I. Intro and hello

II. Rohit Sharma, MD, FACS

III. Sunscreens - thorough explanation of the ins/outs of sprays, lotions, creams for cancer prevention; rash guard clothing; wide brimmed hats; collective measures. 

IV. Moles and blemishes: bad and good.

V. Interpreting the biopsy report 

VI. Tumor thickness and surgical margins

VII. Lymph nodes and “Sentinel lymph node biopsy.”

VIII. Horizontal and vertical growth phases; four types of melanoma.

IX. How to talk skin with your General Practice Physician or Clinician.

X. Staging the disease: Local, Regional, Metastatic.

XI. Impact and utilization of Immunotherapy & Targeted Therapies.

XII. Predicted survival of different Melanoma stages

XIII. How do I self-advocate?

XIV.  Clinical Trials explained

XV. Closing and Thank you

Key takeaways:

1. Ounce of prevention… learn your sunscreen options, how they complement one another, and use them from childhood on!

       2. Moles that are uniform and unchanging are safer; moles that are irregular and changing are more dangerous

       3.  Thicker and ulcerated melanomas are more problematic

       4.  In certain patients, harvesting a sentinel lymph node gives important prognostic and treatment-related information.

       5.  Be clear and upfront with your doctor about your moles and blemishes

       6.  New types of treatments exist that are powerful and important.

       7.  Stick with established, well-known websites (such as American Cancer Society) when starting your self-education on Melanoma

       8. Clinical Trials are fundamental to the advancement of Medicine, but they may or may not be what you’re looking for

1. R6tul3mxsjVJhOqCSBHV

paul_roach:

Hello and welcome back to SoDoc. It's Cancer, a podcast to understand cancer, how it happens, how it's treated, how we arrive at a diagnosis and a prognosis, cancer's impact upon a person's quality of life, and how to move forward in life after a cancer diagnosis. The show airs monthly, and we welcome your engagement and feedback. This month from the regulars, it's just Mike and Paul. Peter and Courtney were out this month. and uh...

michael:

But we have

paul_roach:

and

michael:

an irregular.

paul_roach:

uh... yeah and uh... and we decided we ought to get professional get a disclaimer so uh... we hired a expensive new york lawyer and this is what we came up with the opinions and ideas expressed in this podcast are for informational purposes only and are not meant to drive specific clinical decisions for that you'll need to be seen by your physician receiving individualized approach to whatever your diagnosis might be Actually, I just made that one up myself. I didn't hire a lawyer. I hope that's okay. So today's guest is Rohit Sharma, MD, FACS, a really dear friend of mine from fellowship, and we're excited. We're gonna be talking about malignant melanoma. And

michael:

Aw.

paul_roach:

Rohit, if you would just introduce yourself to the audience, and we'll just learn a little bit about you, like where you're from and where you grew up and things like that.

Rohit Sharma:

Thanks Paul and Mike for having me. I'm really honored to be here with you. And I think this is a wonderful thing that you guys are doing with this podcast.

michael:

Paul's calling time out. Time out on the field. Luckily

paul_roach:

I...

michael:

this is all editable.

paul_roach:

Oh. I don't know if it was me, but I couldn't hear anything.

Rohit Sharma:

Can

paul_roach:

I can

Rohit Sharma:

you hear

paul_roach:

edit

Rohit Sharma:

me?

paul_roach:

all that out.

Rohit Sharma:

Can you hear me or no?

paul_roach:

Yeah, I think

michael:

Yeah,

paul_roach:

it was

michael:

I

paul_roach:

actually

michael:

can hear you

paul_roach:

a

michael:

fine.

paul_roach:

chord.

michael:

Paul.

paul_roach:

I think it was the chord here.

michael:

Paul's

paul_roach:

I'm

michael:

an

paul_roach:

sorry.

michael:

excellent

paul_roach:

All of

michael:

doctor.

paul_roach:

a sudden I couldn't hear a single thing. And I can't hear it now.

Rohit Sharma:

Oh my god, are you serious?

paul_roach:

Alright, maybe now I can.

michael:

Testing, testing,

Rohit Sharma:

Are

michael:

one,

Rohit Sharma:

you able

michael:

two,

Rohit Sharma:

to

michael:

Paul.

Rohit Sharma:

hear us?

paul_roach:

Yeah, but I don't know why it would come in and come out, but now I can hear you. All right. So Ro...

michael:

For you, that might be your push your cord all the way in and check the cords aren't pinched.

paul_roach:

My buttocks are pinched.

Rohit Sharma:

Hahaha

michael:

Well, since I've known you.

Rohit Sharma:

Ha ha.

paul_roach:

Alright, alright, I straightened out the chord and it's

Rohit Sharma:

Alright.

paul_roach:

pushed in. Alright, so row hit,

Rohit Sharma:

Okay.

paul_roach:

go for it.

Rohit Sharma:

All right, so Paul and Mike, thank you so much for having me. It's really an honor to be here with you guys. I wanna compliment you first and foremost for this idea of having this kind of podcast. I think this is really providing a lot of valuable information and filling a niche that I think there's been a huge gap for. I think patients are really wanting information like what you're desiring to provide, and we hope that we can benefit them in this process. So, you know, I grew up in the Northeast in the New Jersey area. I'm a general surgeon by training. I did my residency in New York City at the Albert Einstein College of Medicine and Montefiore Medical Center. And then I had the privilege to join Paul at the University of Chicago for fellowship training in surgical oncology. And now I'm working as a surgical oncologist down in Dallas, Texas. So

paul_roach:

So.

Rohit Sharma:

it's a little bit of a journey westward in the country, little by little.

paul_roach:

Rohit, how did you get interested in going to med school to begin with? Was it one of those things where like you knew from an early age or did you start, you know, start down another path and then say, you know what, I want to do something else.

Rohit Sharma:

For me, I did not have any in utero inclination to become

paul_roach:

Yeah.

Rohit Sharma:

a physician. I think for me, it was really an evolution over my lifetime. I really liked the basic sciences. I liked the idea of working in a profession where you use the knowledge that you have and skills to actually help others. That seemed to be very rewarding. And to have that opportunity to care for others, I think is a true privilege. From the standpoint of surgery, I think what was exciting to me is when I was in college, I actually got a chance to work and shadow with a thoracic surgeon. And so as a part of that opportunity, I was able to actually go into the operating room and just observe some of the operations that this individual is performing. And I think the first trans-hiatal esophagectomy I saw where the arm of the surgeon went up through the abdomen, the diaphragmatic hiatus, and into the chest to mobilize the esophagus

paul_roach:

That's pretty amazing,

Rohit Sharma:

As soon

paul_roach:

isn't

Rohit Sharma:

as I

paul_roach:

it?

Rohit Sharma:

saw that, I was like, any

michael:

No

Rohit Sharma:

field

michael:

idea.

Rohit Sharma:

where you can do something like that is cool, amazing, I gotta do it.

paul_roach:

So, so

Rohit Sharma:

And

paul_roach:

for

Rohit Sharma:

so that

paul_roach:

my

Rohit Sharma:

had me hooked.

paul_roach:

awesome, that is awesome. You know, for me in my first clinical rotation at, at rush in med school, it was Dr. Dulles and he was doing a trans hiatal esophagectomy. And we'll explain that to Mike and to the audience in a sec.

michael:

It sounds like they made someone into a hand puppet.

Rohit Sharma:

Hahaha.

paul_roach:

It's just the most amazing thing. So your esophagus is your food pipe and it connects your throat to your stomach. And it goes through the center of your chest and the back of it. And so if a person needs it removed, for example, for esophageal cancer, um, you got to get it out somehow. And so the usual way has always been to open up between the ribs. and enter into the chest and take it out that way. Although the thing, it goes from the neck to your chest to your stomach. So there's a stomach, I mean, an abdominal aspect and a chest aspect. But it was too much,

michael:

damage.

paul_roach:

it was just too hard, yeah, for people to recover from. So I think it was pioneered in University of Michigan, wasn't it, by, oh, now I'm blanking on his name. And he did like a thousand of them. And... And so what you do is you just make a big incision in the belly and you dissect up as far as you can into the chest from the belly, and then you make an incision in the neck and you dissect down. And then for that last little section, you just close your eyes and you just do it with your fingers.

michael:

Yank? Oh my god.

paul_roach:

And then. You're behind the heart, you're behind the trachea. It's really amazing. And then, boop, out it comes. And then you fashion the stomach and bring it all the way up. And so it's amazing that it can be done. And so for me, that was

michael:

So you

paul_roach:

also

michael:

just pull

paul_roach:

the thing that

michael:

an

paul_roach:

blew

michael:

esophagus

paul_roach:

my mind.

michael:

out of somebody and you don't, I mean, you must be putting some other kind of PVC piping or something

paul_roach:

Yeah,

michael:

in there.

paul_roach:

it's exactly what you use you're like, hey, get me some of that PVC pipe

Rohit Sharma:

Ha

michael:

Don't

Rohit Sharma:

ha

michael:

forget

Rohit Sharma:

ha.

michael:

the joint compound.

paul_roach:

Yeah, yeah. All right. So that's so and then how did you get interested in cancer, Rohit? Specifically of all the

Rohit Sharma:

Yeah.

paul_roach:

different subsets of general surgery.

