Scenario
An Australian presents with a skin cancer.
Tasks
- List the recreation-related cancers.
- Describe the decisions facing patient and doctors in selecting therapy for this skin cancer.
Opinion
The Wikipedia definition of recreation is "expenditure of time in a manner designed for therapeutic refreshment of one's body or mind", and provides a long list, including Art, Computer games, Cycling, Dancing, Drawing, Eating and drinking, Hobbies, Hunting and fishing, Kite flying, Music, Martial arts, Partying, Pet ownership, Reading a book, Recreational drug use, Sexuality and Dating, Sledding, Shopping, Singing, Sports and exercise, Travel and tourism, Texting, Using the internet, Video games, Visiting an amusement park, Watching movies, Yoga, Painting and the more recent skiing, snowboarding, bungee jumping, sky diving, hang gliding, paintball, rock climbing, backpacking, canyoning, caving, BASE jumping, adventure tourism and motor sport.
I suppose that some aspects are controversial,but below is a list of the recreation-related cancers:
| sun baking | skin cancers - basal cell carcinoma in the glasses line, squamous cell carcinoma, melanoma, Merkel cell carcinoma |
| alcohol drinking | elevates risk of smoking cancers; hepatocellular carcinoma in cirrhosis |
| smoking | lung, Head & Neck, Oesophagus, Bladder |
| betel nut chewing | mouth cancer - actually its not betel nut by itself, its betel nut WITH slaked lime |
| Sexuality and Dating | cervix cancer (risk factors are identical to STIs) |
| Recreational Drug use | viral infections HIV - lymphoma (cerebral and non-cerebral), Kaposi's (not really with the drug user variety though) HCV/HBV - hepatocellular carcinoma |
| Leather dyeing | Aniline dyes - Bladder cancer (but usually a lengthy and substantial exposure is needed) |
| Travel and Tourism | dose of HPV if indiscriminate, but then how do you be discriminate in this case unless you take a testing kit with you? |
The Skin Cancer
Our patient demonstrates what can only be called an IMPRESSIVE skin cancer on the right shoulder. The question is what to do? And how much morbidity is going to be incurred.
Firstly the lesion doesn't have a raised rolled edge to suggest that it is a BCC, or pigmentation to be a melanoma, so the assumption is that this is a SCC - and that assumption is correct. To rid the patient of this disease there are two available stratgies with some minor modifications and sequencing issues. All of these options have to be factored into the patient's condition. What's the point of advising surgery if the guy gets angina when he thinks about changing his mind? Fortunately, this bloke is young and fit.
What? WHAT? How could this get to this size? Here it is easy to be high and mighty about timing, but let me ask - when did you start studying for your HSC? Were you what my old principal called a "Jacaranda student"? (blossoms in September!) While some of us are obsessive compulsive hypochondriacal perseverators, others have a more laid back attitude to health. But I agree this one was a bit more than 'laid back'. So why? We see similar circumstances in breast cancer also. I personally think that there is a spiritual dimension here that harks back to the creation story where naming of animals conferred power. Sometimes I think that some people think that if no-one has said the C word, it's not the Big C.
But enough of that. The options to rid the cancer is two fold - surgery or radiotherapy. Chemotherapy, hormone therapy, immunotherapy and "morning spit on the left breast" (or any other form of alternate therapy) also will have no lasting impact on this. He is not suffering from an immune deficiency, or vitamin deficiency, so replacement or system-tarter-ups won't work either.
There is an issue of using chemotherapy concurrent with radiotherapy though.
The issue of which to use first is determined by how far the tumour has extended and what operation is required. If a local (or should that be suburban?) excision is possible because there is minimal infiltration, then that's the way to go. However, if it is infiltrating the shoulder and the opinion is for a forequarter dissection, then primary radiotherapy might be a more preferable starting point. Particularly if a local recurrence after the radiotherapy will see a forequarter dissection anyway. Life with an arm will be preferable to life without an arm.
But the initial surgery should aim for complete extirpation of the tumour, not debulking or such like. Cancers is not like love, it is always more difficult to cure the second time around.
A later problem with this fellow is going to be the likelihood of him attending follow up.
