Skin cancer is the commonest type of cancer: There are more new cases each year than there are of all other cancers combined. The principal cause is exposure to ultraviolet radiation from the sun, with the usual contributions from genetic bad luck. Basal cell carcinoma is the most widespread and least-frightening variety. It almost never metastasizes, and, if the tumor is superficial and small, it can sometimes even be obliterated non-surgically, with repeated applications of a topical cream or with a particular kind of light therapy. Next in severity is squamous cell carcinoma, the treatment for which is trickier but usually also straightforward unless the cancer has spread. The worst kind—and, fortunately, a relatively uncommon one, although its incidence is increasing—is melanoma. If melanoma isn't caught early, it can metastasize rapidly to distant parts of the body, and once that happens it's often fatal. Invasive melanoma accounts for a tiny percentage of all skin-cancer cases but for the majority of skin-cancer deaths.
Golfers have always been at greater risk of developing skin cancer than people who never go outside or visit tanning parlors, but even among nongolfers the incidence has been rising for years, worldwide. Studies cited by the Skin Cancer Foundation have shown that, in the United States, cases of nonmelanoma skin cancer increased by 77 percent from 1994 to 2014, and that there will be 7.7 percent more melanoma cases this year than there were in 2018. (Whales are also affected. They're exposed to the sun when they surface, and the skin damage they suffer appears similar to the skin damage suffered by humans.) The main cause for the increases is the depletion of the earth's ozone layer, which is a part of the stratosphere that begins about nine miles up and absorbs ultraviolet radiation that would otherwise broil us. It's like sunscreen for the entire planet. (...)
An excellent place to study the long-term effects of sunlight on human skin is the PGA Tour Champions. If you look closely at Andy North's face during one of his appearances as a commentator on ESPN, for example, you'll notice that his left and right nostrils are different sizes. The reason is that in 1991—after his wife had pointed out that his nose looked odd—he had surgery to remove a large basal cell carcinoma that extended into his left cheek, followed by plastic surgery to repair the quarter-size hole that the excision had created. The USGA persuaded him to write about his experience for Golf Journal, and his article had a big impact on players at all levels. Since that time, he has been an active and effective advocate for skin-cancer prevention and treatment.
North and many other seniors and super-seniors grew up, as I did, in an era when sunburn was viewed as no big deal. In those days, if you applied anything to your skin before going outside, it was almost always in the hope of increasing sun damage, not preventing it. (Sun-darkened skin blocks some UV rays—it's the body's attempt at producing its own sunscreen—but the darkening itself is an indicator of damage. “To be clear,” a dermatologist told me, “there is no such thing as a healthy tan.”) My friends and I used to compete, at the swimming pool, to see who could peel the largest intact sheet of skin from his stomach. When I was in college, I fell asleep on a beach in Mexico and burned my back so badly that I had to lean all the way forward in the passenger seat of a friend's Volkswagen Beetle during our 20-plus-hour drive back to school. The peeling skin hardened into curls the size, shape and approximate color of Fritos: My back looked as though a woodcarver had worked it over with a chisel. A professor of mine removed the curls by (agonizingly) rubbing me down with cold cream—a service that college professors no longer provide to students, I believe. (...)
Golfers have always been at greater risk of developing skin cancer than people who never go outside or visit tanning parlors, but even among nongolfers the incidence has been rising for years, worldwide. Studies cited by the Skin Cancer Foundation have shown that, in the United States, cases of nonmelanoma skin cancer increased by 77 percent from 1994 to 2014, and that there will be 7.7 percent more melanoma cases this year than there were in 2018. (Whales are also affected. They're exposed to the sun when they surface, and the skin damage they suffer appears similar to the skin damage suffered by humans.) The main cause for the increases is the depletion of the earth's ozone layer, which is a part of the stratosphere that begins about nine miles up and absorbs ultraviolet radiation that would otherwise broil us. It's like sunscreen for the entire planet. (...)An excellent place to study the long-term effects of sunlight on human skin is the PGA Tour Champions. If you look closely at Andy North's face during one of his appearances as a commentator on ESPN, for example, you'll notice that his left and right nostrils are different sizes. The reason is that in 1991—after his wife had pointed out that his nose looked odd—he had surgery to remove a large basal cell carcinoma that extended into his left cheek, followed by plastic surgery to repair the quarter-size hole that the excision had created. The USGA persuaded him to write about his experience for Golf Journal, and his article had a big impact on players at all levels. Since that time, he has been an active and effective advocate for skin-cancer prevention and treatment.
