By Andy North
From the Golf Journal Archives - Sun Stroked
May 07, 2010
(Note: This article originally appeared in the May 1987 issue of Golf Journal.)
IT WAS A FLUKE, REALLY. At first I thought my wife, Susan, was joking. We were sitting at breakfast in our hotel room during the week of the Honda Classic in 1991. This morning seemed no different from any other time my wife had joined me on the road. Susan kept looking at my face, and felt something just wasn’t right. Finally she said, “The left side of your nose is smaller than the right side.” My reaction was, ‘Aw, c’mon,’ but she insisted she was being serious. “No, no, it looks thinner than normal, the outside of it,” she said. We began a typical husband-and-wife conversation, and it ended with her deciding that she would make an appointment for me with the dermatologist when we returned home.
That’s how every one of our major health problems begin. You wake up one morning and say, “My back hurts a little” and you don’t think it’s a big deal. And the next day you’re in the hospital getting something done. I’ve had six operations on my knees, one on an elbow and one on my neck. This was along that same line. You’re in the process of trying to figure out what’s wrong, and the next thing you know the bright lights are on and guys in surgical scrubs are leaning over you, contemplating what they’re going to do next.
During the spring of 1991 I missed nearly two months of tournaments on the PGA Tour but, more importantly, became part of a group that grows larger every day. More than 500,000 Americans develop skin cancer every year, and in 1991 I was among those counted. I had basal cell carcinoma, the most common type of skin cancer, but its least common subtype, morphea. Even thought the doctor believes the tumor had grown for more than a year, it was invisible to the naked eye.
When people think of skin cancer, they envision an oozing sore or a mole that gets real ugly. But with this you could not tell any difference. That’s the scary part. At first I thought Susan was nuts, that one side of my nose could not look any different from the other – it certainly didn’t look any different to me. I had seen my dermatologist four or five months earlier, and he didn’t notice because it didn’t look any different.
But I appeased my wife by seeing another doctor. Five operations later the cancer had been cut out, and the doctor had removed most of my left nostril and left a hole on my face the size of a quarter. Thanks to plastic surgery, no one can tell unless they are looking at my nose from the proper angle and in bright light. I’m one of the lucky ones.
SINCE BEGINNING MY career on the PGA Tour, I have tried to see a dermatologist once a year as part of my physical. It was as much a part of the routine as a blood test. More players began using sunscreens in the late 1970s, but there were not as many players wearing hats or visors as there are today. I was much more aware of skin cancer than most people, and started getting my skin checked early. My family has a history of cancer – my father has had nearly 20 skin cancer-related operations – so I was much more aware than most people.
Still, the unfortunate part of this whole skin cancer problem is that so much of the damage is done 15 or 20 years before it appears. Scientists have determined that 80 percent of an average person’s lifetime exposure to the sun occurs by age 18. Back when we were kids, there wasn’t any sunscreen and people didn’t pay attention to sun damage. When the sun came up you went outside, and when it went down you came in. We were out getting barbecued 12 hours a day doing stuff. I think of the baby oils we used, putting ourselves on a spit. The kids still do that – perhaps not as much as we did, but so much of the damage has been done by the time you get to an age that you understand it.
My wife scheduled that first appointment for March 22 at what is probably the best skin cancer facility in the country, the Mohs Surgery Clinic at the University of Wisconsin Hospital. It is one of the finest teaching hospitals in the country, and fortunately for me is located 10 minutes from my home in Madison. The clinic specializes in the treatment of skin cancer and takes a much more aggressive stand than most dermatologists. It was the Friday before The Players Championship when I met Dr. Stephen Snow, who asked the inevitable question as to why I was there. All I could say was, I don’t know, but...
Dr. Snow looked all over and studied that spot in particular. “I want to take a biopsy,” he said, and removed a chunk probably half the size of an eraser on the end of a pencil. Walking out of his office I thought, ‘Obviously there must be something there, or he wouldn’t have wanted to do the biopsy. So he cuts a little bit out, big deal.’
When the biopsy result came back from the lab, Dr. Snow called. “We’ve got a problem. You’ve got some skin cancer. I want you to come in right away.” I was on my way out the door for The Players, so he said that I should see him immediately after I came back home.
