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Unmasking Skin Cancers

Hugh Royer and Dr. Evan Graboyes
Hugh Royer and Dr. Evan Graboyes formed a strong bond during his extensive treatment.

Some people get cancer, and no one ever knows. That’s the way they like to keep it.

For Hugh Royer, who lost a quarter of his cheek and his nose to a very common skin cancer, that was never an option. He learned that his face was his window to the world, affecting how people interacted with him.

Early in his treatment, he had people stop dead in their tracks in stores to stare openly at him. Some kids shied away from him.

One half-drunk man leaving a bar even  asked if he had gotten beaten up in a mixed- martial arts fight.

“No, just cancer,” Royer answered, silencing the man.

Becoming more of a hermit to avoid the embarrassing interactions, Royer struggled to find his bearings. Now, seven surgeries and 30 rounds of radiation later, the Myrtle Beach professional golfer is just grateful to be alive. And he’s a man on a mission to educate others in hopes they can learn from his cautionary tale.

Cancer is scary for people, and then having a hole in your face is scary. And those two combined, I think, just magnify that challenge because no one thinks about it until you have a defect or a scar on your face. But that’s how we all recognize each other. That’s how we communicate with each other.
- Dr. Samuel Oyer

Royer’s nightmare started with basal cell carcinoma, the most common form of skin cancer. People get it all the time. In the U.S. alone, an alarming 4 million cases are diagnosed each year. Most cases are curable and cause minimal damage. But not all, as Royer would learn.

He had a basal cell carcinoma removed from his nose in 2012 and got a recurrence treated in 2015. Then in 2016, a bump appeared on the side of his nose, and it kept growing. Three different doctors said it was nothing. But Royer kept seeking different opinions, finally finding a Myrtle Beach ear, nose and throat specialist who did a biopsy. Royer was diagnosed with basal cell carcinoma.

Royer was glad to get a diagnosis that made more sense for the spot on his face that just kept growing. He was referred to Hollings Cancer Center at the Medical University of South Carolina. “It comes down to that point where you know that you’ve got to go with your gut. You know something’s not right. It’s your body. You know what your body does and what it feels like. And it just didn’t feel right,” he recalls.

“My advice now is don’t be afraid to upset that doctor to go get another opinion. Because if it comes back the same, then everybody’s correct,  and it’s a win-win for everybody. But if it’s a different answer, then you need to find out exactly what’s going on. That’s kind of what happened to me, and it ended up saving my life.”

Meeting with specialists at Hollings, Royer learned that his tumor had grown, following along the  pathway of a nerve. It had inched along and come within a centimeter of his brain. Scheduling his surgery in May 2018, doctors told him there was no time to waste, and treatment wouldn’t be easy.

Royer, typically talkative and energetic, remembers going home speechless. “I never said a word,” he recalls. “When I got home, I immediately took a shower. And I got in my pajamas, and I got in bed. The depression – I can’t tell you how bad it was. And then, at like 10:30 that night, my phone rang.”

Royer didn’t answer it. But his wife, Heather, did. It was Evan Graboyes, M.D., a head and neck oncologic and reconstructive surgeon and researcher in the Cancer Control Program at the Hollings Cancer Center, who had seen Royer earlier in the day. She put the phone on speaker and made her husband sit up and listen. The conversation would last over an hour.

“He talked me off the ledge and explained things to us to where, not only was it comforting, but it also helped us to understand what they were talking about,” he says. It wouldn’t be the last time a pep talk from Graboyes would be a vital lifeline. Royer recalls another time he came into his room as he was recovering from one of his first surgeries. “He walked in and sat on the bed and smiled at me and patted me on the leg. And I’m half out of  it, but I’m  looking at him, and he says, ‘This is going to be OK. We’re going to get it.’ And he got it. When you have a doctor that really cares about you, and shows you, that says a lot about what you’re trying to accomplish here at Hollings.”

