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Mohs surgery a good solution for recurrent skin cancer

It used to be that dermatologists treated skin cancer patients mostly in their 50s and 60s. Today, however, we’re seeing younger patients, including women in their 20s. While we don’t know why skin cancer is affecting people at younger ages, I think this rise might be attributed to the use of tanning parlors, especially popular with women, and a continued increase in the popularity of having a tan. Tanning booths use artificial ultraviolet light that can be as damaging as natural sunlight. There is no such thing as a safe tan. A tan means that the skin has been damaged.

We continue to raise awareness about the importance of sun protection, but our message is often unheeded by members of the younger population, who might feel invincible or think they’re too young to be affected. But we now have the data to know that they can – and do – get basal cell or squamous cell cancers.

Dermatologists are also now armed with tools that can help patients recover from skin cancer. I tell patients that very few people die from squamous cell cancer of the skin and although it is potentially disfiguring, death from basal cell carcinoma is rare enough to not be considered a risk. With the right treatment, almost 100 percent of people will have their skin cancer eliminated.

Mohs micrographic surgery helps

One of the most effective treatments for specific types of non-melanoma cancer is the Mohs micrographic technique, a type of surgery that is extremely thorough at removing all cancerous cells. It is especially good for recurrent cancers, larger cancers or facial cancers where a good cosmetic result is essential. Not all skin cancers require Mohs surgery, and in some cases, other approaches are preferred. Examples are small skin cancers on the legs or trunk.

Named for Frederick Mohs, MD, a general surgeon at the University of Wisconsin in the 1940s, Mohs surgery is the gold standard for removing many basal and squamous cell cancers. Today, doctors use a fresh tissue technique in which the skin cancer tissue is analyzed in a mapping fashion during the course of surgery to ensure it is all removed. The Mohs surgery cure rate is as high as 98 to 99 percent.

Skin cancer can have microscopic roots, so a skin cancer can often be larger than it appears on the surface to the naked eye. Mohs surgery allows doctors to get all the cancer, without having to take a lot of tissue. This can be especially important with cancer on the face, the site of 70 percent of basal and squamous cell carcinomas.

Skin tissue examined under a microscope

Dermatologists need to be specially trained in the Mohs procedure, and while it is now available at most university centers and practiced by many community-based Mohs surgeons, not all dermatologists are trained in it.

Mohs surgery is an office procedure conducted in the course of a couple of hours, depending on the size of the lesion and how many times a layer must be taken. Under local anesthesia, a layer of cancerous skin as thin as a dime, or thinner, is removed from the patient in a disk-like shape. The doctor maps out the specimen and then studies it under the microscope to see if any cancer remains. If the microscopic study shows that residual cancer is deeper, the surgeon will take another disk-like thin layer of skin, until all the cancer is removed.

Not all instances of skin cancer require Mohs surgery, but it is an important and attractive option for skin cancers of the face, scalp or neck; for recurrent cancers; very large cancers; or cancers in difficult-to-treat areas. Patients usually need to be referred to a specialist in Mohs surgery, so ask your doctor about different options and if he or she feels you’d benefit from Mohs surgery.

Mohs surgery the gold standard

Mohs surgery, while not new, is still the gold standard for recurrent skin cancers, large skin cancers and facial skin cancer where the cosmetic result is important.

Other new procedures also get good results. Photodynamic therapy is appropriate for some types of precancers such as actinic keratosis. In this relatively new procedure, a solution is painted on the lesion and activated by light. Creams are also available that help stimulate the immune system.

Still, the best strategy is to avoid skin cancer in the first place. I tell my patients to see their dermatologist once a year to check for moles, marks and bumps that may be precancerous.

This is especially important for those who are more at risk for skin cancer – people with blue, gray or green eyes; people with fair skin who burn more easily; people with light hair; and people with a previous skin cancer or a family history.

David J. Leffell, MD, is professor of dermatology and surgery and at the Yale School of Medicine and chief of the section of dermatologic surgery and cutaneous oncology at Yale-New Haven Hospital. He is also author of Total Skin: The Definitive Guide To Whole Skin Care For Life (Hyperion, 2000).