Rohit Sharma:

So, so actually for the longest time, I thought I would actually go into thoracic surgery. And then I had a fortunate opportunity to take some time off during residency to research. And I worked in the lab of a surgical oncologist, actually our department chairman. And I found that to be very exciting, the research side of it, the investigative nature of the specialty. And what I realized that I liked about thoracic surgery was really the cancer side. things

paul_roach:

Uh huh.

Rohit Sharma:

and here

paul_roach:

Yeah.

Rohit Sharma:

a specialty that really created opportunities to focus on almost any type of cancer, really that was exciting to me. And so that really just started that journey in that direction for me.

paul_roach:

Well, man, I remember when you came into the fellowship and it was exciting. You're so, I mean, blow sunshine in your direction, but you're so smart, so eager and, uh, just so talented. It was, it was amazing to have you, uh, as you know, to be working with you and working in the lab and it's exciting to see all the things that you've been doing ever since. So,

Rohit Sharma:

Well,

paul_roach:

uh,

Rohit Sharma:

thank

paul_roach:

we're

Rohit Sharma:

you.

paul_roach:

really

Rohit Sharma:

And I, you

paul_roach:

lucky

Rohit Sharma:

know, I

paul_roach:

to have you here.

Rohit Sharma:

thank you. I really appreciate the honor for joining you, but I would have to echo the same sentiments in reverse to you

michael:

Oh, don't do

Rohit Sharma:

and

michael:

it. Don't do it. His

paul_roach:

Yeah.

Rohit Sharma:

the other

michael:

head

Rohit Sharma:

colleagues.

michael:

is already...

Rohit Sharma:

So.

michael:

He's... Don't stop right there.

paul_roach:

That's right, Mike. Mike knows. Mike and I went to high school together. Oh,

Rohit Sharma:

So

paul_roach:

thanks.

Rohit Sharma:

we may have to talk Mike a little bit later and get some interesting stories about Paul. I may have some stories to share with you as well.

michael:

There you go.

paul_roach:

All right, all right. So I think that's a really good signal that we should move on to the topic of the day, which Rohit, you want to, it's going to be malignant melanoma. And where do you want to begin?

Rohit Sharma:

I think let's just start kind of with some of the basics, right? And so I think one of the things that I really would want individuals who are listening to this to really begin with understanding is that, you know, the incidence of skin cancers has been going up in recent years. And while we may not think about that as at the forefront of issues with health and so on, it does become an important part of one's health. And so. I think it's important from a patient's perspective to make sure that you're getting skin exams periodically, especially if you live in regions of the country where the incidence of skin cancer is higher. If you are someone who spends a lot of time outdoors, perhaps has had a history of a number of sunburns over your lifetime, a number of moles on your skin, you probably should be getting some regular skin exams with the help of a dermatologist. And so make sure that you're getting the appropriate screening. Certainly your primary health care provider can also participate in that and guide the process. But it is important to get your skin evaluated as well, just like you'd go in to get your heart and lungs checked out or seek your provider for other health care concerns. So I'd want to make sure that people understand that the skin is a very important part of our body and we need to look after it as well. And unfortunately, skin cancer is a reality for some people. Here I live in Texas. It's a very sunny climate. That's one of the advantages of living here. You can be outside pretty much all year round, but along with that comes a lot of sun exposure. And so there is a higher incidence of skin cancers in this part of the country. And so people are more vigilant about checking their skin. We definitely encourage that more. You'll see even at preschool levels, for example, a strong push to make sure children are protecting their skin as well. And oftentimes. Preschools will encourage parents to send hats and sunscreen and things like that. That becomes a little bit more difficult as children start to get older and enter elementary, middle school and high school where sunscreens and other protective measures are considered medications. And so I think it's important to educate our children as well in the process for their health to make sure they're careful in their outdoor activities, that they're trying to protect themselves as best as possible. and as parents to look out for them as well and make sure that we're checking on our children and getting them the appropriate care if a concern arises.

paul_roach:

No.

Rohit Sharma:

So I think one has to have that kind of mindset to begin with to be proactive about skin health and if you live in a region of the country where skin cancer incidence is higher, to make sure you're getting appropriate medical attention.

paul_roach:

Now my understanding is that most people can benefit from some sunblock, not just the people with really fair skin.

Rohit Sharma:

Absolutely.

paul_roach:

Is that correct?

Rohit Sharma:

Absolutely. Yes. We know that UV exposure contributes to the formation of skin cancers, whether that is outdoors in activities where you're getting UV exposure from the sun or if you happen to be using tanning beds. We know you're getting concentrated UV exposure there. And certainly we would discourage the use of tanning beds and even outdoor tanning.

michael:

Aren't there some therapies that some people actually use tanning beds for some kind of treatment of something?

paul_roach:

Oh yeah, for people with seasonal affective disorder.

michael:

So it's

Rohit Sharma:

So

paul_roach:

Right?

michael:

just

Rohit Sharma:

I

michael:

something

Rohit Sharma:

think you

michael:

that

Rohit Sharma:

want

michael:

they

Rohit Sharma:

to

michael:

need

Rohit Sharma:

be,

michael:

to do. Yeah.

Rohit Sharma:

yeah, so I think you want to be careful. Yes, there are some approved uses of UV therapy for the skin in particular and other conditions, but I think you need to make sure you're doing that under the guidance of a properly trained professional. And certainly those doses may differ from what you might get over a lifetime of sun exposure, especially if you're someone who likes to be outdoors, engages in outdoor sporting activities, or perhaps uses tanning beds.

paul_roach:

Now, do you know, is there a difference between infrequent, but intense exposure? For example, someone who goes for vacation down in the South and gets blistered and then comes back.

michael:

You're writing

paul_roach:

I've heard

michael:

the story

paul_roach:

that

michael:

of

paul_roach:

there's,

michael:

my life there, Paul,

paul_roach:

I know mine too,

michael:

with my

paul_roach:

right?

michael:

fair

paul_roach:

I

michael:

Irish

paul_roach:

mean,

michael:

skin.

paul_roach:

I, uh,

michael:

Beat red in the first day in Florida or wherever, yeah.

paul_roach:

I have two

michael:

It's a great

paul_roach:

colors,

michael:

question.

paul_roach:

really white and bright

michael:

Really

paul_roach:

red.

michael:

red.

paul_roach:

Yeah, I there's no tanning in between. I've got like one melon Melanocite that just runs

michael:

Yeah, I love

paul_roach:

around.

michael:

this question because it pops into my head all the time. Like I don't, some of my siblings, they're out in the sun all the time running and lots of external sports. I'm in front of my computer a lot. But when I do head out into the sun and I forget or it's the first day of spring and I get zapped. Am I kind of at a greater risk for that kind of level of severity of burn or are they because of their constant exposure?

Rohit Sharma:

And so we certainly are worried about that, especially if you're getting that intermittent exposure and if you're burning in particular, that really is suggesting quite a significant UV exposure in that short window of time. The cumulative effects are ultimately also gonna play a factor in your risk for developing skin cancer. So to my earlier point, these measures really begin at a young age. We wanna protect our children as they progress into adulthood and hopefully, have them adopt good behaviors that allow them to protect their skin over their lifetime. Because as all of us have probably engaged, how many times were we in soccer or outdoor sporting activities where our games are smack in the middle of the day? I mean, I remember being outside as a child playing soccer. I don't recall at that time as much attention being paid on skin protective measures. And so I think here we have an opportunity over one's lifetime to really make sure that we're implementing those behaviors that hopefully help protect ourselves. And these, whether concentrated intermittent exposure certainly increases the risk for skin cancer or cumulative exposure of one's lifetime are both going to be important factors.

paul_roach:

Alright, alright.

michael:

You guys might not be the right people to ask, but that SPF system and the fact that I have a can of something in my car and it's been there for three years, do I, do I, can I still use that basically? Or do you recommend that I actually pony up every year and buy some new cream and sprays and stuff?

paul_roach:

Well, if

michael:

What's...

paul_roach:

you have one bottle that lasts you several years, you're not getting out enough, you know?

michael:

It's in my car,

paul_roach:

Are you in

michael:

just

paul_roach:

jail?

michael:

in case. Right?

paul_roach:

Yeah.

michael:

Ha!

