There are a number of options for successful treatment of skin cancers. Some of these are not appropriate for all skin cancers, and I am happy to discuss these details with you. Also, your goals for treatment may affect which treatment is the most suited for your situation.
Most skin cancers are successfully treated with this straight-forward option. In the case of a Basal Cell or Squamous Cell Carcinoma, a 4mm margin of non-involved skin is added to the margins to insure adequate clearance. Basal Cell Carcinomas treated in this way have a 95% cure rate, whereas Squamous Cell Carcinomas tend to be a little less at 92%. Melanomas require a larger margin (usually 1-2 cm), depending on the depth of the tumor (described in the pathology report). This procedure is best performed by a specialist. Patients are sometimes surprised as to the length of their surgical excision. The excision line may be longer, as in order to remove a lesion with a wider margin, I need to convert the shape to a sinusoid ellipse for you to have a smooth, more aesthetically-appealing outcome. This may be alarming to you at first. Once the healing process is complete, chances are that you will have a beautiful, barely recognizable scar and be pleased with the outcome.
Mohs Micrographic Surgery (MMS)
This technique gets its name from the pioneering surgeon who first described it, Frederic Mohs at the University of Wisconsin. Formal training in Mohs began in the 1980s and currently, it is mainstream treatment. This technique is best suited for Basal Cell, Squamous Cell, Melanoma In-Situ, Lentigo Maligna, and Merkel Cell Carcinoma. Other rare skin tumors may also be appropriately treated. Mohs is optimally performed by a specialist who has completed additional fellowship training in Mohs and reconstructive techniques (dermatologic and skin cancer surgery).
MMS allows the surgeon (skin cancer specialist) to excise the cancer with a very small (1mm) margin, thereby significantly reducing the size of the surgical defect. The small margin is possible, as the tissue removed is mapped, processed by frozen-section, made into slides, and examined by the surgeon microscopically. This process allows the surgeon to identify any residual cancer at the margins of the specimen and strategically return to that particular area to re-excise (using the same technique). Stages and samples continue to be taken until all margins are microscopically clear. Once the margins are clear, options for repair involve allowing it to heal on its own or surgical repair. Because of large number of Mohs cases that occur on the face, neck, and hands, I will often do a reconstruction flap (plastic surgery) if indicated for a superior result. In some instances, I may work with another specialist to give the absolute best result possible. Mohs surgery is performed while you are awake, but it may require you to be with us (or near our office) for multiple hours on a given day.
Cure rates using MMS for Basal Cell Carcinoma are 98% and for Squamous Cell Carcinomas, 96%. This procedure offers by far, the highest cure rates of any treatment modality. That being said, MMS is not clinically indicated for all tumors in all locations. Current guidelines (and insurance reimbursement) dictate that the tumor is in a cosmetically-sensitive area (e.g. the face, ear, neck), in a functionally important area (hand), of larger size, or recurrent. Please check with us on the specifics of your tumor.
When choosing a Mohs surgeon (skin cancer specialist), it is important to consider a formally fellowship-trained surgeon. Fellowship-trained individuals complete an additional 1-2 years of formalized training concentrating on perfecting the technique and refining reconstructive (plastic surgery) skills. I trained in Mohs surgery at Washington University under Roberta Senglemann, MD, and performed hundreds of Mohs procedures and reconstructions under a high level of scrutiny. I pride myself in my perfectionism and meticulous technique and want everyone to be satisfied. All Mohs Surgeons perform skin cancer surgery, but not all of us are professionally trained to a level of excellence with at least a year of focused fellowship training.
Topical Immunotherapy is appropriate for some Basal Cell Carcinoma subtypes, Squamous Cell Carcinoma In-Situ (Bowen’s Disease) and Melanoma In-Situ. Topical Imiquimod is used for a number of weeks to destroy these malignancies and can cause significant inflammation and discomfort during the treatment time. This medication penetrates the skin and actually causes recruitment of immune-fighting mechanisms to migrate to the site of treatment, so that your own body treats the malignancy. Cure rates are lower than surgeries but still respectable at 86% and 78% for BCC (nodular and superficial subtypes, respectively), and 73% cure rate for SCC In-Situ. Cure rates for Melanoma In-Situ using Imiquimod are less clear.
Electrodesiccation and Curettage involves using a round knife (curette) to scrape tumor, followed by an electric needle to destroy tissue using burning heat. This procedure is reserved for BCCs and non-invasive SCCs only. It is a simple and quick procedure that has cure rates approaching excisional surgery (depending on the skill of your specialist). I don’t like this procedure, because it leaves unsightly scars. If you don’t mind the scars, this may be an option for you; it’s reasonable treatment.
Superficial Radiotherapy Treatment, (not to be confused with radiation treatment administered by a Radiation Oncologist), involves directing x-ray beams at a tumor and involves multiple treatments, up to 30 visits. Cure rates vary considerably, as there is no precise control in identifying/destroying residual cancer cells at the margin of the tumor. What’s more worrisome are the long-term cosmetic problems and radiation risks. This is a treatment that may be reasonable for patients in poor health, the elderly, or for those whom surgery is not a reasonable option. BY NO MEANS should it be offered to you as first-line therapy if you are a healthy 40-75-year-old. Your risk of eventual recurrence (and of a more aggressive tumor) is unacceptably high. Some providers are now doing this in their office and designating extender staff to monitor this treatment. It may be attractive as a “non-invasive treatment”, and forgive me, but I think you are selling your soul.
On the other hand, Radiation therapy administered under the watch of a Radiation Oncologist (and we have some great ones here in town) is certainly an option for more aggressive/ recurrent tumors, or in patients for whom surgery is unadvisable. I am happy to work with these physicians on a regular basis to give you the best care possible.
Dr. Schroeder is a Diplomate of the American board of Dermatology, a Fellow of the American Academy of Dermatology, a Fellow of the American Society of Dermatology Surgery, and is adjunct faculty at the University of Colorado School of Medicine. She has been formally trained as a skin cancer specialist and completed a Dermatologic Surgical and Cosmetic Fellowship and Washington University in St. Louis, MO in 2001. Since that time, she has performed countless surgery procedures and is well-known for her excellent results. She is well-equipped to handle all of your skin cancer and surgery needs.