A pound of flesh for touching the progress of science

I should have gone straight to Wikipedia. Instead I put the Latin words “In Situ” into Google. The dermatologist had spelled it for me, and the Wikipedia entry appeared at the top. It said the following, “In archaeology, in situ refers to an artifact that has not been moved from its original place of deposition. In other words, it is stationary, meaning ‘still.’” Wikipedia’s definition echoed the dermatologist’s, who verbally translated the phrase as “in place.” That was reassuring and also not quite to the point. 

I should have started with the full phrase, “In Situ Melanoma.”

That brought up a flood of reassuring headlines, among them, “Stage 0 Melanoma,” and “Melanoma at its most curable.” Everything except Wikipedia. Google’s algorithm brings the most popular to the top. Apparently most people with melanoma do not go to Wikipedia.

Wikipedia makes science accessible, and includes large doses of detail for the curious. Most entries are done by volunteers, and most readers do not really care why the volunteers do it. These volunteers never hear a word of thanks from anybody. In a world of hacking and malicious bots and virtual money laundering and the surveillance state, Wikipedia represents something inspired by a more optimistic time, a reminder of the Internet that gave me hope, and still does.

If you happen to be one of the contributors to the article on melanoma, please accept my thanks.

The entry for melanoma is long and detailed. I skipped the details and went straight to the key finding for five year survival and took a deep breath. “Stage 0: Melanoma in situ (Clark Level I), 99.9% survival.” Some very helpful diagrams also made it clear that I had been very lucky. As they say, we caught it early.

Freckles

It started as a collection of freckles. They had been on my arm for decades.

They got there from a sunburn at the beach, from a hike in the mountains, or perhaps from a sunny afternoon reading in the backyard in California as a teenager. My childhood included optional suntan lotion. Sunscreen was not part of my vocabulary. Nobody lectured us about it. Suntans made you attractive.

A couple months ago the collection of freckles started to look different. It itched. I must have scratched it at a moment when I was not paying attention because it became a scab. It did not heal properly. The skin appeared redder and rawer than normal. It just did not look right.

The surface was even. One symptom, uneven surfaces, had somehow latched onto my memory. That had fostered a false sense of security.

It was my first dermatologist appointment in years. I immediately liked him. Great conversationalist. He asked about family history, as he should, but he was not all business. Our conversation wandered hither and yon.

The doctor paused at the freckles. He stopped talking to look. He asked questions about them. When did I first notice something? He looked elsewhere on my body and came back to them. Finally, he took a sample for a biopsy. Promised to call when the results came in. No, not email. He would call. I like email, I insisted. He hated email, he responded.

He phoned on Monday, and predictably, we played phone tag. I made an effort to reach him. It did not seem like something I should let go for a while. It was just an intuition. Maybe because he kept coming back to the freckles.

After our conversation I sent an email to my siblings and father. They all have faced skin issues, and had basel cells and squamous cells removed. These go by the label “Precancerous.” Not Melanoma. Nothing “pre” about it. It is cancer and it can kill you if left untreated. In Situ melanoma is the least deadly form. My sister’s email began with “Yikes!” It is funny how email sometimes can capture a person’s voice.

I am writing this blog post now to pass along the key lesson. If the freckles do not look right, get them checked out. Early detection is so much better than the alternatives. Treatment after early detection is routine and easy, albeit, not painless.

Look, that last sentence is not the entire truth. I also am writing this post for another reason. Writing helps me digest events. Communicating with others helps make connections. Making connections motivates me to find the right words. Finding the right words helps me assay an event and digest it. Like I said, I am trying to digest events.

Why digest in such a public format like a blog post? My favorite science writer, Stephen J Gould, discussed his own cancer in his writing before it eventually killed him. Well, if he can do it, then so can I.

Also, I have been around this block once before. Some years ago I suffered an episode with Sepsis, which could have killed me, and I wrote about it on my blog post with much the same set of motives – to help others learn lessons and help me digest. As it turned out, and to my surprise, that post became the most read blog post I have ever written. And by far. Nothing else ever came close.

At the time it was a tad humbling to realize that only a few people ever cared about my posts on IT, but a significant slice of humanity was willing to read about my story of near-death. I would have preferred to be known for the former, and not the latter.

A good friend gently explained: it is the way humans are wired. I have learned to accept this. So here comes another.

One fact distinguishes this episode from the last one, and perhaps makes this episode less interesting. The prior episode had been a crisis, involving an emergency room and low blood pressure and eleventh hour antibiotics. In contrast, in this case I merely escaped a bullet.

More to the point, in another era, no more than half a century ago, the itch on my arm would have led to less dramatic events, a slow death sentence played out over time as the cancer slowly ravaged my body. Not today. I did not die, or really get close to it this time. I merely glanced its cold shadow far away around the corner in a possible future that never took place. If there was any drama it took place at the surgery, and even that was routine.