North and many other seniors and super-seniors grew up, as I did, in an era when sunburn was viewed as no big deal. In those days, if you applied anything to your skin before going outside, it was almost always in the hope of increasing sun damage, not preventing it. (Sun-darkened skin blocks some UV rays—it's the body's attempt at producing its own sunscreen—but the darkening itself is an indicator of damage. “To be clear,” a dermatologist told me, “there is no such thing as a healthy tan.”) My friends and I used to compete, at the swimming pool, to see who could peel the largest intact sheet of skin from his stomach. When I was in college, I fell asleep on a beach in Mexico and burned my back so badly that I had to lean all the way forward in the passenger seat of a friend's Volkswagen Beetle during our 20-plus-hour drive back to school. The peeling skin hardened into curls the size, shape and approximate color of Fritos: My back looked as though a woodcarver had worked it over with a chisel. A professor of mine removed the curls by (agonizingly) rubbing me down with cold cream—a service that college professors no longer provide to students, I believe. (...)
Stewart Cink had a basal cell carcinoma removed from the side of his nose in 2018. Two years earlier, Cink's wife, Lisa, had begun treatment for advanced breast cancer, and some sportswriters (though not Cink) reacted as though their health problems were roughly equivalent: two cancer cases in one couple! But basal cell carcinoma, by comparison with Stage Four breast cancer, is more like a skinned knee than a medical emergency. People don't die from it, except in the rarest of circumstances, and the treatment doesn't overturn lives, families and careers.
Melanoma, by contrast, truly is scary. Ellen Flynn—a member of my golf club and an occasional mixed-event partner of mine—has had three melanomas, beginning about 15 years ago. “The first was on the back of my calf, and that wasn't so terrible,” she told me recently. “Then, four or five years later, I suddenly saw this major mole on my shoulder.” She'd been having regular checkups with a melanoma specialist, but she couldn't get an appointment right away. “I didn't want to be neurotic, but the mole had come from out of nowhere,” she continued. “So I pursued it, and as soon as the doctor saw it I could tell that it wasn't a good thing.”
The surgeon to whom Flynn's specialist sent her shocked her by telling her that he couldn't guarantee that, after the operation, she'd still have the use of her right arm. (“I'm, like, seriously?”) The visible part of a melanoma can be a minor element of a large and rapidly expanding cancer network, and surgeons sometimes have to cut out huge amounts of tissue. Flynn's tumor, fortunately, turned out to be far less extensive than the surgeon had feared: her golf swing survived. Then, a few years ago, she found a third melanoma, on her shin of her other leg. This one—whew again!—was also neither life- nor golf-threatening. “Plus a thousand other skin cancers, on my face mostly,” she said. “So without makeup I look like a hockey player.” (...)
Ellen Flynn was in her late 50s when she found her first melanoma. That makes her statistically typical—although the statistics are changing. The incidence of melanoma has risen during the past 85 years, from a lifetime risk of roughly 1 in 1,500 in 1935 for people with white skin to something more like 1 in 40 today. (The darker the skin, the lower the risk of skin cancer, although even for people with very dark skin the risk is not zero, and there are melanoma types that are unrelated to sun exposure and appear at similar frequencies across all racial groups.) Diagnoses among people much younger than Flynn have also increased. Melanoma is now the most common skin cancer among people 15 to 19, the most common cancer of any kind among people in their 20s, and the leading cause of cancer death among women 25 to 30. I realized recently that I know shockingly many people who have had melanomas, including two people who were in their 20s. One of those is Tyler Fairbairn, another occasional golf partner of mine (and a former playmate of my children), who's now in his mid-30s. “When I was in graduate school, I noticed that I had a kind of dark, raised thing, like the size of a pencil eraser, on my lower back,” he told me. “The surgeon who operated on it made about a two-inch incision and cut out a bunch all around it.”
Flynn's and Fairbairn's melanomas had not penetrated far into their skin, and for such cases the cure rate, through surgery alone, has always been high. The truly dangerous melanomas are the relatively few that have metastasized. (Skip Nottberg, a high-school classmate of Tom Watson's and an acquaintance of mine, died of one of those in 1997, when he was 47.) Hensin Tsao, who is the clinical director of the Melanoma & Pigmented Lesion Center at Massachusetts General Hospital, told me, “The thicker the tumor, and the bigger the tumor, the more likely it is to reach a blood vessel in the skin, crawl into it, and take off into an internal organ.” Tsao said that as recently as 10 years ago there was very little that could be done for patients whose melanomas has spread to the brain, the liver, the lungs or other body parts, but that several recently developed drugs have turned out to be extremely effective for many patients—so much so that doctors have begun to speak of cures in cases that once would have been considered hopeless.
