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Out Damned Spot: What Actor James Rebhorn Says to Us

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Although Lady Macbeth says "out damned spot" probably to a blood stain she thinks she has on her hands, it's a more damned spot when it represents a malignant melanoma, the deadliest of skin cancers. Melanomas, usually associated with sun exposure, are increasing in frequency and represent a significant health threat, but one we can prevent.

Recently, actor James Rebhorn died of widespread melanoma. He was best known for his roles in Homeland, White Collar, Scent of a Woman, Meet the Parents, and Independence Day. Some people may not recognize his name right away, but his face has been familiar to all of us. But his best role, I think, was that of a patient battling cancer who did not let the diagnosis of widespread malignancy get him down. In fact, he worked until only two months before he died, even though he was continuing to receive therapies.

For 22 years, James Rebhorn took his treatments for melanoma. When first diagnosed, very little therapy other than surgery, immunotherapy with interferon or activated T cells, and a use of a single chemotherapy drug dacarbazine were known to control the disease.

But over the last 10 years, there has been an explosion of therapies with dramatic benefits to patients. Use of sentinel node biopsy in addition to surgical removal of the melanoma in the skin has improved ability of doctors to select which patients should have wider node removal and adjuvant immunotherapy. The available immunotherapies have increased with the discovery and approval by FDA of ipilimumab (Yervoy). And now PDL1 and PD1 antibodies offer promise to increase the impact of immunotherapy even further. Chemotherapy roles have increased with approval of temozolamide (Temodar), as well as targeted drugs against melanoma mutations such as vemfurafnib (Zelboraf), trametnib (Mekinist) and dabrafnib (Taflinar).

But even despite all these drugs being available, James Rebhorn still succumbed to this often relentless disease. His courageous struggle is a sign to anyone suffering from cancer that has become widespread to continue to try to find a treatment that will control the disease longer so that life can be extended and enjoyed.

So here are my tips for preventing and treating melanoma:

• Melanoma is usually due to sun exposure, so avoid sun radiation to your skin by slip, slop and slap, seek and slide: When going into the sun, slip on a shirt, slop on SUV 30 or greater sunscreen, slap on a hat, seek shade, and slide on sunglasses. Avoid excessive sun exposure.

• When avoiding sun exposure, be sure to have your doctor check your vitamin D levels, since they are often decreased in Americans, especially when following the advice to avoid sun. Decreased vitamin D can lead to weak bones (osteomalacia and osteoporosis), fractures and may also be associated with increased breast, colon, or prostate cancers, multiple sclerosis, and other diseases.

• Don't use tanning treatments. They increase your risk of melanoma skin cancer by 74 percent, and even 250 percent if you have used tanning for over 50 hours or 10 years.

• Always disrobe when seeing your doctor for a checkup so all your skin can be examined for early melanomas. Better, see a dermatologist for a complete skin exam every year to diagnose any melanomas early, in addition to any other less serious skin cancers.

• Watch for any spots that are suspicious of a small early cancer. Watch for ABCDE: spots or moles that are asymmetric (not round), with borders that are uneven, color that is not uniform, diameters above ¼ inch, or are evolving (changing in size, shape or color).

• When you see a spot, immediately see your doctor for evaluation, and if appropriate, removal of the spot.

• If it is diagnosed to be a melanoma, ask for a second opinion on the pathology to be certain of the diagnosis. If confirmed, be certain you are referred to a surgeon who is expert in treating melanomas to be sure a wide enough surgery is performed and a sentinel node biopsy is considered. Ask if adjuvant therapy is appropriate or not necessary. Get a second opinion from a medical oncologist if the doctors are uncertain. See my book Surviving American Medicine for advice on when and where to get a second opinion.

• If the cancer should recur despite initial treatment, ask your doctor to refer you to a doctor or a center expert in handling advanced melanoma.

• If the cancer becomes resistant to standard therapies, consider a clinical trial. You can find out about melanoma clinical trials available to you in your community.

• Remember James Rebhorn and do not give up. Continue to get treatment to try to control the disease and improve your quality of life. Remember, cancer is usually not a short term illness, but a chronic one that has remissions and exacerbations that, appropriately treated, can allow you to have satisfying life. Using a melanoma support group can help you make decisions about your disease and help you find the courage to continue on.

• If there are several individuals in your family with melanoma, or if you have had two or more melanomas, consider gene testing to see if you have an inherited gene mutation (like CDKN2A or CDK4)that could result in more melanomas (you can have increased screening to detect them early), or could be passed on to your children (so they can have gene testing and increased screening and prevention). If your doctor does not know about these, ask for a second opinion with an oncologist or medical geneticist.

Each of us has about 22 square feet of skin, all of it susceptible to getting skin cancer. Work with your doctor to prevent, screen, diagnose and treat skin cancers especially melanomas as early as possible. Remember James Rebhorn's struggle and don't let melanoma take you down.

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