Rohit Sharma:

So I think that's a really good question you asked, Mike. So let's talk a little bit about sunscreens. So they come in different varieties. So you have lotions that you can apply and you have sprays. Both can be effective in protecting your skin. Whether you choose one or the other may be a personal choice. It may be out of convenience, maybe ease of application that may influence that. When you're selecting a sunscreen, you want to choose nothing less than an SPF of 30. That's the minimum that's recommended. Several years ago, the FDA actually modified how labeling should be on sunscreens. And so they tried to make it less confusing and try to have a more appropriate information on there. And in fact, there is testing that's done to ultimately achieve whatever SPF rating has been designated for the sunscreen. And so The original methodology that the FDA had indicated was that it was going to be 30 and then it's going to be a maximum of 50 or 50 plus kind of as a designation that you are not going to see as many sunscreens labeled with an SPF of 75 or 100 or so on. Because those numbers don't really equate to percentage degree of sunblock. They're all like over 98% blockage of UV radiation. So the incremental increase is small as you go higher and higher. And so they wanted to try to eliminate some of the confusion perhaps there, especially with numerous brands. And I'm sure campaigns trying to advertise a full R sunscreen is better because perhaps it has a higher number. They also try to standardize the labeling to say whether it's a broad spectrum or not, which is something that's really important. You want to see that to cover the different spectrum of UV light that's out there to be more protected. Usually we're worried about UVB. light, but UVA can contribute to skin aging as well as some skin cancers. So the broad spectrum helps to address those. The third component of the sunscreen is its water resistant factor. And so there the FDA designated two time points, 40 minutes and 80 minutes. And so if you're someone who is exercising a lot outdoors, you're sweating, perhaps you're swimming or engaged in some kind of other water activity. you would need to reapply your sunscreen based on that water resistant time frame. Okay. Which is much shorter than the timeframe we would normally encourage people to reapply sunscreen, which would be at least every two hours for sure. Some people might even advocate a shorter timeframe than that. But the important thing is you need to continuously reapply the sunscreen. It does wear off a single application in the morning is not going to cover you for the entire day.

paul_roach:

Ah, yeah.

Rohit Sharma:

The other aspect of it is that there are other measures that help to protect us. A sunscreen is just one component of this. And so we want to make sure that we're incorporating those things as well. Before I get into those, just an interesting article came out in Consumer Reports probably about three to four years ago. where through their own testing, they began to call into question some of the SPF ratings for these sunscreens. And basically the gist of the article was that there was gonna be some variability in the SPF performance of these sunscreens. Some, even though they might be rated at 30, might actually be performing at that level. Others might be performing less than that. So I think it's reasonable to consider perhaps even choosing a slightly higher SPF rating to allow for some potential variations in the manufacturing process that better cover you.

michael:

Is there a brand that four out of five cancer

paul_roach:

Doctors.

michael:

doctors recommend?

paul_roach:

Yeah.

Rohit Sharma:

Yeah. So

michael:

Sounds silly

Rohit Sharma:

unlike,

michael:

but...

Rohit Sharma:

that's a really good question. So unlike toothpaste, you know, we've not had any rating systems for, uh, sunscreen so consumer reports try to develop something like that or a ranking system. Um, that had some variability just in my own review of that. So I can't point to a specific brand, but I think a one that is working effectively for you where you're not tanning or burning, uh, and that you're using on a regular basis. I think it should be effective. I don't think you have to buy something that's terribly expensive because you can buy sunscreens that are about $40 to $50 in price for a single cube of it, but there are others that are less expensive and can perform just as well. And those could be your local box store brands that are out there as well. So I'd rather you use a sunscreen that works effectively for you and gives you protection than try to steer you towards a specific brand may not be adding a lot of benefit, but certainly may have additional cost.

michael:

So the best sunscreen is the one you have with you. Got

paul_roach:

Yeah.

michael:

it, got it. Okay,

Rohit Sharma:

and the end that you use

michael:

that's true. Not

Rohit Sharma:

so

michael:

like the one

Rohit Sharma:

if

michael:

in

Rohit Sharma:

it's

michael:

my

Rohit Sharma:

just

michael:

car.

Rohit Sharma:

sitting

michael:

Ha ha

Rohit Sharma:

in your glove compartment

michael:

ha.

Rohit Sharma:

it's probably not working for you

paul_roach:

All right, so the main thing, you know, here is prevention. Uh, but, and, and also those, those, uh, those shirts and whatnot that the little ones can wear is a lot easier than slathering them with, uh, sun, sun protection too, um, you know, if you can get the kids to wear those SPF shirts, do those work very well?

Rohit Sharma:

So some people do like to use that. We definitely encourage people if they're swimming in a pool. So living here in Texas, numerous people do that. That's a very common activity. So we encourage people to get rash guards, protect your children, protect themselves. That use of long sleeve clothing can protect your skin and that can help you in the long term as well. So absolutely. Definitely you should incorporate those things in your day to day practices to protect your skin. Even just from a standpoint of Individuals going to work or school or so on long sleeve clothing of a heavier. Weed can protect your skin as well So while we've been talking about sunscreen long sleeve clothing staying indoors when possible Avoiding the midday sun for outdoor activities. So usually between about 10 a.m. And 4 p.m. We'd prefer people to be inside if it's possible. I Understand that that doesn't always work for everyone people have occupations that require them to be outside then we want to make sure you're incorporating these other measures to help protect your skin.

paul_roach:

And so if people

Rohit Sharma:

The

paul_roach:

are going

Rohit Sharma:

use of

paul_roach:

outside and it's going to be sunny, just be smart.

Rohit Sharma:

Yes, absolutely. So wear a hat with a wide brim. Make sure you're wearing sunglasses. Make sure you've got that sunscreen applied to exposed skin. And those collective measures are what are gonna protect you long-term. So sunscreen in and of itself is not the perfect solution. It's a combination of these efforts.

paul_roach:

Very good. Very good. All right. So let's say a person has a mole or a blemish and they're worried about it

michael:

Wait,

paul_roach:

what

michael:

this is

paul_roach:

kind

michael:

two different

paul_roach:

of

michael:

things though. Because I have moles, and I've had them my whole life. But if somebody has a blemish, that's new, right? That's kind of what you're... Let's take

paul_roach:

Yeah,

michael:

this in

paul_roach:

yeah,

michael:

two

paul_roach:

yeah.

michael:

parts.

paul_roach:

Like either something that's been there for a while and maybe it changed or something that's just brand new.

michael:

Yeah,

Rohit Sharma:

So

michael:

how do you identify

Rohit Sharma:

actually,

michael:

that?

Rohit Sharma:

before we get on the mold, do you mind if I just digress for a moment about the sunscreens? Because I think there's another piece of information that's important for people to

paul_roach:

No,

Rohit Sharma:

know

paul_roach:

no, go right

Rohit Sharma:

about

paul_roach:

ahead.

Rohit Sharma:

that.

paul_roach:

Yeah, yeah.

Rohit Sharma:

Okay, sorry to change the topic. So the other thing to keep in mind about sunscreens

michael:

He's good, Paul. He's good.

paul_roach:

Yeah. Ha ha.

Rohit Sharma:

is that they come in different varieties, right? So Mike, you had mentioned the fact that you had a spray. Okay, and I imagine there were factors that influenced you to choose that. There are lotions as well that are out there. And so some things that you want to keep in mind when you're trying to select the appropriate sunscreen are the following things to consider. So there are sunscreens that have physical blocking agents. All right. So like your zinc oxide, titanium dioxide, they go on a little bit heavier. They're a little bit more pasty, but some people actually like that because they feel like it's giving them a little bit more protection. The alternative to that are going to be sunscreens that are more chemical based. So these are designed with chemical agents that actually help to neutralize the UV radiation. Those can work conveniently. They certainly are effective to the same extent that a physical blocking agent would be. But some individuals have concerns about the degree to which those chemicals are absorbed in the skin. There are some lotions and sprays that use these chemical agents where... They are not allowed in certain parts of the world because they actually damage coral reefs. So you have to be very careful where you're traveling that a sunscreen that you may like or prefer may not be allowed in a certain part of the world. So you may have to do a little bit of research if you're traveling to make sure that that is acceptable. Sprays are another form of sunscreen, which are really convenient, especially when you're dealing with young children that are squirming around. Sometimes it can be really easy to apply sunscreen on them with the use of a spray. But there are a few things you need to pay attention to with sprays as well. You certainly don't want to breathe the harmful fumes from them. And the quantity of sunscreen that you need to apply is also important. So with the spray, you want to make sure that you're saturating the skin reasonably well, so you have a sufficient quantity that remains on your skin for protective measures. When it comes to lotions, you want to use at least a shot glass full. So it's not an insignificant amount of sunscreen. And so you need to make sure you're having a generous application

michael:

Sorry for how much

Rohit Sharma:

plus

michael:

body

Rohit Sharma:

that

michael:

coverage.

Rohit Sharma:

free.

michael:

You know, you're saying that like a shot glass for your whole, like if I'm in a swimsuit and that's for all of me, or are you talking about

Rohit Sharma:

So.

michael:

shot glass per limb?

Rohit Sharma:

So you may need more than a shot glass full to cover your entire body. So it really depends on how much exposed skin we're really talking about. So probably a single shot glass might be fine to cover your face and your arms and maybe a portion of your legs, but you might end up needing to use more than that to get effective coverage. So it depends considering that, you know, the quantity of sensory may differ for a young child versus a six, eight adult, you know. So there's gonna be some variation. point there I think is really don't use just a minor or minute amount of the sunscreen you need a significant amount to make sure you're getting the benefit of it. Your choice in any of those I think is really personal whichever you feel more comfortable with I think is reasonable and just as you had said Mike earlier the sunscreen that you have and that you use regularly is going to be the most beneficial thing. Sorry for the digression, but I wanted to make sure just complete the thought on sunscreens, because some people

paul_roach:

Oh, that was

Rohit Sharma:

need

paul_roach:

great

Rohit Sharma:

guidance

paul_roach:

stuff.

