can work until a heart attack abruptly takes me out, I’ll be a happy person.

Sources:

1. Robert J. Torphy, Chloe Friedman, Felix Ho, Laura D. Leonard, Daniel Thieu, Karl D. Lewis, Theresa M. Medina, William A. Robinson, Rene C. Gonzalez, Camille L. Stewart, Nicole Kounalakis, Martin D. McCarter, Ana Gleisner. Adjuvant Therapy for Stage III Melanoma Without Immediate Completion Lymph Node Dissection. Annals of Surgical Oncology, 2021; 29 (2): 806 DOI: 10.1245/s10434-021-10775-8
2. University of Colorado Anschutz Medical Campus. “Changing the standard of care for stage III melanoma surgery.” ScienceDaily. ScienceDaily, 4 March 2022. www.sciencedaily.com/releases/2022/03/220304124017.htm
3. https://www.cancer.gov/about-cancer/treatment/types/immunotherapy

Yep, that’s rather what my surgery would have resembled.