‘I am not someone who gets skin cancer’: Risk, time and malignant melanoma

‘Delay’ is a term used in the cancer literature since the 1930s to describe the period between self-detection of a concerning sign of possible disease and presentation to a health professional. This linguistic choice carries an implication of blame for apparent failure to manage a risk appropriately, drawing attention away from the contemporaneous perspectives of those who respond to suspicious indicators more or less quickly. We present findings from a grounded theory study of accounts given by 45 patients about their slower or quicker journeys to a diagnosis of cutaneous malignant melanoma, a cancer which can ‘hide in plain sight’. There has been little research exploring in qualitative detail patients’ perspectives on their decision-making about what subsequently turn out to have been signs of this most risky of skin cancers. The findings frame referral time-lapses in terms of normalisation of symptoms, sometimes buttressed by reassurance derived from health promotion messages, disconfirmation of patients’ concerns by their general practitioners and prioritisation of other life concerns. We argue that a shared sense of urgency surrounding melanoma self-referral derives from a clinical representation of current knowledge which conceals numerous evidential uncertainties

Problematic pigmented lesions: approach to diagnosis

A number of pigmented lesions are difficult to classify and raise the possibility of a melanoma diagnosis. Care should be exercised to exclude non-melanocytic lesions, and benign melanocytic entities, both of which can mimic melanoma histologically. In addition, the possibility of the lesion being a melanoma variant or epidermotropic metastasis should be considered. There will still be some cases that are difficult to resolve. These usually fall into one of three categories: atypical junctional melanocytic lesion versus early melanoma; naevus versus naevoid melanoma; and atypical Spitz, cellular blue, and deep penetrating naevi versus thick melanoma. These will pose problems even for experts. The atypical Spitz lesions are perhaps the most important category because they tend to be from younger individuals, the differential diagnosis is thick melanoma, and there is no single discriminating histological feature. Key Words: difficult diagnosis • pigmented lesions • melanom