Among the many challenges with melanoma is that, although 90 percent of cases are related to solar exposure, some types can appear on parts of the body that have seldom, if ever, been exposed to the sun: between two toes, within the folds of the bellybutton, inside the esophagus, on the anus. In Palm Desert a year and a half ago, I played golf with a retired CEO who was undergoing treatment for a melanoma on the tip of a big toe. He said that the cancer had spread to his lymph nodes, an ominous sign, and that the main reason it hadn't been diagnosed earlier was that its odd location and unusual appearance had fooled his doctor into thinking it was something else. A number of years ago, a nephew of a friend of a friend of mine was told by his ophthalmologist, during a routine eye exam, that he needed to see an oncologist right away. He did so, and learned that what the ophthalmologist had noticed, inside his eyeball, was an ocular melanoma. Six weeks later, he was dead.
Melanoma, by contrast, truly is scary. Ellen Flynn—a member of my golf club and an occasional mixed-event partner of mine—has had three melanomas, beginning about 15 years ago. “The first was on the back of my calf, and that wasn't so terrible,” she told me recently. “Then, four or five years later, I suddenly saw this major mole on my shoulder.” She'd been having regular checkups with a melanoma specialist, but she couldn't get an appointment right away. “I didn't want to be neurotic, but the mole had come from out of nowhere,” she continued. “So I pursued it, and as soon as the doctor saw it I could tell that it wasn't a good thing.”
The surgeon to whom Flynn's specialist sent her shocked her by telling her that he couldn't guarantee that, after the operation, she'd still have the use of her right arm. (“I'm, like, seriously?”) The visible part of a melanoma can be a minor element of a large and rapidly expanding cancer network, and surgeons sometimes have to cut out huge amounts of tissue. Flynn's tumor, fortunately, turned out to be far less extensive than the surgeon had feared: her golf swing survived. Then, a few years ago, she found a third melanoma, on her shin of her other leg. This one—whew again!—was also neither life- nor golf-threatening. “Plus a thousand other skin cancers, on my face mostly,” she said. “So without makeup I look like a hockey player.” (...)
Ellen Flynn was in her late 50s when she found her first melanoma. That makes her statistically typical—although the statistics are changing. The incidence of melanoma has risen during the past 85 years, from a lifetime risk of roughly 1 in 1,500 in 1935 for people with white skin to something more like 1 in 40 today. (The darker the skin, the lower the risk of skin cancer, although even for people with very dark skin the risk is not zero, and there are melanoma types that are unrelated to sun exposure and appear at similar frequencies across all racial groups.) Diagnoses among people much younger than Flynn have also increased. Melanoma is now the most common skin cancer among people 15 to 19, the most common cancer of any kind among people in their 20s, and the leading cause of cancer death among women 25 to 30. I realized recently that I know shockingly many people who have had melanomas, including two people who were in their 20s. One of those is Tyler Fairbairn, another occasional golf partner of mine (and a former playmate of my children), who's now in his mid-30s. “When I was in graduate school, I noticed that I had a kind of dark, raised thing, like the size of a pencil eraser, on my lower back,” he told me. “The surgeon who operated on it made about a two-inch incision and cut out a bunch all around it.”
Flynn's and Fairbairn's melanomas had not penetrated far into their skin, and for such cases the cure rate, through surgery alone, has always been high. The truly dangerous melanomas are the relatively few that have metastasized. (Skip Nottberg, a high-school classmate of Tom Watson's and an acquaintance of mine, died of one of those in 1997, when he was 47.) Hensin Tsao, who is the clinical director of the Melanoma & Pigmented Lesion Center at Massachusetts General Hospital, told me, “The thicker the tumor, and the bigger the tumor, the more likely it is to reach a blood vessel in the skin, crawl into it, and take off into an internal organ.” Tsao said that as recently as 10 years ago there was very little that could be done for patients whose melanomas has spread to the brain, the liver, the lungs or other body parts, but that several recently developed drugs have turned out to be extremely effective for many patients—so much so that doctors have begun to speak of cures in cases that once would have been considered hopeless.
Among the many challenges with melanoma is that, although 90 percent of cases are related to solar exposure, some types can appear on parts of the body that have seldom, if ever, been exposed to the sun: between two toes, within the folds of the bellybutton, inside the esophagus, on the anus. In Palm Desert a year and a half ago, I played golf with a retired CEO who was undergoing treatment for a melanoma on the tip of a big toe. He said that the cancer had spread to his lymph nodes, an ominous sign, and that the main reason it hadn't been diagnosed earlier was that its odd location and unusual appearance had fooled his doctor into thinking it was something else. A number of years ago, a nephew of a friend of a friend of mine was told by his ophthalmologist, during a routine eye exam, that he needed to see an oncologist right away. He did so, and learned that what the ophthalmologist had noticed, inside his eyeball, was an ocular melanoma. Six weeks later, he was dead.
by David Owen, Golf Digest | Read more:
Image: C.J. Burton
