San Antonio Express-News (Sunday)
Skin cancer exam should include full body, scalp
Q: I am a 78-year-old woman who, in my early years, was exposed to many sunny days at the beach. Sunscreen was still a relatively new product in 1954 and not formulated to the standards required to prevent skin cancers the way today’s strong sunscreens are. In those early years, sunblock was not widely used by the public, or me.
As a result, I see a dermatologist twice a year to identify and prevent the spread of skin cancer and its damage to the skin. What I want to know is what should I expect from a dermatologist’s full-body scan. In the past, I have stood a few feet from the doctor with just my underpants on and a medical tissue gown opened in the back. Meanwhile, I had a friend tell me that her dermatologist checks “where the sun doesn’t shine.” Another person said the doctor feels their arms for signs of cancerous cells. And another lady I know said her doctor discovered a cancerous growth on her waist.
With a tissue gown on, the area between my chest and waist are not exposed to the doctor’s view. Should the scalp be checked? I am not sure I have confidence in the full-body check I am receiving!
A: Melanoma is the most dangerous skin cancer, and the one that doctors most want to find early. The correct technique for a skin cancer check is to examine the whole body under strong light and with magnification if needed. The gown has to come off for a proper exam. The scalp should definitely be included, as it is very hard for a person to examine it themselves, but genitals are typically not, unless the person has a specific concern. The thighs and legs are particularly important in women, and the back is particularly important in men. But, any sun-exposed areas should be carefully examined.
Skin cancer screening is mostly done by sight, not by feel, but I did have a dermatology professor tell me to gently palpate the scalp, as it can be hard to see the whole scalp, and he said he had found cancers there by using feel.
Q: My wife is a Type 2 diabetic and takes metformin twice a day. However, her new primary doctor said that metformin deprives the muscles of sugar, which they need for energy; therefore, muscle wasting will slowly occur. Should she continue taking this medicine?
A: That’s not correct. Metformin works primarily by reducing the amount of sugar the body makes. Blood sugar can either come from what you eat or by the liver producing and releasing sugar into the blood. With less sugar in the blood from the liver, the insulin a person with diabetes has relies on the sugar from the diet.
Insulin is needed to bring sugar efficiently into the cells, so when your insulin is working more efficiently (metformin actually helps muscle cells get and use sugar through a second mechanism), your muscles work better. Metformin does tend to help people lose weight, but they tend to lose fat, not muscle. Metformin remains one of the most important medicines for Type 2 diabetes and is associated with improved overall mortality, compared to several other drugs.
Q: I’m 72, and I have had arthritis for three years: two years in both knees, one year in my right hip and the base of my spine. I am 5’3” and weigh 221 pounds, with a body mass index (BMI) of 39. I lost 23 pounds from January to June.
What is the BMI needed for an orthopedic surgeon to do a hip replacement for someone with osteoarthritis — without a broken hip? I recently had an assessment of my hip X-rays. I was told I’m at the outer cutoff of a BMI of 39, so I’m eligible for a hip replacement operation. Then, a few weeks later, I saw the surgeon, who rejected me — claiming that 39 isn’t the outer limit, 35 is.
After a long talk, the surgeon said he’d do it for me, but I’d get a better result if I lose 20 more pounds and get my BMI down to 35. I felt jerked around but said I’d wait and lose weight. I’m also trying to find a surgeon I like more than him.
So, what is the BMI needed for knee surgery: 35 or 39?
A: There is no standard cutoff BMI for joint replacement surgery. It is true that people with a BMI over 40 are at higher risk for medical complications; however, it is also true that people with severe arthritis and a high BMI still get improvement in their quality of life with surgery. Denying a person a cost-effective surgery that can greatly improve their quality of life simply because of a BMI number (which, in itself, is a flawed metric) is inappropriate.
I can understand why you would want to see a different surgeon, as it sounds like you were not treated well. However, the surgeon was right that surgical outcomes are better if a person can lose at least 20 pounds, according to a 2019 study. This included shorter lengths of stay in the hospital and a lesser chance of needing surgical revision. I wonder, though, if part of the benefit seen in the study was due to increased exercise prior to surgery, which is known to be beneficial in surgical outcomes.
Q: My 45-year-old son has hemochromatosis. The treatment is phlebotomy of a pint of blood, sometimes every two weeks, until the iron level is normalized. My understanding is that the blood is discarded. Is there anything wrong with the blood? If not, I would think blood banks would welcome the donation. What are your thoughts on this subject?
A: Hereditary hemochromatosis is caused by the body absorbing too much iron due to a genetic defect. With no way to get rid of iron, it builds up and damages many organs, especially the heart, bone marrow, joints and adrenal gland. As you say, the best treatment is to remove iron in the form of red blood cells. This is effective at preventing most of the organ damage, if started quickly enough.
There has never been anything wrong with the blood of people with hereditary hemochromatosis, and the Food and Drug Administration here in the U.S. has always allowed the blood to be donated. However, until recently, the American Red Cross has not accepted blood donations from people with hereditary hemochromatosis. I am pleased to say that they have just changed their policy and will now be using this precious resource to help others, so long as the person meets all the criteria for being a blood donor. The blood will undergo all the standard and rigorous testing prior to being pronounced safe for use.