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.
Every day a patient contacts me as a nearby Dermatology group is running a television advertisement of a new treatment for skin cancer that does not require surgery. Interestingly, every patient says it is a laser. Well, this is not the case. This “new” treatment is not new at all. It is electron beam treatment, a form of radiation. This has been used for decades for the treatment of skin cancer at most radiation oncology centers in the United States. Well, what’s new? A smaller, in-office version of this machine is available and is being sold to Dermatologists, all of whom prior to having this machine had no training in treating skin cancers with radiation. Why is this practice advertising on Television? Simple. The average reimbursement for treating one cancer is in the tens of thousands of dollars, versus under $1,000 to have the average cancer on the face treated by other modalities and those not on the face costing $600 or less in most cases.
This treatment requires patients to come to the office 4-5 times per week for up to 24 treatment sessions.
According to a study published in the Journal of the American Academy of Dermatology, 74% of persons using black salve were not aware of the possible side effects of the remedy, including infection, scarring, and disfigurement. Black salve can destroy the top layer of skin, but most cancers lie beneath this layer and continue to grow.
CONCLUSION: Black Salve is NOT recommended for the treatment of nearly all skin cancers, and should not be used unless under the supervision of a board-certified Dermatologist.
A study published in The Lancet by Dr. Peter Gillgren indicates that a 2-cm excision margin is safe and as sufficient as 4-cm margins for the removal of melanomas that are at least 2-mm thick. This study took place in Sweden and involved a total of 936 patients.
This study indicates what has been believed for over a decade, that large melanoma margins are likely not necessary and do not increase one’s survival rate. Clearly, smaller surgical margins will result in less disfigurement and a simpler reconstruction after surgical removal of malignant melanoma.
Patients with advanced malignant melanoma taking the experimental drug, vemurafenib, were 63 percent less likely to dies than those who were given chemotherapy. After three months, patients had a 74 percent reduction in the risk of skin cancer progression and half had tumor shrinkage compared to chemotherapy. This drug is designed to be used in patients whose melanoma tumors have a mutation in the BRAF gene that allows melanoma cells to grow. About half of melanomas have this genetic mutation.
In a different study, patients with advanced malignant melanoma who were treated with ipilimumab plus chemotherapy lived an average of two months longer than those who were given chemotherapy alone. This drug stimulates the immune system to help fight off the cancer cells.
One always gets a scar after any surgery. Mohs’ Surgery is a method of tumor removal. In most cases, one will receive plastic surgery to repair the defect after the tumor is removed. Therefore, it is essential to choose a surgeon who will repair the defect carefully, as this will have a significant impact on the final cosmetic result. Obviously there are many other factors that play a role in the final cosmetic outcome, including the size of the tumor, the location of the tumor, & the depth of the tumor.
As Mohs’ surgery removes the least amount of normal skin it should have a cosmetic result that is superior to other forms of surgical removal (excision).