CANCER: THE INCREASING INCIDENCE OF MALIGNANT MELANOMAThe incidence of malignant melanoma is increasing rapidly in many countries. During the latter part of this century it has been doubling every ten or twelve years. The effect varies between countries and is most striking in those parts of the world where fair-skinned populations are exposed to intense sunlight. This makes Australia and the hot parts of the United States the highest-risk areas and Queensland in Australia is the melanoma ‘capital’ of the world. In Queensland, 30 people out of every 100,000 now get a melanoma every year. This is much higher than in Western Europe, where the figure ranges from 1.2 per 100,000 per year in Poland to over 10 per 100,000 per year in Scottish women. Within Europe, the United Kingdom overall is in the middle of the range at about 7 cases per 100,000 per year, possibly higher in Scotland, where accuracy and completeness of studies of melanoma are excellent. In many countries, the incidence is increasing rapidly, and we have illustrated this with diagrams representing the changing incidence of melanoma in the United States as reported by Dr Rige and colleagues in 1987 and in Scotland as reported by Professor MacKie and colleagues in 1992. In Scotland the current rate of increase is 7.4 per cent per year but fortunately many more melanomas are now of the thinner, less dangerous type.This has increased from one in 1,500 in 1935 to an estimate of one in 90 in the year 2000. In view of the potential seriousness of malignant melanoma these trends have to be viewed with alarm. Upward trends in incidence have also been seen in Western Europe and in the United Kingdom. Interestingly enough, though, the public-education programmes started in 1985 in Scotland may be having an effect, for in Scotland the proportion of melanomas which fall into the thin and superficial category, and which are therefore more easily cured, has grown significantly.*68\194\4*

However, I think that the best way to get rid of any physical or mental symptoms of nervous tension is to tackle the cause directly. Stop trying to hide or deny your feelings of sadness, anger, or fear. When you try to force these natural feelings underground they are more likely to express themselves in the form of some unpleasant symptoms. So try to let them out — talk about them and allow yourself to feel them. You may be able to do this with family, friends, your practitioner, a nurse, a priest, social worker, psychologist, or psychiatrist. Choose one or more of these people that you trust and feel comfortable with.

Any or all of these approaches may reduce your discomfort and help you to take and keep control of your life. Don’t let your need to appear tough and able to cope with anything prevent you from seeking relief of all your symptoms, whatever their cause.

We’ll now go on to look at some of the symptoms you could experience and what you can do about them.

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Like many fathers, doctors are used to being in a position of power and authority. They want their patients (children) to be obedient and submissive. They are used to telling patients what to do and they are used to patients meekly obeying their instructions. To share basic information and explain and justify their own decisions would be to weaken their power and to undermine their authority. Patients who ask questions are often treated like naughty and rebellious children. How do fathers deal with children who threaten their authority? They get angry. Or they act as though they are too busy and/or important to bother with answering such silly questions. Or they simply ignore the questions. Or they answer using words that are beyond the child’s understanding, hoping to embarass them out of asking any more questions. Or they dismiss the questions with a fatherly pat on the shoulder and a patronising statement such as: ‘Just leave it all to me’ or Til take care of you’ or ‘I know what’s best for you’. Do you recognise these tactics? Many doctors use them to establish and maintain a paternalistic type of control over their patients.

Don’t let your doctor treat you like this. You are a responsible adult and you deserve to be treated like one. It is your cancer, your comfort and your life that’s at stake. You can make better decisions for yourself than anybody else can. Don’t let anyone bully or cajole you out of your basic right to be in control of what happens to your own body.

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But times have changed, and so should our attitudes-in this case, from cowering fatalism to bold confrontation. “You don’t have to be cancer’s victim,” says Dr. John Wurzelmann of the University of North Carolina at Chapel Hill School of Medicine. “And you don’t need to be afraid to think about it. There really is a lot of reason to be optimistic.”

To be sure, cancer is still a scourge, still the number two cause of death in the United States. Three of the four most common and fatal cancers (colorectal, prostate, and lung) affect men most often. What’s more, almost all cancers attack and kill men at higher rates than women.

But here’s the rest of the picture. People are surviving almost all kinds of cancer more than they ever did before. Early-detection techniques are better, so more cancerous tissue is being removed before it spreads. Treatment options have expanded.

It’s not just the doctors who got smarter. The rest of us are learning that there are a whole lot of things we can do-or stop doing to keep cancer away in the first place. We’re taking control. As a team of Harvard-affiliated researchers put it in the Harvard Report on Cancer Prevention, “Cancer is indeed a preventable illness.”

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The function of the breasts in all mammals is to produce milk for the developing young. Milk production occurs in the lobules, and the milk passes via lactiferous ducts to the nipple. Around each nipple is a pigmented area called the areola, which is lubricated by oily secretions from sebaceous glands in the skin.

Blood is taken to and from the breast through a rich supply of arteries and veins. There is also a system of lymph vessels which drain lymph from the breast. Lymph is a clear fluid which surrounds the cells of the body tissues and contains a large number of disease-fighting cells called lymphocytes. The lymph drains from the surface to deep within the breast, and from there to lymph nodes in the armpit (axilla) and in the chest wall adjacent to the breastbone or the collar bone.

The lymphatic drainage of the breast is particularly important in malignant disease as cancer cells are able to spread via the lymph vessels to other areas of the body, particularly to the axillary lymph nodes of the armpit. However, swollen lymph nodes can also develop in benign conditions, and their presence is therefore not necessarily a sign of cancer.

As a fetus develops in the womb, part of its chest wall turns inwards to form a series of branching ducts. Just before birth, the ducts turn out again, forming the nipple. In girls, at puberty, many small sac-like alveoli sprout from the ends of the ducts and fat is laid down around them. The glandular alveoli develop further during pregnancy and secrete droplets of milk in lactation.

As women get older, the gland tissue in their breasts is gradually replaced by fat, which is why the breasts become softer and tend to droop with age. Eventually most of the ducts and lobules disappear.

Tender nodules may appear as the breasts begin to develop at puberty, and this tenderness may remain for months or even years. But once the breasts have developed, any pain or lump that forms needs to be investigated. It is possible that the early detection and removal of a cancerous breast lump may give a better chance of cure and survival than does treatment of one which has begun to spread to other parts of the body.

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