Rohit Sharma:

about how to select one. And I think it'll be important for them to understand those differences.

paul_roach:

I didn't know half of that, so no, I'm grateful.

Rohit Sharma:

So let's, I guess, get to your question that you had posed to me about a mole. So how do you

paul_roach:

How does it present?

Rohit Sharma:

decide that something

paul_roach:

Yeah.

Rohit Sharma:

on your skin is actually concerning? So in a med school, we're taught about sort of the ABCDs of moles, right? Moles on your skin that show asymmetry, irregular borders that have variation to the color, an enlarging diameter. So... If it's bigger than the size of a pencil eraser, you need to start paying more attention and perhaps get that looked at. And certainly

michael:

wait,

Rohit Sharma:

lesions that

michael:

let

Rohit Sharma:

are

michael:

me stop

Rohit Sharma:

evolving.

michael:

you again. Is

Rohit Sharma:

Sure.

michael:

it if it's changing and becoming larger? Because I was born with some that were larger than that. You know what I mean? So like,

Rohit Sharma:

Yeah, so.

michael:

no doctor has ever told me, hey, you have moles, we're gonna check you every year and we wanna see your moles. In fact, most of the time, that's not happening at all. So is it because they're not changing, I'm okay, or do I need to be aware of that?

Rohit Sharma:

So I think you do need to be aware of that because there are some people who do have larger moles on their skin that over their lifetime can change. It doesn't have to change in the entirety of that mole, but you could have a small section of that where there is actually some evolution to it. And that could be a sign that there's some evolving skin cancer there. So, you know, if there's ever a concern or question, you're unsure about whether a mole is worrisome or not. get yourself to a dermatologist, get it looked at by a professional, so that way they can make a judgment about whether further investigation needs to be done on.

paul_roach:

One thing that I do, and maybe it's because I work in a system where I don't have to worry about billing or getting paid in the VA, is if there's a mole on a person's back where they can't see it, I'm

michael:

Bingo.

paul_roach:

really quick to biopsy them so that they don't have to worry about it, because they can't really see that. They can't monitor it.

michael:

Yeah,

paul_roach:

But if

michael:

that's

paul_roach:

it's...

michael:

where mine are and no doctor has ever, you know, I'm in my 50s. This is,

paul_roach:

Well,

michael:

that

paul_roach:

come

michael:

was

paul_roach:

on

michael:

news

paul_roach:

over to my

michael:

to me,

paul_roach:

kitchen,

michael:

Paul.

paul_roach:

man. I'll, I'll take care of that. Yeah.

michael:

With the potato peeler. Thanks.

paul_roach:

Um,

michael:

I have my own doctor.

Rohit Sharma:

Ha ha ha.

paul_roach:

but yeah, I mean, if a mole has been there, it doesn't mean, correct me if I'm wrong, it doesn't mean it's going to stay behaving forever. So a mole that exists can change. And then that's a sign of melanoma. Or you can have on your skin. a brand new thing show up that was never there. And that's also potentially a sign of melanoma. And one thing you can do if you're wondering is you can take a photo of your skin and save it in your computer. And if you're wondering, hey, did this change or not, you can take another photo and compare them side to side. What do you think of that? I tell people to do that sometimes. I don't know if I'm

Rohit Sharma:

I think that's

paul_roach:

giving

Rohit Sharma:

a reasonable

paul_roach:

them good advice

Rohit Sharma:

suggestion.

paul_roach:

or

Rohit Sharma:

I think

paul_roach:

not.

Rohit Sharma:

in the current era, we benefit from easy access to technology. We're all carrying a smartphone practically. I think gone is the era of those flip phones with the really rudimentary cameras. We now have camera phones that are 20, 30, 40, 50 megapixels that can get some really high resolution images. So I think you can use those tools to effectively monitor a site. that you're concerned about. To your larger point, individuals may have existing moles that never change, that never become cancer. That certainly is a possibility. But if you have an existing mole that is evolving, perhaps if it's becoming symptomatic, maybe it's starting to itch on a regular basis or it's starting to bleed, that's a concerning feature. You need to get that looked at.

michael:

are moles.

Rohit Sharma:

You could have moles that are otherwise unchanging and As you pointed out, Paul, you could develop a brand new mole that really is the site of concern.

michael:

Are

Rohit Sharma:

The

michael:

moles

Rohit Sharma:

other thing to

michael:

generally

Rohit Sharma:

keep in mind.

michael:

trouble spot areas though? Or like to me it's just part of my skin, it's just a darker, weirder little area. Is it potentially more problematic than the rest of my skin?

Rohit Sharma:

For some people it could be. I think it does warrant careful monitoring. You should examine your skin on a regular basis. Certainly certain regions of your body, like your back, are gonna be harder for you to see. If you have the benefit of a significant other who can help you look out at that, or a family member that can help you monitor those regions, I think that is helpful.

paul_roach:

Well, I think

Rohit Sharma:

The

paul_roach:

also,

Rohit Sharma:

other thing I think to keep

paul_roach:

oh.

Rohit Sharma:

in mind is that we're talking about moles, and especially when it comes to melanoma, people think that you have to have this dark black what we call hyperpigmented mole, and that's really the melanoma. But there are some people who have melanomas that have no pigmentation to them whatsoever. That's something we called amelanotic melanoma. So even a red spot on your skin that's perhaps progressive, symptomatic in some way, could be a concern for a skin cancer. So don't assume that if it's not black in color that it's not melanoma. It very well could be in some more limited instances. Again, the key is if you have a concern, get your dermatologist, get to a professional who can look at it. And dermatologists are very skilled at looking at the skin. And for some individuals that are in higher risk categories, they can do even full body skin checks, they can do full body photography that's at a very high resolution. So if you're someone who has numerous moles on the skin, monitoring those may actually be a challenge. And so you might actually benefit from full body skin photography. where they can zoom in, look at a specific site, compare that to how you are presenting at any given follow-up visit, and they might be able to discern some subtle changes that could prompt a biopsy and maybe an early diagnosis of a concerning spot.

michael:

You said something interesting that was if it starts to become itchy or it starts to bleed. And from our earlier podcasts, that was kind of a symptomatic issue that I had asked about as well, where the team had basically said, if you're noticing changes in your energy level or you're noticing changes in your just... how you feel. Is it sort of the same? Is it localized like to the little parts of your skin or is it sort of the same idea? Would I start to feel fatigue and would I start to feel, you know, a kind of a life changing, like I'm not doing the things that I used to do? Or is it kind of a combination of both of those things?

paul_roach:

I think

Rohit Sharma:

It could...

paul_roach:

I remember that other conversation. So I'll jump in if that's right. I think like with respect to the skin cancer that we are talking about today, at the earlier stages, you're going to be completely fine. You're just normal. And then there's this thing on your skin. Um, you wouldn't necessarily notice what we call constitutional symptoms or symptoms. that have to do with overall energy levels and weight changes and, and how you feel until this thing had sort of evolved, uh, fairly far down the road. So, but with respect to the skin itself, so your skin has a really important function. It is a barrier between you and the world and it's comprised of all these different cells. And for the most part, there are these things called, you know, squamous cells or keratinocytes, which are these cells that have structural details that enable them to hold together and to not fall apart when they're stressed, to be relatively waterproof and relatively bacteria proof or very bacteria proof. And, and for some people somewhat photon proof, certainly not for others. So those are the majority. And then you also have pigment cells, which is where the melanin comes in for melanoma. And different races of skin have different amounts of pigment in their melanocytes. That's the cell that holds the pigment. And so if the other cells, those keratinocytes get cancer, it's one type of skin cancer or two, or others, but If it's the melanocyte that gets cancer, then that's melanoma. And so that's why we're keep talking about the colors because the melanocytes frequently have the pigment. Does that summarize it or does that only make it more confusing?

Rohit Sharma:

I agree, I think that's a very clear description of that. I agree with what you've said.

paul_roach:

Uh, Mike, how,

michael:

Hmm.

paul_roach:

how did that register? Or was it mostly just Rohit and I talking to each other?

michael:

Well, he had said that you need to be looking out for those changes in your skin that aren't dark. That aren't... melanin laced basically. So you're kind of confusing me Paul. Are we talking about... So this is the podcast about melanoma.

paul_roach:

Right,

michael:

So

paul_roach:

yeah.

michael:

is that we're only talking about the things that show up dark on our skin and we're going to talk about the other one a month or two from now? Or is it all the same thing and sometimes it's going to show up as a colorful lesion of some sort and other times it's not?

paul_roach:

So Rohit and I were talking before the show and we made the executive decision to just focus on melanoma because otherwise the topic gets so big, so fast. If we were going to take on all of the different skin cancers, such as basal cell carcinomas and squamous cell carcinomas and Merkel cell carcinomas and whatever else, that might

michael:

good

paul_roach:

be

michael:

to

paul_roach:

a

michael:

know

paul_roach:

little bit overwhelming.

michael:

that there are other things that we'll come back and talk about, assuming you're available. Yeah,

paul_roach:

Yeah,

Rohit Sharma:

Absolutely.

paul_roach:

if you'll come back, yeah.