I took part in The Players with a small circular bandage on the side of my nose, and endured the usual ribbing from fellow players and questions from everyone else. It wasn’t that big a deal. It sounds silly, but if all you did was sit around and think about what might happen and how you would deal with an occurrence like this, you’d go crazy. Heck, if you took the field this week, 10 guys probably have something big they are dealing with. I’m not sure how I answered everyone when they asked about the bandage, but I didn’t tell them about my next appointment, the Monday of Masters week. That’s when the real carving began.
DR. FREDERIC MOHS developed his system of micrographic surgery during the 1930s. Its cure rate is 95 percent – the highest of all skin cancer treatments – and it’s designed to leave the smallest possible wound.
Before Dr. Mohs’ system, there were two methods to remove skin cancers: heating and freezing, both inexact at best. Neither dependably guaranteed eradication of every cancer cell, since many tumors sprout tentacles of malignancy below the surface. Leaving just one cancerous cell means the malignancy returns. Using a blistering hot or freezing cold instrument also left few options for repairing scar tissue.
Dr. Mohs theorized that a surgeon using a scalpel and magnified vision could slice off multiple thin, horizontal layers of the cancer and presumed healthy tissue around and below the lesion. It’s like peeling the skin off an apple where it’s bruised. Every layer of tissue removed is inspected under a microscope for evidence of cancer cells, which have the marbled look of fatty tissue. If cancerous cells show anywhere within the specimen, the doctor must cut deeper.
The doctor’s first priority is to take care of the cancer, but he wants to keep the person looking half-decent. The easiest thing is to just come in, have your nose cut off and be fine. That’s not realistic. By taking a little at a time the doctor makes it harder initially for the patient, but in the long run it’s better because it makes the process of plastic surgery easier.
Of course, I learned all this in the most difficult manner: going through the surgery. When it came time to operate, the first thing Dr. Snow did was numb the left side of my nose with a local anesthetic. When it comes to this type of surgery on the nose, the needle is placed inside the nostril. You take a shot in the rear end or the shoulder it’s not that bad, but you stick one up inside your nose and it’s pretty rude. It’s the most painful part of the operation.
Once my nose was numb, an area of about three or four square inches, Dr. Snow took his first carving. That is basically what they do: carve. Since the anesthetic is local, you are aware of what they are doing, and there were a few times when I tried to look almost cross-eyed down my nose to witness the procedure. Dr. Snow removed a pretty good chunk, bigger than the piece for the biopsy, an elliptical shape about the width and depth of a dime. The incision went from the inside edge of my left cheek, down beneath my nose, and took off the lower part of the left side of my nose. When I was bandaged up, Dr. Snow said he’d send the tissue off to pathology for a biopsy and told me to call back three hours later.
Once the doctor is done, technicians place the tissue under a microscope and inspect it for cancerous cells. Since cancer cells are linked like a chain, they can follow its roots through the sample. When I called the doctor’s office, the news was not good. “First of all, it’s cancerous,” Dr. Snow said. “Second, we didn’t get it all. You need to come back this afternoon.”
So it was back to the clinic at mid-afternoon and the process started again. They shot up the area, which was a bit sore and raw and pretty ugly. Dr. Snow took off a little more, another sample about one-sixteenth of an inch deep, I was bandaged up again and told to call back later. The hours dragged while my wife and I were waiting. I don’t recall what we were doing to pass time, but it seemed as if I’d look at my watch every two minutes and wonder why the hands were not moving. When I finally called the clinic, the news was the same: “We need to see you again tomorrow morning.”
THE ONE THING that I’ll never forget is the feeling of walking into that clinic for the first time. I was 41 years old, probably in the youngest 10 percent of skin cancer patients. I was the youngest person in the waiting room by maybe 30 years. I’m thinking, ‘What am I doing here?’ The people were all the age of my dad, who sees this guy religiously. And yet I had probably spent more time out in the sun than any one of those people.
On top of that, I did not wear a hat when I was playing until 1986, the year after I won the U.S. Open for a second time. I absolutely could not stand playing in them. It just wasn’t comfortable. I didn’t like the feel of trying to hit shots with something blocking my vision. As a matter of fact, I had a hat company, a corporate sponsor, offer me a lot of money to wear its hat on Sunday at the 1985 U.S. Open, and I wouldn’t do it. I was more worried about winning.
