LIFE SAVED: PRICELESS
The most important skill that a dermatologist hones over time is visual pattern recognition. With experience, our eyes basically can scan the skin and be immediately drawn to the “Where’s Waldo?” spot that is hiding among the plethora of otherwise benign spots. Recently, I had a patient with melanoma that placed the important pattern recognition as a potential weakness. While there are scattered case reports of melanomas that look like completely benign skin lesions, it took thirteen years and nearly 100,000 skin exams to find one of these cases.
This honing of pattern recognition plus today’s intense scrutiny by both the insurance companies and, if you see Medicare patients, the federal government, has led most dermatologists to decrease their number of biopsies to remain under the bell curve. To better determine the value of early detection versus too many biopsies, biostatisticians at the University of Missouri- Kansas City recently published a study looking at the economic impact of diagnosing melanoma six months earlier in the course of disease. They factored in the cost of a simple skin biopsy and the cost of care for a more invasive melanoma six months down the road in a course of treatment. For instance, the new drug for metastatic melanoma, Keytruda, is over $150,000 per year of therapy. The outcome of their study is that not counting the value of a saved human life, the pure cost savings justifies 170 benign biopsies for every melanoma detected.
To put that number into perspective: In our practice, approximately 40% of all of our biopsies are positive for cancer or precancer. We diagnose over 100 melanomas a year and are well short of the 17,000 benign biopsies that would be justified. But let’s get back to that patient – I shared the photo with my colleagues and every one of them agreed that it looked like a textbook photo of a benign seborrheic keratosis (a mark of maturity). I removed the lesion because it was bothering the patient and, as we always do, sent it off for pathology just in case. You could imagine my surprise when I received the urgent message from the pathologist with his case report.
However, it is not all bad news. The melanoma was caught early, it was less than 1mm, which is considered low risk for metastasis, and a simple excision was all that was required to give a likely cure. The patient is doing well and is grateful that we were able to get a fast result and provide definitive treatment. That patient did not care about the potential injudicious use of biopsy for an apparent benign lesion that saved his life. In life, there will always be those that find fault in others and I have heard complaints that “this dermatologist” or “that dermatologist” removes more spots than others. What I can tell you as a skin cancer specialist is that a biopsy never killed any of my patients and that, in most cases, they leave little to no scar. An undiagnosed melanoma is a killer and I have had the misfortune on too many occasions to deliver bad news to patients who either never previously saw a dermatologist, or saw one that felt like biopsies should only be performed when you are pretty certain it’s a cancer.
Physicians are here to save lives, not fail to deliver care to save a few dollars. Center for Medicare Services recently awarded our practice with a top 1% commendation for high quality and low cost. So, as American Express likes to do in their commercial – Cost of the office visit: $129. Cost of the biopsy and pathology: $267. Life saved: Priceless.