Rohit Sharma:

Absolutely,

michael:

but because

Rohit Sharma:

I would love to.

michael:

I wasn't aware that there were other skin cancers besides melanoma, that's the only one I'd ever heard of. So, okay.

Rohit Sharma:

There

paul_roach:

Yeah.

Rohit Sharma:

are, I think the point that I was trying to express is that yes, most commonly when you think about melanoma, you're thinking about that darker lesion on the skin that's evolving in some way, and that that may reflect the diagnosis of melanoma. But there are, in a more limited number of cases, melanomas that don't have to look dark in color. So if you have another skin lesion that looks concerning, even if it's not dark, I think the important point is get that looked at by a dermatologist.

michael:

Alright, I know we're not going to talk about it, but what might that look like? Just for now.

paul_roach:

Ah, oh,

Rohit Sharma:

So.

paul_roach:

can I jump in?

Rohit Sharma:

Absolutely.

paul_roach:

All right. So, uh, I love this type of stuff trying to. trying to convey in a way that's simple and memorable, you know, a life lesson regarding some sort of cancer problem. So what I try to describe to people is if a mole or a thing on your skin looks as if it's made in a factory, if it's perfect and completely uniform, let's say it's perfectly round with a perfectly uniform color and it's got sharp borders and it's flat, you know, it looks like it just got spray painted on you. That's usually a good sign, you know, particularly if it's not too large. And then if it's everything opposite to that, that's something that I need to see. If it's not round, but if it's irregular in shape, if the borders are not pristine, rather some are vague and feathered out and others are pristine. If it's not one color, but it's multiple colors, or if it's not flat, but it's, it's enlarged or enlarging. then I need to see that or anybody in my role needs to see that. Rohit, how do you describe it to people?

Rohit Sharma:

I think that that's exactly what you described, I think, is a very good representation of that.

michael:

Right, but that's melanoma

Rohit Sharma:

So

michael:

though. So I guess what I was

Rohit Sharma:

the

michael:

asking

Rohit Sharma:

same

michael:

was

Rohit Sharma:

concepts

michael:

just...

Rohit Sharma:

apply regardless of the type of skin cancer, because you're looking for, as Paul described, a very sort of manufactured or uniform appearing mole that may be benign versus one that now has a more irregular appearance that actually could be suggestive of some evolving type of a skin cancer. It doesn't always have to be melanoma, it could be some other type, but you're looking for those fundamental changes to help you at least trigger the idea that you need to get this looked at.

michael:

All right, I guess that's my ultimate question. And I know that we're gonna talk about this at a future podcast, but because it came up in this one, I'm worried that, I'm already worried, there's other people who are listening like, oh, I don't have to worry about this thing on my hand that's just like some wrinkles or something. Is there another presentation that we're gonna talk about later that doesn't look like a melanoma, but it's a skin cancer? So just real briefly, what should I be concerned about for those non-melanoma

Rohit Sharma:

So,

michael:

cancers?

Rohit Sharma:

yeah, so the reality of it is that other types of skin cancers, as Paul mentioned, squamous cell is one type and basal cell is the other type. Those two are much more common when it comes to skin cancers than melanoma and miracle cell carcinomas, which Paul also mentioned. That's a much more rare type of skin cancer. The good thing is that with squamous cell carcinomas and basal cell carcinomas of the skin, those often are caught early. They have very effective treatments. and most people are going to be cured with those treatments for those skin cancers. Melanoma is a little bit of a different player in that we worry about its aggressive potential and for some people even in earlier phases of its development.

michael:

But what do the other ones look like? I guess

paul_roach:

They,

michael:

this is what we're...

paul_roach:

a lot of times will have shiny, clear white appearance. They'll also feel differently. They'll feel firm

michael:

like a

paul_roach:

rather

michael:

rough patch

paul_roach:

than your

michael:

of

paul_roach:

normal

michael:

my skin or something.

paul_roach:

soft appliance skin. Cause I know you use lots of skin softeners, Mike. Uh, but yeah,

michael:

tender.

paul_roach:

they'll have, uh, uh, like a firm nodule and Um, and irregular, and this is really embarrassing. So I'm, let's say in my mid twenties and,

michael:

You're not.

paul_roach:

and, uh, my wife and I were newly weds and we're down in Florida. I'm in the Navy and we're about to go overseas to Okinawa and I've got this thing on my face, this blemish or whatever that is trying to heal and then it stops healing and it tries to heal and then it opens up again. And Megan said, I need to get that checked out before I go to Okinawa. And, uh, and I was blowing her off and blowing her off and, and, um, she said, you gotta get this checked out, you know, get it checked out. And I said, Meg, I'm the doc. Okay. And then I w that was really

michael:

Thank you.

paul_roach:

bad and it didn't go over well. And it was a marriage lesson. And she forgave me later, especially when I went to the doctor and they biopsied it and a, it turned out to be cancer, even though I was young. And B, it was a bad kind of, of basal cell cancer, the spreading kind. So I needed this big chunk of skin cut out of my face, um, emergently before I transferred to Oklahoma with the, uh, with the Navy is a morphia form. And, uh, and so even though I was only 26 or 27, um, I still got a skin cancer. And that's

michael:

Okay,

paul_roach:

pretty young

michael:

and

paul_roach:

for

michael:

you wouldn't

paul_roach:

that.

michael:

have thought so because it wasn't presenting as a dark

paul_roach:

No, it just looked

michael:

changing

paul_roach:

like a.

michael:

thing.

paul_roach:

You know, it's kind of like when you nick yourself shaving, it was up on my cheek, but it was just this little, little thing that just wouldn't heal

michael:

Okay,

paul_roach:

and I was blowing

michael:

that's where

paul_roach:

it

michael:

I was

paul_roach:

off.

michael:

going is before we launch into melanoma fully, since it came up I wanted to know if there's any non-healing little thing, any white raised bump,

paul_roach:

Yeah.

michael:

and it's not just a pimple that goes away after a few days, then I should look into that and also tune in for a future podcast. Got it. All right. Now we can go back.

paul_roach:

All right. So really, so the person comes in, they've got this changing mole and you are talking to them and you're giving them their options for biopsy and, and you think it's going to be a melanoma. So what do you say?

Rohit Sharma:

So usually that conversation is primarily going to happen in the dermatologist's office. But the options there are whenever you have a concerning mole is we need a tissue diagnosis. We need an answer. We need to put a name to what is going on there to decide what are the next steps in care that may be necessary to resolve whatever that happens to be. For some people, it may end up being something totally benign and it's resolved and they move on. don't need to think anything further of it. For other individuals, it could come back as a melanoma. So what are the different biopsy options? So you could do a limited excision of that mole and send that off to the pathologist for review. You could do what's called a punch biopsy, which you can use sort of a round cookie cutter-like blade after numbing up the area and take sort of a punch out of that. like you'd put a hole punch in a piece of paper, and send a more limited sample off to the pathologist for review. That's very useful if you have a smaller size mole or concerning lesion where you can get a reasonably representative sample of what's going on. The alternative to that, which is very commonly used with dermatologists is something called a deep saucerization. So it's more of a gouging out of the lesion itself. that's of concern, so you're excising the entirety of it to a reasonable depth where you can hopefully fully characterize whatever is happening in that location. Oftentimes, you'll hear a term that is used to represent a synonym to that, which would be a shave biopsy. But really speaking, sometimes a shave biopsy could imply a more superficial sampling of that mole, but really speaking, what you want is a deeper biopsy to make sure you're getting. the entirety of it for evaluation.

paul_roach:

All right, and then let's just say the pathology comes back and the person shows up in your office and they have a stage one or a stage two or a stage three melanoma. When you're trying to explain that to them, what's the way you describe it? Cause that is an issue that's always confusing for people.

Rohit Sharma:

paul_roach:

All right, all right, so anything one millimeter or greater firm, we're doing a sentinel lymph node biopsy because knowledge is power. We find out if there's tumor cells in those selected lymph nodes, and if there are, that really changes predictions and therapy. If it's less than a millimeter, you don't necessarily do the lymph node mapping technique. You just... watch, but if it's just a little less than a millimeter in thickness, somewhere like 0.8 to 1, and it has some adverse features, then we go ahead and do the lymph node mapping, if I'm just going to summarize that.

