Expert: Karen Brawner - 7/30/2004

Question
Hello Karen,
I am preparing for a possible visit to a dermatologist regarding a red spot on my upper chest. I am thinking that I do not want any treatment for a condition that is diagnosed as pre-cancerous or cancerous without a biopsy. Question 1: Is this reasonable and fair?

I am asking because about four years ago I had a small red spot on my forearm. A dermatologist looked at it, declared it to be actinic keratosis (AK), and sprayed it with liquid nitrogen. I was very uncomfortable that no biopsy was performed. I became even more uncomfortable when I later learned that some doctors believe that “it can be difficult to almost impossible to distinguish an AK from a squamous cell carcinoma (SCC) without doing a skin biopsy.” Perhaps that dermatologist was right to skip the biopsy since I've seen no additional brown or red spots in that area, but this time I want to be better prepared and more involved in the decisions about my treatment.

Questions 2-3: Is it possible for the dermatologist to recommend surgery with a biopsy performed after the surgery? Can this be the best way to go, as opposed to biopsy followed by surgery?

Question 4: Have I missed the most important questions to ask? I will appreciate any suggestions for questions and, if the dermatologist indicates I may have skin cancer, a list of procedures to seek.

P.S. Just in case it makes a difference in the questions I should ask and the procedures I should seek, here is more info about the red spot. (Important: I am not looking for a diagnosis here.) I discovered the red spot (about 1/8” wide, 1/4” high) on my upper chest about a week ago. It looks like pictures of superficial basal cell skin cancer (and some pictures of squamous cell skin cancer). It is flat and has a sightly-raised, scalloped border with a smooth, shiny surface. No pain, no itch. I have treated it daily with Neosporin, alcohol, and Lamisil, but it is not significantly different. I fit the profile of people at high risk for skin cancer: super white skin that does not tan, at least three severe sunburns when young, now 63 years old.

FYI, I am asking 3-4 other experts this same question.

Answer
Dear Jann,   You as the patient can demand or refuse any type of treatment you do not want or do want....

Most dermatologist can look at a lesion and know if it is cancerous or not....  However, I have learned that no matter what type of lesion I have (even a wart etc) I want it surgically removed and biopsied...  I take no doctor at their word and therefore, any lesion or lump I have, is always removed and biopsied....  This can be done right in the dermatologists office with local anesthesia, cutting to remove the entire lesion and then stitches to close it...  I have a wart done this way by my family doctor, who told me it was probably just a wart, but it didn't act like a common wart to me and that is why I had her cut it out and send it off for biopsy....  It was just a wart and not pre-cancerous or cancer, but I believe in better safe than sorry....  So my answer to your FIRST QUESTION is, I do not believe in freezing or cortorizing anything...  Cut it out and send it for biopsy.....

Question TWO and THREE my answer is surgical removal of the lesion or lump or bump (what ever you want to call it) is first, then sending it away for biopsy next, and if it were to come back as pre-cancer or cancer the pathologist would then tell the doctor if the sample lision had "clean borders" and if not, then more surgery would be needed to get rid of the rest of the cancerous tissue and another biopsy would be needed to be sure that this sample had "clean borders"...

Question FOUR is you have listed here very good questions to ask or tell your doctor...  Remember, you are the patient and you have rights regarding your TYPE of treatment (surgery and biopsy as opposed to freezing or burning a lesion) and if this doctor will not do surgery and biopsy as you wish, then leave and find one who will....  Since you are the patient, you have the right to choose your own course of investigation into this lesion and what it truely is based on a biopsy and not what some doctor THINKS is MAY be....  As for a list of possible treatments, I can not give you that information at this point....  The reason is because the different types of skin cancer, the staging of the skin cancer etc actually determine the type of treatment required....  Once you see the dermatologist, get the surgery to remove this lesion and get the biopsy report and it says exactly what this lesion is, then I can help you more with treatment or interpretation of the reports.....

Regarding your P.S. comments....  Based on what you have said, this could be a basal cell carcinoma or a squamous cell carcinoma either one....  Yes, you are more at risk for development of skin cancer based on your light complexion, prior sunburns and your age....  With this in mind, stick to your guns and DEMAND that this be surgically removed and sent out for biopsy....  Like I said earlier, if this dermatologist will not or does not want to do this, then find a doctor who will....  Even a family doctor will often remove skin lesions and then it is cancer, based on biopsy, will then send you to a surgeon or dermatologist/surgeon if more extraction is needed to get "clean borders".....

I hope I have help you in some way and if you have more questions, just feel free to ask....

Thank you,   karen