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

Abstract

‘Delay’ has been 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, ironically, 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.

Keywords:

• delay
• time frame
• categorisation
• risk
• perceived risk
• risk management
• cancer recognition
• cutaneous malignant melanoma

Notes

^1. The thinning of the ozone layer is rarely mentioned as a risk factor for cutaneous malignant melanoma, despite evidence of its significance (Diepgen and Mahler 2002).

^2. The privileging of relative risk over absolute risk increase, sometimes reinforced by graphical iconography, provides a means of emphasising the importance of managing a risk factor which misleads for uncommon adverse events (Gigerenzer 2002, p. 34), most notoriously in relation to the contraceptive pill scare of 1995 (Barnett and Breakwell 2003).

^3. Gandini et al. (2005) concluded from their systematic review of research evidence that high, steady exposure to UVR is, statistically, an apparently protective factor for melanoma risk. However, they argued that this finding results from the low exposure group including more individuals who have been exposed sporadically to, for them, unusually high doses of UVR from the sun. Ironically, vitamin ‘D’, mostly obtained from sunlight, may reduce melanoma risk (Egan 2009).

^4. More impressive relative risk statistics might be obtained for greater contrasts between the higher and lower risk categories, for instance between individuals with histories of severe childhood sunburn and ‘the rest’. As always, the size of odds-ratios may depend upon how a comparison is specified.

^5. Ironically, given that sunlight is an important source of Vitamin D, reduced levels have been identified as a possible melanoma risk factor (Egan 2009).

^6. Time-lapse could not be ascertained for 3 of the 39 research participants in this sub-sample.

^7. Although this research participant had failed to meet the requirement of responsible risk management, his rationale draws on an inherent ambiguity of risk-thinking, which oscillates between the precautionary principle and the idea that actions should be evidence-based.