Rohit Sharma:

Exactly. So I think that's a really good summary of it. And so that's where the help of a cancer specialist who deals with melanoma and can understand those nuances becomes really important because they can help guide the patient in understanding what those concerns and considerations are and where we may need to consider this additional assessment.

paul_roach:

So let's

michael:

When you're

paul_roach:

say you

michael:

talking

paul_roach:

have a

michael:

about

paul_roach:

patient,

michael:

melanoma,

paul_roach:

oh sorry.

michael:

just a couple of questions popped up in my head while you were talking and that the depth being as important as it is, is that primarily how melanoma grows? Does it grow down into my skin or is it growing broadly across my skin first and then starts moving down? Just me, how do I identify? kind of where I'm at if I'm even as I'm deciding if I want to go to the doctor or not you know like I

paul_roach:

That's

michael:

know you guys

paul_roach:

a great.

michael:

like just go to the doctor but the rest of us are like that's gonna cost me there's an insurance

paul_roach:

Yeah, yeah.

michael:

guy so

paul_roach:

That's a really great question. So melanoma has like a horizontal phase of growth and correct me if I'm wrong Rohit, and a vertical phase. And so the horizontal phase is non-threatening and the vertical phase is threatening. And so let's say there's four basic categories of melanoma. For the moment, we'll just call them A, B, C, and D. And on one side, one extreme, you'll have straight, or pure horizontal and very, very little vertical. So that one's pretty safe. That, what is that, a Hutchinson, Hutchinson's freckle or something they call that. And then on the other extreme, it's straight vertical with very little horizontal. So even a fairly narrow one will go straight deep. And I think that's what Bob Marley had on his toe. And then the other two in the middle are variations of that. Is that still a legitimate characterization Rohit or?

Rohit Sharma:

Absolutely. So when you talk about the biology of melanoma, as you said, there's this horizontal or radial growth phase that these melanomas begin with. That's the ideal time that we want to catch them. And so oftentimes you'll see in people who've had melanoma diagnoses, they may have been diagnosed with something called melanoma in situ. So this is melanoma that's hanging out just on the surface of the skin. It hasn't started to burrow deeply at all. And so for those individuals, removing that melanoma could essentially be curative. And so that's ideally the time we want to catch those. And that's where regular follow-up with a dermatologist, especially if you are an individual who is, perhaps has had prior skin cancers or is believed to be in a higher risk category for skin cancer, your dermatologist might catch that melanoma at that time period. It's when it starts burrowing deeper, becoming invasive, that now the greater potential for aggressive behavior. exists. Paul, you pointed out also another feature that, you know, there are different types of melanoma as well. The most common type is something called a superficial spreading melanoma, but there is an entity called a nodular melanoma as well, where rather than kind of riding the surface of the skin and growing radially on the surface before burrowing down, that nodular melanoma tends to burrow deeply early on. And so for those people, they can have a more aggressive course of their melanoma earlier on in the course of the disease than later because of just this biological behavior of this tumor.

michael:

That sounds particularly frightening because if I have something that's, this is my cue right there. If it's spreading out, that's what we were talking about earlier where now I have this irregular thing or this new thing in my skin and I can see it and I can photograph it and I can say, yep, it's changed in a week. But if you're telling me that there could be, you know, there's just this tiny thing that just burrows in and down, how do I know? Am I feeling different in that area? Is it painful? Is it itchy? How would I even know if like a freckle sized thing is going into my skin rather than something

paul_roach:

Well,

michael:

that

paul_roach:

usually

michael:

I can kind of measure and watch?

paul_roach:

if it's burrowing down, it's also typically building up.

michael:

It's going to

paul_roach:

So

michael:

raise up at the same time.

paul_roach:

it's, if it's raising up, uh, I don't know, I think of nodular as being nodular, as being bumpy. So if there's a new mole or something that has now, instead of spreading wide, if it's If you're feeling the surface of it and it's getting bulkier, then you bring that in. And now I know every time we do one of these podcasts, we give you all these things to keep you up at night worrying about. So I'm sorry about that, but there's nothing in our line of work that's ever like simple or, um, or completely safe.

michael:

I mean, we're talking about cancer. The name of the podcast is

paul_roach:

Yeah.

michael:

so doc, it's cancer.

paul_roach:

Yeah.

michael:

I get that it was never going to be like, hey, good news.

paul_roach:

Yeah.

michael:

Sunshine news for you. Oh, and I have to have to bring this one up to I have one doctor. It's GP. I have no dermatologist. How and I'm I'm probably the typical male out there. How do we get around? not, you know, I don't have an array of doctors that I go see. I just have the one. What should I be talking about with my GP since I'm not seeing a dermatologist? And

Rohit Sharma:

So

michael:

don't

Rohit Sharma:

I

michael:

say

Rohit Sharma:

think

michael:

just go to a dermatologist.

Rohit Sharma:

it's gonna depend on, obviously, the nature of the visits. So if you're going in for a routine checkup and it's not unusual for the GP to say, well, you know, what are the concerns you have today? What can we address beyond just routine health maintenance concerns that I would want to talk to you about? So if your skin health is of paramount concern to you, then that's probably something you want to lead with. look, I've got all these moles, I'm worried about them, maybe there's a specific mole that is more concerning to you, then I would show that to them and make sure that that's a priority as a part of that visit. Because there may be a number of things that have to be discussed. The GP may have some priorities based on your general health, your age, et cetera, of things that they need to communicate with you, but you wanna make sure that the concerns you have are also being focused on and resolved. If there's ever at all any degree of uncertainty, the best thing is to go and have a dermatologist look at it. That's the right expert to take a look. And sometimes they can notice some very subtle changes to a mole that might actually trigger the need for a biopsy. They also have some specialized techniques that they can use in tools at their disposal, something called dermoscopy, which is like a magnifying glass that they can place on the skin to really look for subtle changes within a mole. that might tip them off to that evolving into something more concerning like a skin cancer. So getting yourself to an expert, especially if there is a more serious concern, I think is a key part of it. But if you're relying primarily on your GP, I think you need to make sure you're having a directed conversation with them about it.

paul_roach:

And that's where this

michael:

Okay,

paul_roach:

podcast

michael:

that helps.

paul_roach:

I think can be helpful is if, you know, you listen to it and you're learning some of the features that you need to know. You can then, when you do see your GP, know some of the language and some of the concepts and you can bring that forth. And I think, um, uh, that by itself is, is the utility of, of dialing in.

Rohit Sharma:

But some general thoughts for your listeners as well to think about is that when you go to your doctor's office, everyone is coming to the table with an agenda, the patient and the physician both, right? You may be coming in at the age of 50 and I as your provider and now recognizing, you know what, you need to make sure you have a colonoscopy, you need to get all these other healthcare screening measures in place, we need to check labs, things like that, that I now have a priority in my own mind that I need to make sure I'm communicating with you as my patient so that I'm taking good care of you. You may be walking in the door as a patient now with another set of concerns. That may be in total alignment with the purpose of the visit for both of us, or it may diverge to some degree. And so as the patient, what I would advise all individuals to do is when you have something of concern and if your physician is not understanding the degree of concern that you have about it, stop them. and tell them, this is worrying me much more than I think I'm able to express to you, or perhaps you're able to understand from our conversation so far. Now, they may be able to help resolve that with you right at that moment, or they may say, you know what, let's schedule a follow-up in a very short period of time so we can focus entirely on that concern you have.

paul_roach:

That's really

Rohit Sharma:

But, you

paul_roach:

good,

Rohit Sharma:

know,

paul_roach:

yeah.

Rohit Sharma:

but keeping in mind that we all have our own priorities and things we need to accomplish, sometimes as physicians as well. We may not always understand the degree of concern that a patient is presenting with, even though we make every effort to try to do so. And sometimes we need to be hit over the head by the patient to say,

michael:

Yeah.

Rohit Sharma:

look, this is more worrisome to me than your understanding. And I

michael:

That's

Rohit Sharma:

think

michael:

an

Rohit Sharma:

patients

michael:

interesting

Rohit Sharma:

should feel

michael:

point,

Rohit Sharma:

free to say that.

michael:

especially where you're talking about that we all have our agendas and priorities going into it. But I have to admit, you know, I go to the doctor once a year to get my annual checkup. And I have, you know, I've even asked about, hey, I have this little thing in my hand that I never noticed before, and they looked at it and went, yeah, that's nothing, which is fine because it was nothing.

paul_roach:

Yeah

michael:

But at the same time, I kind of rely. probably more than I should and I think I'm not alone. It's like, oh, I'm going in for my annual checkup, they're gonna draw blood, they're gonna look at me, they're gonna do whatever. I guess I'm kind of relying on them to tell me if they see something wrong rather than me kind of going. Well, you know, here's my long laundry list of stuff. In a way, I'm sometimes kind of sheepish about bringing things up because it sounds stupid. Like it actually took me a while to say, should I mention this little weird freckle that I just noticed on my hand? Cause it just seemed, you know, and I think there's a lot of people who are like that. We're like, well, I'm going to see the doctor for my checkup. The doctor will tell me if there's something wrong, I'll bring up the one or two things that maybe I noticed. Maybe I won't bring them up. Um, so this, this is basically happening. Every podcast, you guys are basically telling me to communicate more with my doctor

paul_roach:

Yeah,

michael:

and basically

paul_roach:

you know,

michael:

tell them.

paul_roach:

I, I think that's a really important point and, and it's, uh, it's definitely, it's a life hack that I, I like to recommend to everybody, which is before you go, before you get in the car or on the train to go to your physician, write it down, write down your list of one, two, three, four things that you want to discuss while you're there and hand it. right up front or hand it after they're done. But don't forget to hand it in before you leave and say, these are the concerns I have. I've got this mole on my side that I am worried about, you know, and because the physician is probably pretty busy and probably has more patients scheduled for them than they would have chosen to have if. if they could, you know? And so I think being efficient really pays dividends.

michael:

Well, that's in a way, that's why I don't bring up some of the things that I don't bring up. It's like, you know, it's a stupid thing that I'm thinking about and they're busy and they're a doctor. And

paul_roach:

No,

michael:

so I'm just going to get my

paul_roach:

I

michael:

checkup

paul_roach:

think it's

michael:

and go.

paul_roach:

so important to do it. Yeah.

