Tattoos and skin cancer
Jay Allen, a former truck driver, sports a multitude of tattoos, but right now only one has his full attention.
It is the crucifix that covers his left inner forearm, which contains two lumps beneath the ink that bear a strong resemblance to a potentially deadly melanoma he had removed from his back last year.
“Doctors picked them up on my three-monthly check but they can’t work out what’s going on underneath because they’re covered with dense ink,” says Allen, 43, of Mittagong, south-west of Sydney.
Allen’s mystery bumps highlight a problem that is becoming increasingly apparent for dermatologists throughout Australia.
They are fast realising that the cardinal rule of early diagnosis to beat this form of skin cancer has been seriously compromised by the tattoo trend that often masks the changes in the underlying skin.
Compounding the problem is research that shows melanoma is the most common cancer among 18- to 30-year-olds, the age group most noted for inking up.
Sydney social researcher Mark McCrindle found in 2016, from a national survey of 1011 people, one in five had tattoos. Among those with tattoos, 15 per cent had four to nine tattoos and 7 per cent had 10 or more.
“It’s the heavily tattooed areas of the skin that are of particular concern,” says Dr Ben Carew, a dermatologist from Queensland, a place considered the melanoma capital of the world.
“We have higher rates of ultra-violet sun rays throughout the whole day in this state, so there’s more incidental exposure to those harmful rays,” he explains.
One in 14 men and one in 24 women in Australia will be diagnosed with melanoma in their lives, but in Queensland that rate increases to one in 11 men and one in 19 women, according to a 2016 Queensland Health report.
“This trend towards tattoos that cover large areas with swirls of different colours provide the perfect camouflage for melanoma and other serious types of skin cancer like basal cell carcinoma and squamous cell carcinomas,” says Carew.
And tattooing around moles, a common practice among tattoo artists spoken to by The Saturday Paper, is no long-term solution.
“Moles keep appearing until we are in our 40s and 50s, so many of these young people may not become aware of the melanoma if it is within the tattoos until a nodule component appears,” says Carew. “And by then the prognosis is poor.
“As physicians, we’re going to have to have a lower threshold for taking biopsies because the existing dermoscopy technology often can’t effectively detect changes under the ink. More advanced detection tools are available but they are expensive and are usually only used in specialist clinics,” says Carew.
With early detection crucial to survival, he foresees the problem escalating in the next five to 10 years.
“These things have a lead time,” he says. “Tumour rates start to exponentially build as you get older because of the accumulated UV damage in a place like Australia, particularly Queensland.”
That was the significance in Jay Allen choosing Brisbane as his starting point in the Melanoma Institute Australia (MIA) annual awareness-raising walk in March last year.
The melanoma on his back was not his first, and by no means his worst. In late 2007 he was coming home from work with bloodied socks from what he thought was a blister from his work boots.
“My wife, Janine [then his girlfriend], repeatedly told me to get it checked because it kept scabbing up and bleeding,” he says. “But I wasn’t worried because I knew nothing about melanoma then.
“But Janine threatened to cancel our Christmas holiday if I didn’t get the mole checked.”
The diagnosis of advanced melanoma took a while to sink in but when it did it left a seed of fear that Allen suspects will remain with him for life.
“It was 1.95 millimetres deep [one millimetre is considered dangerous] and by then had spread to 15 lymph nodes in my groin that had to be removed,” says Allen.
He realises now that with fair skin and ginger hair he was a high-risk candidate for skin cancer, but he suspects the first melanoma might also be linked to the fact he underwent 30 sessions in a solarium in his late 20s to smarten up in his dating years.
His tattoo collection was also part of that new image. His first one, at 18 – a single lion on his shoulder – was the result of a bet.
“Once you get one tattoo you just can’t stop,” he says. “I don’t know what it is – they look good and you go through so much pain getting them done you feel you are conquering something.”
Allen regrets it now, “but it is what it is and I have to live with it”.
So far his melanomas have been on clear skin but he realises the two suspicious moles within the forearm tattoo, which he wants removed for peace of mind, may be a sign of an ongoing detection problem.
Associate professor Saxon Smith, who is attached to Sydney University and Royal North Shore Hospital, estimates he performs skin cancer surgery within a tattoo six times a year.
He says some patients are more worried about surgeons ruining their tattoos than saving their lives.
“The older patients not so much, but the younger patients, who commonly now have very large tattoos whose artistry they value, do sometimes worry about the cosmetic outcome. But realistically it’s all about making sure we clear the skin cancer, because it is about saving lives and not the art.”
For the past year MIA CEO Carole Renouf has been looking at the problem of skin cancer detection through a different lens.
She has been tracking a Brazilian study that aims to train tattoo artists as intermediaries to alert clients to what the medical fraternity call “lesions of concern”.
“The difficulty generally with millennials is that they tend to think they are bulletproof and obviously still carry the notion that bronze is beautiful in spite of the fact there are tanning products they can use.
“And they like getting tattoos so it seems like the perfect match to have them alerted by people like tattoo artists who they would consider to be way cooler than a boring old parent,” she says.
The study is based on an online training program and once it is evaluated Renouf says she will raise it with MIA clinicians for consideration.
“There are a whole lot of skin intermediaries like beauty therapists and hairdressers who could be enlisted,” she says. “We know anecdotally from some of our patients that it was their hairdresser who first noticed the lesion.”
Jay Allen says he wishes he had listened to his tattoo artist who, like his wife, urged him to get the mole on his ankle checked.
“I’m petrified now for my life and my four kids. In fact, I’d never even taken the two youngest, six and nine, to the beach until this year.”
Allen left his job as a truck driver soon after he discovered the first melanoma, “because mentally I couldn’t stand sitting all day thinking the disease is going to come back and get me”.
After numerous approaches to the MIA, he was taken on as a community coordinator.
“It was a bit confronting at first when I’d hear about people passing away,” he says. “I’ve had 30 friends I’ve met through my support groups who have died.
“But I don’t want fear to rule my life. The other day a friend named Elizabeth phoned to say she had been cancer free for five years and that she was coming off treatment. That’s the sort of news that makes my skin tingle with joy.”
This article was first published in the print edition of The Saturday Paper on Feb 23, 2018 as "Hidden dangers". Subscribe here.