Linear or circular

Let’s demystify the removal of In Situ Melanoma. This should cement your motivation to visit the dermatologist, just in case you are not already convinced that it is worth your trouble to get early detection.

Here is how the treatment went. The surgeon walked in and introduced herself. We chatted. Another good conversationalist. Maybe this field draws good conversationalists because the patients do not sleep through the procedures. The conversation wandered to and fro. She had been an undergrad at Stanford when I had my postdoc there. We made a connection. It put me at ease.

She pulled out a big felt-tipped purple pen and drew a circle around the patch of melanoma. The circles included plenty of “margin” so she could be sure she took all the diseased skin. Then she drew two parallel lines out from the circle, forming a long thin parallelogram on my arm.

“Two choices.” she said in that matter-of-fact voice that every doctor possesses. The cut could follow the border of the circle or the parallelogram. The scars differed. The latter took more skin, but the scar looked nicer.

Having no experience with such choices, I asked her what was medically best. She said linear without hesitation. If linear is better, I wondered, why had she offered the choice in the first place? Does anybody prefer less skin removed and an uglier scar?

Everyone left the room as they waited for the Novocain to act. I texted my wife, who is a physician, and asked which one she recommended. Again, no hesitation. Linear. When she returned I told the surgeon my wife’s response. The doc smiled.

I could have watched the surgery, but chose not to. It would have made me light-headed. So I looked away and we chatted. The conversation took my mind off the surgery. We talked about our paths to Stanford. I hesitated momentarily and then let her know that before I got my PhD at Stanford I had been a Cal undergrad, a participant at the local rival. Don’t hold it against me, I said. She giggled. I told her that I had been present during “The Play.” I do not meet many people outside of the Bay Area who have any idea what that is, so it is fun to make that connection on rare occasion. In case you missed it, five Cal players lateraled to each other on the final kickoff, and they managed to get the ball into the end zone, where they ran into the Stanford band, who had started celebrating too soon. It was one of the craziest endings ever to a college football game. She did not say anything. She grew up in the Boston area. I guess she did not care about the history of the Bay Area football rivalry.

Curiosity got the best of me at the end, and I took a peek. Surgical strings and surgeon’s tricks tied together a long bloody line on my arm. It made me light-headed.

An assistant dressed the wound. He lectured me on proper care.

Then I was allowed to go home. That was it.

Not far out of the office, my mind wandered at a stoplight. Stephen J Gould used to say the mind was a pattern-making machine. What pattern arose here? The parallelogram did not even amount to a pound of flesh, the collateral Shylock asked for his loan in Merchant of Venice. Was life taking its pound of flesh as collateral for some cosmic debt I owed? No sunscreen on a hike? A cavalier run on a sunny day? As some sort of punishment for the joy enjoyed while being outside? Shakespeare’s famous lines for Shylock bounced around aimlessly in the ether. “If you prick us, do we not bleed? If you tickle us, do we not laugh? If you poison us, do we not die?” I had bled and the poison had been removed. What did that have to do with tickling?

A pound of flesh is a small price to pay for a much longer life. I could not jettison the thought.

I took a deep breath. It was soothing to think that these horrible things occur as part of an organized balancing act, as if governed by a longer and greater narrative. The illusion of balance distracts from staring into the dark abyss of randomness, where a chance lack of ozone on a clear day let in UV light and pointlessly touched me at a particular moment because I failed to move a little to the left.

The light turned green, and I drove home in silence.

The morning after

I did not sleep well. My arm hurt, and my thoughts kept coming back to a friend of mine, an old roommate, who had recently suffered through an advanced form of melanoma. Not stage zero. He had one of the higher numbers. He told me about it at lunch last year. He got treated with the new medications that put the autoimmune system into overdrive. It worked for him. He would have been dead by now if not for advance in science. I think I will call him soon and try to catch up. It has been a while.

I made my way down to the morning’s coffee, and after reading the news, I groggily opened Facebook, which showed me a photo from five years ago, and asked if I wanted to share it. It was from the Chicago Marathon. What a coincidence. I took up long distance running after my bout with Sepsis. The running began with an almost cavalier attitude of “what the heck” and “Why not?” Eventually the running grew into a determination with its own momentum, a desire to prove something to myself. It was as if Facebook was teasing and tickling me this morning, whispering, “Alright, mortal, what are you going to do next?”

I began to grin. It was miserable outside, rainy and gloomy. Inside the kitchen it was sunny, and there was no need for sunscreen. I flipped through Facebook, sipped my coffee, and waited for the kids to awake. French toast was on the menu this morning.