Rohit Sharma:

I think you've got an idea for the next podcast.

paul_roach:

Yeah. Yeah. Yeah. All right. All right. So let's, to wrap this up, let's, let's just say you've now got a patient who they're setting on those positive and, and then you do a, uh, a CT scan and they've got, they've got something on their lung now too. What is the melanoma stage four treatment? You know, the, the state of play for metastatic melanoma. And I know that's a huge subject, but

michael:

I feel like

paul_roach:

I don't know if we

michael:

we're

paul_roach:

need

michael:

kind

paul_roach:

to

michael:

of

paul_roach:

get

michael:

jumping

paul_roach:

into.

michael:

ahead. Isn't there some, I mean we just talked about there's the ones that are relatively benign and can be taken off. And then there's the ones that start to burrow in. And now we're at stage four. What happens

paul_roach:

Oh, I

michael:

in

paul_roach:

sort

michael:

between?

paul_roach:

of. Well, we talked about stage three would be the lift nodes are positive. So we can go back to stage three.

Rohit Sharma:

So, we talked about this whole concept of excising the primary melanoma and then for some individuals evaluating their lymph nodes to kind of stage their disease to determine what is the extent of their disease from not only the local site but what are called regional lymph nodes. Individuals who have no evidence of melanoma in those regional lymph nodes, we presume they truly have local disease and they likely will have a favorable prognosis. those that have melanoma within the lymph nodes through this sentinel lymph node biopsy procedure that has been done are now in a much higher risk category. They're at higher risk of having additional disease within the lymph nodes that remain, plus in a higher risk category of having melanoma develop in other regions of the body. So typically that excision of the melanoma and the sentinel lymph node biopsy portion of the procedure, we do those together. at the time of the initial operation to manage the disease. And usually about a week, maybe 10 days later, we get that information back on the adequacy which we've removed the primary melanoma and the status of the lymph nodes. So now treatment for this has evolved over the years for individuals who now have a concern for melanoma in the lymph nodes. If you and I were having this conversation a decade ago, we would have said if you had one melanoma cell in your lymph node, we'd be having a conversation about removing every last lymph node in that region because that was the best way to try to control the disease and hopefully prevent it from manifesting in other regions of the body or recurring within lymph nodes in that region. A very aggressive operation, certainly a higher risk for complications and consequences of the procedure. And so, and not something to be taken lightly, but because we didn't really have great treatments beyond aggressive surgical control, we felt this need to be appropriately aggressive in trying to control the cancer. But that landscape has totally changed in the last 10 years. We've seen the introduction of numerous new types of chemotherapy in the category of what we call immunotherapies or targeted therapies that can modulate the immune system. and actually allow our bodies to fight off the cancer. And so this has created a very different and renewed sense of optimism for prognosis in these individuals where we didn't have that a decade ago. And so that has further now modified how we approach managing these melanomas because we are curing some individuals of their melanoma with these medications. What has... evolved to this date now is that we are much more selective in those patients that have lymph node disease in removing all of those lymph nodes. Because what we have come to learn in more recent studies is that we don't necessarily improve survival

michael:

Thanks for

Rohit Sharma:

by

michael:

watching!

Rohit Sharma:

being aggressive about removing lymph nodes in the wrong context. Because it's not the regional control of the disease that shortens one's lifespan, it's the disease that develops in the lung. in the liver or in the brain or other regions of the body that's going to determine longevity for the individual. And so for those people that are in high risk categories, that have lymph node involvement on a limited basis, those individuals are the ones that we want to get on these immunotherapies early on. Because those are the individuals that we may actually effectively treat microscopic disease that may exist elsewhere and actually prevent them from getting cancers. from having the spread of this cancer manifest somewhere else in the body. So for those individuals, getting them on immunotherapies or targeted therapies early on is really important to alter their prognosis. And so we're being much more selective in that paradigm even more recent studies have looked at melanomas that are very thick and ulcerated so those that are more than two millimeters of thickness with ulceration are now also being considered for Immunotherapy at that stage even in the absence of any lymph node involvement of melanoma Now some people may argue that's a little bit more controversial in some circles Other data suggests that even those melanomas behave as aggressively as the higher stage three melanomas where we know they have lymph node involvement. And so people are considering and in many cases implementing immunotherapy even earlier on to hopefully more effectively alter outcomes for those individuals. So the landscape has completely changed. where

paul_roach:

Wow,

Rohit Sharma:

we

paul_roach:

yeah.

Rohit Sharma:

were very aggressive with operative interventions, we're now moving to more effective systemic therapies, and we're reserving these more aggressive operations for people who recur on those therapies, or perhaps have other needs to address their disease.

paul_roach:

That's really interesting. I didn't know about the institution of the immunotherapy for even, you know, aggressive biology stage twos, but that's like the whole biology is destiny paradigm that, that even if it is, you caught it early and it's not that far advanced, if it's got a nasty looking, uh, aspect to it under the microscope, or if it's got the, uh, the genetic signals of aggressiveness that Hit it with everything you've got up front. Don't ever give it a chance to escape.

michael:

Um.

Rohit Sharma:

I would agree. And I think these treatments that these immunotherapies and so on are showing great promise. You know, we started off with some limited options that's evolved into numerous choices, combination therapies, and I think that's going to get more and more sophisticated as time goes by, as we understand the mechanisms of these cancers better. And even as these are similar medications are being used to treat other types of cancers, we may more broadly start applying them to different malignant seeds. where they may show benefit as well.

michael:

What are the, I guess, survival rates if I'm at different stages of this and where do I need to be basically?

Rohit Sharma:

So I think the key here is to really get your diagnosis as early as possible. For stage one disease, you're looking at 10 year survival that's gonna be somewhere around 70, 80% easily, if not higher than that. If you're looking at a stage two type of disease, on the lower end, this could be closer to about... a 50 to 60% 10-year survival, depending upon the characteristics of the melanoma. When you start pushing stage three disease, then you may be down into more of the 30 to 40% 10-year survival. And certainly stage four disease has a poor prognosis to begin with. Yet, with the advent of these new immunotherapies, we are seeing some individuals that are being cured of it. And that's the remarkable thing where in the past patients that had widely metastatic melanoma You know 10 or 12 years ago We would have probably been having a very different conversation with them and saying, you know start getting your belongings in order Start, you know reaching out to family and friends and making your preparations because we don't have any great options for you We'll still keep trying but Unfortunately, the die is cast But nowadays we still have some optimism that we may find some effective combination therapy or some new clinical trial is gonna be out there with an investigational drug that may actually make a difference for these individuals. And we've seen it happen. We've seen melanomas literally melt away with some of these treatments. And that's not the case for everyone. So I don't wanna mislead people into thinking this is some perfect solution, it's not.

paul_roach:

When,

Rohit Sharma:

And so I think, go

paul_roach:

oh, when Rohit

Rohit Sharma:

ahead.

paul_roach:

and I were like in, in residency or, or med school, the only treatment for stage three or four melanoma was interleukin two. Was there anything else? Um, I think.

Rohit Sharma:

There are some more conventional chemotherapies. None of those were really very

paul_roach:

None of

Rohit Sharma:

effective.

paul_roach:

those were very, yeah, there was some conventional chemo, which is just like toxins that you're hoping to, that the cancers will ingest at a greater rate than the healthy cells. And that's the chemo. And then the other thing, the biological one, was interleukin-2, which was a biomolecule that, made people extraordinarily sick, and it worked very well for a small percentage and not at all for the vast majority of people. And then suddenly now there must be 20 or 30 different things out there in a variety of different categories that are proving to be effective. Now they're not curing it outright all the time, but they're far, far more effective than anything that was available just 10 or 15 years ago.

michael:

How do

Rohit Sharma:

We definitely

michael:

I

Rohit Sharma:

have

michael:

find

Rohit Sharma:

a renewed

michael:

out

Rohit Sharma:

sense

michael:

about those

Rohit Sharma:

of optimism.

michael:

things? That's become a recurring theme again. There are studies out there, there are tests, like beta programs basically that we talked about in some of the other cancers. How do I find out? if I've been diagnosed, like where do I go to look? How do I find out, hey doc, I heard there's a study, is it possible for me to get into that? Is that an avenue that I can pursue? Because you know, Paul just said, I wasn't aware of some of these things. And if Paul's my doctor, as good as a doctor as he is, he can't do everything, how do I try to help myself with this and where do I look?