Hugh Royer 
Royer sits in the clinic at Hollings Cancer Center, ready to discuss the next step of his treatment.

The Back Nine

If there’s one thing that golf teaches you about life, it’s about having the right mindset to face tough challenges. Royer, known as “Little Hugh” in golfing circles, knows all about that. His face lights up when he talks about the game and the professional players he has been around all his life.

Royer excelled at Brookstone School and Columbus State University and was considered one of the best amateur golfers in Georgia history, eventually turning pro. He won four times on the Ben Hogan/Nike Tour, which is now the Korn Ferry Tour, and had three top-10 finishes on the PGA Tour. He is having to take it easy during his recovery, but he hopes to be part of the Champions Tour qualifying school this fall to prepare for the 2020 season.

Though he’s back to playing golf,  his journey this past year has forever changed him. For one thing, it has led him to consider many on his MUSC Health care team as a part of his family, including two of his main providers, Graboyes and Samuel Oyer, M.D., a facial plastic and reconstructive surgeon. He jokes about how young they are, both under 40, but how their personalized way of approaching his care is reminiscent of “old-timey” country doctors.

“I’m so grateful because they literally saved me. Dr. Graboyes took my face apart, and Dr. Oyer put it back together. And they’ve been there for me to talk me off the ledge. You don’t always find that in doctors. They’re young, but they get it. They are the ones who are going to change medicine.”

The trio joke together like they’ve known each other for years. Graboyes even FaceTimed Royer recently, when he turned 55, to wish him happy birthday. And it’s not just the care from Graboyes and Oyer for which he is thankful. There are  the nurses and Anand Sharma, M.D., a radiation oncologist at Hollings, who did the 30 rounds of radiation. “It’s knowing exactly where to hit and what to hit and what to do because it is your face. And it’s pretty scary,” he  says. “And  it was pretty amazing.”

Heather and Hugh Royer 
Royer and his wife, Heather, appreciate the special relationship they have developed with their health care team.

Zachary Soler, M.D., an otolaryngologist and specialist in sinonasal tumors, came on board to rebuild his right sinus and make sure he could still breathe out of that side of his nose. Royer says he’s grateful for how his doctors coordinated what was very complicated care throughout the process.

His professional team had to get creative. They ended up taking cartilage from an ear and rib, fat from his abdomen and fascia from his leg to rebuild his cheek and nose. They also performed two forehead flaps, a procedure that involves taking skin from the forehead with its own blood supply and attaching it to the nose to replace the missing skin. The flaps remain attached until the nose is fully healed.

Oyer says head and neck cancers pose special challenges for patients and require a multidisciplinary approach.

“Cancer is scary for people, and then having a hole in your face is scary. And those two combined, I think, just magnify that challenge because no one thinks about it until you have a defect or a scar on your face. But that’s how  we all recognize each other. That’s how we communicate with each other. And you can’t cover that up, you know. It’s right there. It’s your billboard.”

With these kinds of reconstructions, the goal is not to make a person look better than he or she used to. “Rather, the  goal is to be able to go to the grocery store and not have people ask you what happened to your face. You want to be able to go about your life and not have people pointing,” Oyer says, adding that in severe cases that is unfortunately not always attainable. “But that’s where we try to set our sights.”

The psychological care is just as important. Graboyes, who also is a researcher in Hollings Cancer Center’s Cancer Control Program, studies body image concerns in patients with head and neck cancers. It’s why he was part of a team of researchers to develop a new program called BRIGHT (Building a Renewed ImaGe after Head and neck cancer Treatment) to help to address the psychological, emotional and social concerns of head and neck cancer patients suffering from body image disturbance.

Graboyes also is part of a multidisciplinary team of Hollings Cancer Center researchers who are developing:

  • Better markers to predict which head and neck cancer survivors will suffer from body image concerns.
  • Tools to measure body image concerns that are centered on the patient.
  • New interventions to help to address body image concerns following treatment for head and neck cancer survivors.

