Skin cancer checks as a routine

The dermatologist took the freezing spray to a small rough patch on my left temple and held it there for ten seconds. The skin went white, then numb, then started to ache like a bruise that had been there for days. He was already looking at the next spot, on my forearm, with a hand-held magnifier. "That one is just sun damage," he said. "The one on your shoulder I want to take off today." I had walked in for a routine annual check, the kind I had been putting off for three years, and I was now booked for a minor excision in twenty minutes.

I am 52. I grew up in Australian summers. I have the freckled, fair-Irish skin that the southern sun was specifically designed to punish. The dermatologist called my back "a working surface," which was a generous way of describing the visual record of forty years of sunburns I no longer remembered.

The number that should change your behaviour

Australia and New Zealand share the highest melanoma rates in the world. By a long way. The lifetime risk of melanoma for an Australian man is approximately one in 13. For non-melanoma skin cancers, the basal and squamous cell carcinomas, the lifetime risk is closer to two in three. Two out of every three Australian men will, at some point, have a skin cancer cut, frozen, scraped, or burnt off their body.

Read those two numbers again. One in 13 for the kind that can kill you. Two in three for the kind that can disfigure you. There is no other cancer in this country with anything close to those frequencies. Bowel, prostate, lung, all of them sit in the single digits of lifetime risk. Skin cancer is the cancer Australian men will, on the balance of probability, get. The only question is when it shows up and how early it is caught.

And yet most of the men I know have never had a full-body skin check. Not once. They will get their cholesterol read every year, their prostate poked at 50, their teeth cleaned every six months, and they will leave a melanoma sitting on their back for a decade because nobody told them to look.

Why your GP is not the answer

Your GP is a generalist. A good GP, with twenty years of experience, will catch the obvious lesions. The bleeding ones, the black ones, the ones that look wrong from across the room. They are not, however, trained to spot the early melanoma that looks like a slightly asymmetric freckle, or the basal cell that looks like a small shiny pimple that will not heal, or the lentigo that looks like a sun spot but is changing shape over twelve months in a way only a dermatoscope will pick up.

A skin doctor, which in Australia means either a dermatologist or a GP with a postgraduate dermoscopy qualification, is the right level of specialism. They will look at every centimetre of your skin under a polarised-light magnifier. They will photograph and map any moles that need watching. They will recognise patterns that a generalist sees once a quarter and they see a hundred times a day.

The cost in Australia is roughly $150 to $250 for an annual check at a dedicated skin cancer clinic. Most do not bulk-bill the screening visit. Medicare will cover part of any subsequent excision. This is not a free service for most men, and that is part of why men skip it. Two hundred dollars, once a year, is the price of one good restaurant meal and the difference between catching a melanoma at stage one (98% five-year survival) and stage three (about 50%).

What a full-body check actually looks like

You strip to your underwear in a small examination room. The doctor turns on a bright overhead light, picks up a dermatoscope, and works through your body in a systematic order. Scalp first, parting the hair in sections. Face, ears, behind the ears. Neck, shoulders, chest, abdomen. Each arm including the underarm and between the fingers. Back, including the small of the back where you cannot see. Buttocks. Legs front and back. Soles of the feet. Between the toes. The genitals, which the doctor will offer to skip if you decline, but most melanomas in this region are missed precisely because men decline.

The whole thing takes 15 to 20 minutes. The doctor will photograph anything they want to monitor and annotate it on a body map you can take home. If something needs to come off that day, they will numb the area, excise it, send it to pathology, and you will have a stitched line and a result in seven days.

That is the routine. Once a year, from the age of 35 if you have any of the risk factors below, or 40 across the board.

• Fair skin, freckles, or red or blonde hair. Higher melanoma risk by a factor of two to four.
• History of childhood sunburns. The damage from a single blistering burn at age eight is still in your DNA at 50.
• More than fifty moles, or any unusually large or irregular mole. Mole-mappers will photograph and track these year on year.
• Outdoor work or sport history. Tradies, surfers, gardeners, runners. Cumulative dose matters.
• Family history of melanoma. First-degree relatives push your risk up sharply.

If two or more of these apply to you, get an appointment this month, not this year.

The ABCDE rule for self-checks

Between annual visits, the self-check is a five-minute job in front of the bathroom mirror, ideally with a hand mirror to see your own back. The standard rule for assessing a mole is ABCDE.

• A for asymmetry. A normal mole, folded in half, matches itself. A suspicious mole does not.
• B for border. Smooth round borders are fine. Notched, scalloped, or fading-into-the-skin borders are worth a photograph.
• C for colour. A single uniform brown is fine. Multiple shades inside one lesion, or any black, blue, or red within a brown mole, is worth flagging.
• D for diameter. Anything larger than 6mm, the size of a pencil eraser, deserves a closer look.
• E for evolving. A mole that has changed in any of the above categories over six months is the single most important sign. Photograph anything new or changing on your phone with the date.

The phone-photo trick is the cheapest cancer screening tool you own. Every six months, take a set of well-lit pictures of your back, chest, arms, legs. When you compare them year on year, the mole that has darkened or grown is obvious in a way it never is in the mirror.

What a removal feels like

The minor excision the dermatologist did on my shoulder took eleven minutes. He injected lignocaine, which stung for ten seconds and then everything went numb. He cut an oval-shaped piece of skin out, roughly the size of a five-cent coin, closed it with three dissolvable internal stitches and four external ones, and put a waterproof dressing on top. I drove home. I took two paracetamol that night because the lignocaine was wearing off and the area felt like a deep bruise. I had the stitches out at day ten. The scar, six months on, is a thin pale line that I have to look for to find.

The pathology came back as a basal cell carcinoma with clear margins. Cured. (The same lesion, untreated for another five years, would have been a much larger excision and possibly a skin graft.)

The reason men skip this

The reason men skip skin checks is the same reason men skip most preventive care. They do not feel sick. There is no symptom. The lesion does not hurt. The cancer, if it is there, is silent until it is not, and by the time it is not silent the conversation has changed from "we will take this off in twenty minutes" to "we need to talk about your lymph nodes."

The other reason is the small humiliation of standing in your underwear in front of a stranger while they examine your body for damage. I get it. I felt it the first time too. It lasts about ninety seconds and then you realise the doctor has seen ten thousand bodies this year and yours is not interesting except as a working surface for their craft.

BOOK THE APPOINTMENT.

It is one phone call. It is two hundred dollars. It is the single most cost-effective piece of preventive medicine available to an Australian man, and most men reading this have not had one in the last three years, and some have never had one at all.

I will go again next April. So should you.

Skin checked. Risk lowered. Routine kept.