Adventures with American Health Care: Melanoma

Probably forty years ago now, WC was defending a permafrost house case.

(Notes for nor non-Alaskans: permafrost is permanently frozen soils, often laced with lenses of ice. When the permafrost melts, anything built on it is likely to collapse. If a house is built on permafrost, the results are often catastrophic. Because it can take years, even decades, for the heat from a house to create a thaw bulb that reaches deeply buried permafrost, buying an older house is no guaranty that there is no permafrost under it.)

For a long time, the tendency of unhappy homeowners facing a collapsing home was to sue everyone: prior owners, contractors, real estate agents and even mortgage lenders. Defending one of those permafrost house cases, WC had as an expert witness a highly regarded Alaska soils engineer. We’ll call him “Rohn.” On the witness stand, his testimony went something like this:

WC: “Rohn, did you cause test drilling to be performed on this property”

Rohn: “I did.”

WC: “Please show the jury on the site drawing that is Exhibit A where you performed those test drills.”

Rohn: [Identified eight locations.]

WC: “Did you examine the materials produced from those test borings?”

Rohn: “I did.”

WC: “Did you find any evidence of ice or permafrost in any of those materials?”

Rohn: “I did not.”

WC: “Can you make a professional conclusion from those observations?”

Rohn: “Yes, I can.”

WC: “What is that conclusion?”

Rohn: “There was no permafrost or ice where I performed those test drillings.”

WC: “Can you draw any professional conclusions about the presence or absence of permafrost on other areas on the property?”

Rohn: “No, I cannot.”

WC brings up that old lawyer war story because it demonstrates that when you perform a limited number of tests on a large area, you generalize from the results at your peril.

WC was diagnosed with melanoma last year. WC’s biennial visit to his dermatologist revealed a suspect spot, about half a centimeter in diameter, on the back of WC’s left forearm. The dermatologist carved the area out, and a biopsy confirmed melanoma. Fortunately, the cancerous cells in the initial biopsy specimen were limited to the epidermis, the uppermost layer of the skin.

The treatment for that particular diagnosis is to carve out an area of skin – epidermis and dermis – a centimeter on either side of the earlier biopsy. The goal is to have no melanoma cells within a half a centimeter of the margin of removed chunk of skin. For WC the result was three consecutive surgeries, about four weeks apart, each involving a slightly larger amount of tissue removed. But the skin carved out in the third effort – a diamond-shaped chunk two centimeters wide and seven centimeters long – had the required half centimeter margin free of melanoma cells.

That’s very good news. And the bonus is that the skin on WC’s left forearm is as tight as a baby’s now, those old age wrinkles all gone. If you remove a cumulative total of about 2.5 inches of skin from a limb, yeah, it’s a stretch to sew it all up.

But WC isn’t “cured.” There were no melanoma cells in the margins of the last chunk carved out of WC, but, like permafrost, you can’t draw a definitive conclusion from those results. Cancer patients might be lucky enough to be be “in remission,” but are not necessarily “cured.” WC’s melanoma is most likely a consequence of hereditary predisposition. Other members of WC’s family have struggled with melanoma, and WC’s maternal grandfather was half Ashkenazi, a genetic group with higher risk for the disease. Melanoma can recur anywhere in WC’s body at any time.

Except for the enactment of Obamacare, the Affordable Care Act, if WC were under age 65 as a cancer survivor he would be uninsurable now. Thanks to President Obama and Medicare, that’s not a risk now (although the Republican Party may try to change that).

Old age is not for the faint of heart. As the late Captain Jim Binkley used to say, “The engine’s pretty good but the chassis’s not worth a damn.”