Royer is a perfect example of why more support is needed, Graboyes says. Not only was he dealing with surgeries and dozens of appointments for his medical treatments, he also had the psychological distress of what cancer had done to his face.

Even though basal cell carcinoma generally is one of the most easily treated cancers, there are exceptions. “Sometimes, because patients and providers don’t take it seriously, it gets undertreated,” Graboyes says. “We see a lot that maybe didn’t get the most complete treatment the first time around, and then the cancer can come back in a much more aggressive manner. We also see cases where patients have ‘something’ taken off their faces and either someone didn’t tell them it was cancer or they didn’t have it tested for cancer.”

Oyer says it’s why he instructs patients to know their medical histories. They’ve had patients come in with partial facial paralyses that were thought to be Bell’s palsy. When Oyer asks if a patient has ever had a skin cancer, often the answer is yes. “The patient thinks the cancer was cleared, but it’s the sort of scenario where it gets into the nerve, and then tracks along the nerve. The nerves are like little highways for cancer sometimes, and there are a lot of nerves in the face. That’s when it can get tricky if it starts heading toward the brain,” he says.

“So just know your history. Know what you have and that this could come back later and be a more aggressive type of skin cancer.”

Oyer says he’s been amazed at Royer’s spirit.

“For me, it was a good reminder and an example of how to take a bad situation and make something good out of it. It is the lemonade out of lemons. Where some other person, most other people actually, would probably still be wallowing in some kind of  ‘self-grief,’ he actually found a way to reinvent himself. He’s literally excited about his opportunities moving forward and this whole new avenue that has opened up where he sees himself as an advocate rather than a victim.”

Graboyes agrees and is grateful that Royer dedicates a portion of his time to educating groups, particularly golfers and those who spend a lot of time outdoors. “We compliment Hugh for his persistence; it’s the reason he’s alive. The advocacy work he has done since his diagnosis is truly inspirational. We hope his story empowers other patients to notice if there is something not right on their body, and go and get it checked out and properly evaluated.”

Hugh Royer and Samuel Oyer 
Royer and Dr. Samuel Oyer discuss the outcome of one of several reconstructive surgeries.

Moving On

It’s not unusual for Royer to take the stage these days, not so much to share his golfing triumphs as to encourage others. He still likes to joke and cut up. That hasn’t changed. He does find he’s more humble and emotional, though. Cancer can do that – strip a man down to the basics, he says.

“I’m looking down at the grass. I’m not looking up at the roots. And that’s the way that I take it – day to day. Being thankful that I’m above ground, and I can live life. I can still go out and hit golf balls and be with my family. I’m just lucky to be alive. That’s how I’m looking at that inner beauty that gets me through day to day.”

Though his face isn’t perfect, he has come a long way from a year ago, and luckily, his wife really loves him no matter how he looks, he jokes. Royer says his wife and four children have been a lifeline, and they’ve all grown closer. At one point in his treatment, he was afraid he wouldn’t get to see his daughter, Abbey, go to her prom. As it turned out, he did get to see her.  “And she was beautiful. It was wonderful.”

One poignant memory he holds dear involves an evening after one of his major surgeries when he woke up to see Abbey, who had taken some time off from school to be with him, draped at the bottom of his bed, sleeping.

“You know, when you wake up in the middle of the night in the hospital and your 16-year-old is sitting on the edge of your bed and you catch her blotting your face,” he says, stopping a moment to compose himself before continuing. “ What 16-year-old does that? It just makes you appreciate life, appreciate your family. It’s brought us all, even though we’re close, that much closer.”

Royer has noticed how often that, after he’s delivered a talk about his story, people will come up to him to thank him and share their journeys.

“That makes me feel like I’m doing some good. And if you can help people, and you help save lives, I  mean, that’s what it’s all about. I always thought God put me on this earth to play golf, but I think it was to go through this and to help people. I’m going to make the most of life.”