When I should have been playing my second practice round for the Masters, my wife and I were back at the clinic. By now I knew the process all too well. I have always tried to laugh stuff off. ‘How much more do you need?’ I jokingly asked the doctor. But I was getting worried. You know they have started to do some really good carving when they are down to cartilage and pretty close to the bone. There was not much left to handle the injection of local anesthetic. The doctor repeated the procedure for a third time, then we left and went back home to wait. A few hours later the answer had not changed: “We need to see you again.”
I was becoming an emotional wreck, and my wife was very concerned, to say the least. I’d had eight other operations and none of them were anywhere near as emotionally trying. There was no place left for them to inject, I’d lost a lot of blood and was starting to feel woozy. I went back into the clinic and was looking around the waiting room at the other patients. Many of them had driven a couple of hours to get there. Fortunately it’s only 10 minutes back to our house, and we could kill time doing other things. It must have been awful for people who came from out of town and had to sit and wait at the clinic for lab results.
By now Dr. Snow was carving on me for the fourth time in less than 36 hours. It was the same: numb, carve, leave, wait. I called again at 4 or 5 o’clock. Finally, I was relieved to hear the words, “We got it all.” The doctor added, “I still want to see you tomorrow morning. We’re not going to take any more, we’re going to try and figure out how to fix this.”
That was the first time I thought about my appearance. Dr. Snow had not mentioned it; until that moment we’d been concerned with removing all the cancerous tissue. I started to think, ‘Geez, can you fix this?’ The next morning my wife was with me in his office when he assured me he could. He removed the bandages to show just how much had been taken out. I realized it was a pretty big hunk, basically the left side of my nostril and out into the cheek area, about the size of a quarter. He told me to look at what had been done, but I did not look for very long. As far as I, was concerned, that part of the procedure was done. I wanted to get on to the next stage.
He laid out three options. The first was that we did not have to do anything and just let it heal by itself, leaving a big divot in my face, which he said some people do. Then there was a graft, where he would cut out a piece on my cheek and flop it over. That would leave extensive scarring. Or he could send me off to a plastic surgeon and go the full boat, which he suggested might be best. While Susan and I were talking he pulled out a book. “Here’s some pictures of people who decided on different options,” he said. There were some pretty ugly photographs. We selected plastic surgery, and were referred to Dr. Venkat Rao at UW Hospital.
I was still playing regularly and had not yet been approached by anyone about working on television. That was not even a factor in the decision to have plastic surgery. I just wanted to live my life and not be too self-conscious to walk into a restaurant. We can say we aren’t vain, but everybody is to some degree, some of us more than others. I’m probably middle-of-the-road; I like to look good, but when it comes to living and dying I’m going to figure out a way to live, regardless of aesthetics.
Dr. Rao needed to give my nose about 10 days to heal before the plastic surgery, and I kept to my usual schedule. It’s not like I was sequestered because there was a bandage on my face. There had been an item in the local newspaper, so most people knew what was going on. But if I had a meeting, I wasn’t going to miss it because I looked ugly.
The following Thursday I showed up at UW Hospital, in what I jokingly refer to as my personal operating room. If it wasn’t the room then, when you include the operations on my knees, elbow and neck, it’s probably my fifth visit to that area of the hospital. When you’ve been through out-patient surgery as much as I have, it’s like taking your car in for servicing: if you don’t have it done, something’s not going to work. I looked forward to the surgery because I would feel better.
The planned procedure would last about an hour. Dr. Rao was going to go behind one of my ears and take the skin for my nose from there, because it had a nice fold and it would work well in the crease. After he went in and removed the graft, he realized there wasn’t enough thickness to make it work – the wall of the nostril is about one-quarter-inch thick. So he sewed that back up and went into my shoulder, where the skin was thicker. The operation took longer than expected; you can imagine how my wife felt in the waiting room, thinking this wasn’t going to take very long and suddenly it’s four hours. But I never knew until the recovery room.
