Denial of Illness in a Patient with Infiltrative Basal Cell Carcinoma

A 73-year-old Caucasian man presented with a pink, pearly papule anterior to his right ear. He was a well-educated, retired stockbroker. Biopsy revealed an infiltrating basal cell carcinoma (BCC). The dermatologist repeatedly attempted to contact the patient encouraging treatment. After ignoring calls and letters, he was lost to contact with dermatology for 10 years. In the interim, the patient presented to the emergency room after discovering maggots in his ear. He subsequently consulted a head and neck surgeon but refused the recommended surgical excision. Although still operable, by this time the patient had developed significant erosion (Figure 1), nerve damage with loss of taste, facial muscle control, and hearing loss. One year after surgical consultation, he returned to dermatology due to ear discharge and pain while chewing. Multiple clinicians urged him to reconsider surgery. The patient stated that he had avoided treatment for the previous 10 years, because he had felt "stronger than the cancer." He had been convinced that cancer "can't hurt me." Despite this, he conceded that denying treatments earlier was "probably the worst decision of my life." By then the cancer was inoperable and required chemotherapy. The patient again refused treatment and later expired.