To those who are patients and those who follow my posts, you know that I am adamant that there has been an over-treatment of these atypical nevi for decades. In short, the data just does not support the removal of these lesions–PERIOD!
Another study was just completed at Emory University (Atlanta) and Atlanta Veterans Administration Medical Center. Here are their conclusions:
Re-excisions are not needed when clinically excised moderately dysplastic nevi have positive histologic margins, based on results of a retrospective study of 438 patients who were treated at nine academic medical centers in the United States. Not a single patient in the study developed melanoma at the excision site after an average follow-up of 6.9 years, and at least 3 years in all cases. [SOURCE: Kim CC et al. IID 2018, Abstract 571.]
So when your Dermatologist or the Dermatopathologist (on their pathology report) states that your moderately atypical nevus should be removed, ask Why!
A recent study published in the Journal of the American Academy of Dermatology has shown that taking hydrochlorothiazide (HCTZ) is associated with an increased risk of basal cell carcinoma and an even higher risk of squamous cell carcinoma. The risk was dose dependent (the higher the cumulative dose, the higher the risk).
An increased risk was not seen with other anti-hypertensive agents or diuretics.
A recent study has shown a positive association of increased alcohol consumption with the risk of non-melanoma skin cancer. The study was small, so larger studies are needed to confirm these preliminary results.
Here is yet another possible reason to limit or eliminate alcohol consumption. Red wine has some other health benefits that, according to some, might outweigh the negative effects when taken in moderation–no more than one glass per day, but even that is somewhat controversial.
The use of PDE5 inhibitors such as sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) are common for those with erectile dysfunction. More and more research has shown an increased risk of some types of skin cancer for those taking these medications. Interestingly, there have been no studies showing an increased risk of squamous cell carcinoma.
For this reason, those with a history of melanoma should take this into consideration when considering taking one of these medications. Those with a personal history of multiple dysplastic moles or family history of melanoma should also take this into consideration. For patients whom have had multiple basal cell carcinomas should also weigh the risks of taking these medications.
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.