Are we doing more harm than good? This has been a question that we have asked for decades regarding the treatment of malignant melanoma. Over the recent decades, margins of normal skin that are removed when treating melanoma have gotten smaller. Recently, the benefit of lymph node dissection to treat involved lymph nodes has come into question and has been recently studied.
According to a study published in the New England Journal of Medicine, patients with intermediate-thickness melanomas (1.2- to 3.5mm Breslow’s Depth) who were found to have a positive lymph node with sentinel lymph node biopsy (tumor in the lymph nodes), were not more likely to survive after having a lymph node dissection than not.
While removal of the lymph nodes resulting in better regional disease control, it did not increase melanoma-specific survival rates. In addition, patients whom have had lymph node dissection were more likely to have lymphedema (swelling).
What is clear is that early detection and treatment of melanoma is paramount to having a good outcome. Luckily, most melanomas grow laterally for years before they grow deeper. Increased patient awareness and education has resulted in earlier detection rates in the U.S. Unfortunately, once the tumor has spread, science has been unable to find a therapy that offers a “cure” for most patients. Medical advances have been made and may increase survival rates by 10% and continued research will likely improve upon these rates.
For all patients, early detection is key. Self-examination is recommended for patients. Any new or changing moles should be evaluated by a board-certified Dermatologist. “When in doubt, cut it out”–my slogan which means if there is a question of whether a lesion is melanoma, take a biopsy.
Patients whom have many moles should take photos and evaluate every 3 months for changes. There are several phone apps to assist with this.
According to a recent study, there is great variation from one Mohs’ surgeon to another when having Mohs’ surgery. In this study, they found that the mean number of stages per case was 1.47 (range, 1.09-4.11). The variation in range is huge!!! Thirty-five percent of surgeons were persistent outliers (performed more stages than the mean) in all three years of this study. Physicians in solo practice had a 2.35-times likelihood of a persistent high outlier status (OR = 2.35; 95% CI, 1.25-4.35). Now this does not make sense! Think about it, often the most difficult cases are referred to tertiary care centers (academic institutions), yet they were more likely to clear a patient in fewer stages.
Why the great variation? In an academic center, there are residents and fellows assisting on cases. What does that mean for patients? There is less risk for “funny business”–surgeons intentionally taking smaller pieces so that they they will require more stages (in a fee-for-service model, the surgeon is paid for each stage taken).
In my practice, approximately 80% of patients are cleared within the first stage. This falls well within the mean average of 1.47 average stages per patient. Unfortunately, many surgeons fall outside of this mean. This increases cost, may adversely affect cosmetic outcome, increases surgical time for patients, and may lead to increased patient discomfort as additional anesthetic may be needed.
How do you choose a Mohs’ surgeon? That is a difficult question. According to this study, a Mohs’ surgeon in Private Practice is more likely to perform more layers than is necessary than a surgeon who is a full-time academic surgeon. That being said, I know of great surgeons who are in private practice and many who rarely clear a patient in one stage. In fact, some of the best surgeons are in private practice.
What do I recommend? When choosing a Mohs’ Surgeon, one must be more cautious when choosing one who is in Private Practice. In my over 2 decades of performing Mohs’, I can count on one hand how many patients during the initial consultation have asked me what the likelihood of clearing them on the first stage is.
Medscape (5/19, Doheny) reported, “About a third of sunscreens tested by experts…provide less than half the SPF protection claimed on the label,” according to Consumer Reports’ annual sunscreen report. According to the article, the Food and Drug Administration does not routinely test sunscreen products’ SPF.
Dr. Bader recommends sunscreens that have a high concentration of zinc oxide and/or titanium dioxide as the active ingredient(s). These are physical blockers, that reflect all of the suns rays (UVB and UVA).
Chemical blockers only work for specific wavelengths and break down, often within a few hours of sun exposure.
According to a study published in Mayo Clinic Proceedings, squamous cell carcinoma rates have increased 263% between 2000 and 2010, while basal cell carcinoma increased 145% over the same time period.
Although the reasons for this increase is not yet studied, increased sun exposure and increased tanning bed use are likely contributing factors. Avoidance of midday sun, wearing sun-protective clothing, and the regular use of sunscreen all help to reduce the risk of developing skin cancer.
According to a recent study, a single dose of at least 100,000 IU vitamin D3 rapidly attenuates sunburn when given within one hour of sun exposure. Lower doses were far less effective.
Melanoma in situ is a common tumor, and often affects the elderly. In some cases, surgery can be extremely extensive and/or patients are not good surgical candidates. For years, Dermatogists have been offering topical imiquimod (Aldara) to these patients as an alternative to surgery, with the full understanding that it is not as good as surgery, but better than nothing.
A recent study published in Dermatologic Surgery looked at long-term recurrence rates for patients who were treated with Aldara. They found that 17% of patients had a recurrence of their tumor, which is far higher than surgical recurrence rates.
In short, some publications talk about a “new” “alternative” to surgery. This is simply not the case. Surgery is the best option and topical treatment with imiquimod, as it has been, should only be considered for those who are not surgical candidates or those who are not expected to outlive their disease.
The US Food and Drug Administration has granted accelerated approval to Bavencio (avelumab) for the treatment of metastatic Merkel cell carcinoma (MCC)–one of the most deadly skin cancers. Prior to this, there have been no FDA-approved treatment for this deadly cancer.