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.
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.
In an article published in the Journal of the American Academy of Dermatology, individuals “with psoriasis who were treated with biologics had an increased incidence of cutaneous squamous cell carcinoma.” The risk increased by over 42% in those exposed to the TNF-alpha biololics, which include:
infliximab (Remicade), adalimumab (Humira), certolizumab pegol (Cimzia), and golimumab (Simponi), or with a circulating receptor fusion protein such as etanercept (Enbrel) which may also affect skin cancer risk.
Thalidomide (Immunoprin) and its derivatives lenalidomide (Revlimid) and pomalidomide (Pomalyst, Imnovid) are also active against TNF and may affect skin cancer rates.
Xanthine derivatives (e.g. pentoxifylline) and bupropion. Bupropion is the active ingredient in the smoking cessation aid Zyban and the antidepressants Wellbutrin and Aplenzin and may have an effect on skin cancer rates.
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.