Rohit Sharma:

So I think it really depends on where you are in this journey. So if you've just received this diagnosis of melanoma, I think you want to be very careful about where you're getting your information. So you need to turn to reputable sources. So your physician, your dermatologist, your treating surgeon, your oncologist, I think could be good starting points. Looking at the American Cancer Society's website, I think would be very useful because you have reputable websites that are presenting objective information that have been vetted by experts in the field That are going to provide you with the facts you need to know because you need objective information There are other websites that are out there that are blogs personal anecdotes of their experiences at different institutions with different providers with different stages of disease I Think those can be helpful at the right time but Early on in the diagnosis, you really need to just figure out where are you in the spectrum of disease, what are your concrete options. I think it's less important to know what an individual's experience is while you're still gathering those early facts. Eventually, you can start incorporating the opinions of others into your own data set to decide what course of action may or may not be appropriate for you. But you want to be very careful that you're not. unintentionally influenced by an individual's personal experience, either positive or negative, at a stage where you're not really ready to consider that information.

paul_roach:

Yeah, I like that advice a lot. I think stick with the tried and true first. Just like Rohit said, the people that you have taking care of you, if you know them and trust them, start there, and then if you're gonna do your own internet search, start with. things like the American Cancer Society. We'll include a couple links on our show notes for people to use to begin to access when we put those out with this podcast. But that's just the beginning. But stick with the ones that are reputable, that are... in the business of, you know, whether it's Memorial Sloan Kettering or MD Anderson or Mayo Clinic or American Cancer Society or whatever, stick with these major institutions for the start.

michael:

But is there

Rohit Sharma:

The other thing to...

michael:

a reputable source for me to go look at and see? I mean, you just told me I've got stage four. And you hadn't been talking to Rohit in a long time. So you weren't aware of some of the things that are breaking. And being the know-it-all that I am, I'm like, OK, but I'm going to go look. Where can I go to find out if there is something a little more experimental than I'm willing to do that you might not even be aware of yet? Is there such a thing for me or is that just closed off to me?

Rohit Sharma:

So there's a website called clinicaltrials.gov, which is a national database of clinical trials that are out there and active, and you can look at it for almost any cancer type. And so you can do your own research if you'd like to find out what clinical trials are active. And then you could even contact the institutions that are running those trials to see if you can be screened to determine if you qualify for that study. Another good option would be to find out if there is a cancer center near where you live, and to contact them and see if they have any active clinical trials for melanoma in this case, or any other cancer if one is dealing with that and listening to this podcast. Those can be useful resources. Now clinical trials are an interesting option, and people fall into different camps from the standpoint of patients on how they view that. Clinical trials certainly can give you access to newer medications, experimental therapies that may or may not make any difference on your disease. Some of these clinical trials are not necessarily therapeutic. They may be testing to see side effects. Some may be looking at efficacy, but for many of them, they may not promise you any positive outcome from using that agent. And depending upon the design of a study, you may or may not receive the experimental drug at hand. So I think you need to carefully look at the design parameters of the clinical trial and see if that's something that you are comfortable with. In many instances, people may be very comfortable with the study design and their ability to access these newer medications that are being evaluated. In other cases, that may be literally the roll of a dice or the flip of a coin. that might determine whether you get the drug or not. And so you, and you may not know in the midst of that trial whether you got that agent or not. And so some people may be comfortable with that idea. Others may be unhappy with that idea. The other thing to keep in mind is you may get the drug of choice and it may be working effectively for you, but when the trial ends, you may no longer have access to that drug. And that's the realistic possibility, especially if it's not something that's been FDA approved and where you can't perhaps have an off-label. use for the drug. So clinical trials have a role, they have a purpose, they really are important helping us to advance medical care for cancers, but you have to understand the environment in which they work and be accepting of it. They can be quite rigorous, have very regimented follow-up, imaging studies, laboratory tests, and some people love the rigors of a clinical trial. They feel like they're being watched like a hawk. and people are scrutinizing them much more carefully for any signs of recurrence or advancement of their disease. And that could be very much reassuring for some people. Others may find the rigors of that just daunting. They can't make it to the lab every single week to get blood draws or meet other requirements for imaging studies and testing and clinic visits and things like that, that can be quite rigorous, especially if you are missing work to do those things. Or have to be... available to fulfill other commitments that now are being impinged upon by the necessities of the trial. So I think before you jump on to a clinical trial, you really need to understand what the requirements of that are going to be, the purpose of that trial, and the potential benefit that it may have to you or lack thereof, and really understand what you are signing up for.

michael:

Fair enough.

Rohit Sharma:

But I don't want to walk out of that statement as sort of being negative about clinical trials. I think clinical trials are a very important part of cancer research. We would not have advancements in cancer care if we did not have them and if we did not have patients who are willing to participate in those trials. And so it needs to be part of the conversation. If you're a cancer patient, you should talk to your oncologist about clinical trials that may be available to you. and consider the options that may be appropriate in that setting.

michael:

Yeah, as framing that question as I'm imagining, if I'm a patient and my doctor tells me I've got stage four melanoma, I wanna know what's out there. Certainly everything that you said is great, things that I wouldn't have even thought about. Is this gonna be really rigorous? Is this gonna be, am I asking for something that's a pipe dream? But... I'm imagining a listener out there who's the reason why they're listening to this podcast is they got that diagnosis and they're here. So I just want to put that out there as there are some things that they might be able to find and then talk about with their doctor as opposed to just sort of being depressed and like, oh my God, there's at least a little bit that they might be able to help themselves with on that.

paul_roach:

Well, I think that everything Rohit said was, was absolutely spot on. And I, in answer to that, to the listener who has received a diagnosis that would make them a potential candidate for a clinical trial. Yes, absolutely. You know, consider it and in trying to figure out if it's going to be something that would work for you, you do really need to either be at a cancer center or being treated by a physician who is in some way affiliated with it. You may live far from an urban center, but your physician is tapped into. to an academic center in the state or something, and they are participating in these kinds of trials. So you do have to go seek them out if you're of that mindset. And the Society of Surgical Oncology is a group that you can probably access, and I think on their website there's a... feature that helps you find someone. I'm sure ASCO or some other groups have it as well, other cancer organizations.

Rohit Sharma:

I think to comments everything we were focusing on earlier, communication is really important here. And so if potentially a clinical trial is of interest to you as a patient, ask your oncologist about it. Ask your surgeon about it. And at least find out what those options may be. If the facility where you're receiving your care doesn't have access to clinical trials, then you may want to ask them, where would they send someone for clinical trials that may be close to where you live? and could access those. Certainly there are major medical centers throughout the country that will have specialists that focus on melanoma among other cancers that may have investigative trials that are active that you may want to consider. And then you have these other highly regarded cancer centers like MD Anderson and Memorial Sloan Kettering that you could also contact by phone and reach out to them and see what they have access to. as well.

paul_roach:

and University of Chicago, our

Rohit Sharma:

University of Chicago

paul_roach:

alma

Rohit Sharma:

as well,

paul_roach:

mater.

Rohit Sharma:

yes.

michael:

Alright, I have

paul_roach:

I think,

michael:

one

paul_roach:

oh,

michael:

last

paul_roach:

go ahead,

michael:

question.

paul_roach:

Mike. Yeah.

michael:

Is there any benefit to someone like me who has moles on their body of having the moles removed almost... I know it's a cosmetic procedure at this point if I don't have any diagnosis, but is there kind of a preventative basis to that or is that just another part of my skin and it is what it is? Until it's not.

Rohit Sharma:

Yeah, usually it's not gonna be recommended to just remove every last mole. Because oftentimes we're not talking about just one or two moles. There's some individuals that might have numerous moles on their body, and it's just not feasible to remove all of them. And so those procedures can become quite disfiguring, and it may not really alter their cancer risk in a significant way. And so I think you want to be very careful. guidance from a qualified dermatologist that can help carefully guide you in this process, especially where a mole may be more concerning and needs to be biopsied or excised, I think is important.

michael:

Paul, you can edit that into the earlier mold discussion.

paul_roach:

Uh huh. Yeah. All

michael:

You're

paul_roach:

right.

michael:

welcome.

paul_roach:

Well. This has been, this has been a fantastic hour and a half. And I want to thank, uh, I want to thank Dr. Sharma here for his generous participation in this. It's been, it's been really great. And, uh, and I want to thank the listeners for dialing in and, and just to say, if you have a topic that you would like to have us discuss, or if you have comments or feedback, please either log into www.PaulBrienRoach.com. Brian with a Y and Roach like the bug. And click on the about and contact page or send them directly to letters at paulbrianroach.com. Mike and Rohit, do you have anything to to sign off with there?

michael:

No, that was a great discussion. Thank you. Thank you for coming in and bailing us out this month.

Rohit Sharma:

Well thank you very much, I really am excited to have had the opportunity to be with you and I think this is a wonderful thing that you guys are doing and I wish you much success in this. 1

michael:

Thankyou.

paul_roach:

appreciate it. I appreciate it. And we'll get you back again someday to talk about non-melanoma skin cancer, perhaps.

Rohit Sharma:

Sounds good. I'd love to do that.

paul_roach:

Alright, thanks very much guys.