There had been one other situation, and I mention it only to relate a humorous story. It seems that in the process of scrubbing my face prior to the surgery, some of the disinfectant seeped into my eyes. Since the surgery took so long and my eyes were bandaged shut, the chemicals burned my eyes and caused severe pain for about three days. The first doctor to look at my eyes in the recovery room happened to be a pediatrician, so when I needed to see him a few days later I went to his office. Just as I had felt out of place in the Mohs Clinic the first time, now I was the only one in the waiting room over four feet tall. I can only imagine what all these 8-year-olds thought upon seeing me. There was a huge bandage on my face, A few of the kids started to ask questions. “What’s wrong with you?” one asked, and another pointed out how ugly I looked. It was the lightest moment in this whole experience.
For several days following the surgery I was well bandaged. When the plastic surgeon finished placing the graft, he packed the nostril and taped a bright yellow sac, almost like a beanbag, on the outside of the nose to stabilize the graft and help it take hold. When the bandages finally came off there was a pretty large scar, but as time passed it has become almost undetectable. The interesting thing to me is that the scar is about one-fourth the size it was at the start. Most people probably don’t notice anything.
THERE ARE MORE and more clinics across the country using the Mohs techniques, and Dr. Mohs, now in his 80s, is still listed as emeritus professor at UW. Since I had the surgery on my nose his techniques have been refined yet again. Now most doctors use microscopes instead of magnifying glasses during the operation, and the biopsy procedure has been simplified. That means most patients can have a tumor removed in just one visit instead of several visits over a period of days. Initially it’s easier on the patient, but it doesn’t lessen the size of the scar.
The week before The Players this year I went back to Dr. Snow. We’ve become quite good friends over the last six years. He plays golf, so he’s always got something to talk about while he’s carving on me. During the latest visit he froze a small circular patch of cancerous skin, smaller than a dime, off my right forearm. It will heal over in a few weeks. I’ve had about 10 procedures over the years, on my back, my arms and my ears. He can use heat or cold, radiation, lasers or the Mohs techniques. I know there will be other times I’ll have things removed. The hope is that it’s not too major.
Some patients in the clinic, who did not see a doctor until they were in their 60s or 70s, are beginning too late. They are losing major parts of their body, or the cancer has spread to the bloodstream. The national mortality rate for skin cancers is about 1 in 5,000. No matter how long the odds seem, I was lucky that my wife made mention of my nose when she did.
As golfers, many of us don’t consider ourselves at risk when it comes to skin cancer. We convince ourselves that if our skin has not turned red and peeled, we have taken the proper precautions; we’re safe. The truth is that every time we go out in the sun without protection – at minimum a cap and sunscreen – we put ourselves in danger. If you tracked serious golfers, someone who plays 40 rounds a year or more, I would suspect the occurrence of skin cancer would be higher than average.
The reaction from both friends and strangers to my operations was amazing. Quite a few players came up and asked me the questions you’d expect, and there was quite a lot written about it. My perception was that a lot more players started wearing hats and sunscreen, and skin care was taken more seriously. Everybody thinks you’re invincible until something happens close enough to you that it gets your attention. And maybe my situation got the attention of some other players.
I think I’ve done my share, when the time was right, to draw attention to the dangers of skin cancer. I never liked groups or people that go to extremes. I’ve tried to talk to people on a more personal basis. I’ve gone in and talked to middle school students, and instead of getting excited about it, I’ll use graphic terms to get their attention. They’ll say, “Oh, man, that’s gross Mr. North,” but it makes them aware of what they should be doing and why. It would be an effective warning if part of health class in high school was to spend a morning wandering through a place like the Mohs Clinic.
You can do all the things you need to do to protect yourself and still have fun. You put your seat belt on in the car. You’re not being a wuss or anything. You’re doing something that’s smart. In the same manner, it only takes 15 or 20 seconds to put on some sunscreen as you’re running out the door.
There are times during a conversation that I’m sure someone believes skin cancer will never happen to them. Perhaps they are right. There's nothing you can tell that person to change their mind. You only hope that no one ever says to them, “Your nose looks a little thinner.”
Andy North understood the susceptibility of his exposure to the elements and the danger of skin cancer. Do you? (USGA Museum)
You’re in the process of trying to figure out what’s wrong, and the next thing you know the bright lights are on and guys in surgical scrubs are leaning over you, contemplating what they’re going to do next. (USGA Museum)