Building A Better Mousetrap: Caring For Patients With Skin Cancer

Evidence-based care is the mantra of our times. Yet, even here there is a possibility to refine those guidelines to clothe a patient population that is anything but one size fits all. 

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Build a better mousetrap and the world will beat a path to your door,” is a phrase often attributed to Ralph Waldo Emerson. Is that what we dermatologists are—better mousetraps?

In April 2016, Major League Baseball fans witnessed a rarity—the pilfering of home plate by Yankee center fielder, Jacoby Ellsbury. The Tampa Bay Ray’s left-handed pitcher, Matt Moore, wound up with the count 3 to 1. His back was to the runner and Jacoby leapt, covering the 90 ft in 3.8 seconds, to touch home just out of reach of Curt Casali, the Ray’s catcher. Speed, strength, and audacious belief in ones’ possibilities led to a much-needed win and excitement for a rare accomplishment in baseball. Dr Fromowitz’s article (page 23) seeks to provide us, who are arguably better mousetraps for the care of skin cancer, with a recipe to steal home every day in the care of our patients. I wonder, though, is it really that easy?

Options for Patients

It is tempting to write cookbooks. Medicine is awash in guidelines for care and they bring comfort and help standardize treatments. The best of them do so, scouring the literature for evidence to gird their recommendations. Evidenced-based care is the mantra of our times. Yet, even here there is the possibility to refine those guidelines to clothe a patient population that is anything but one size fits all. 

Eleni Linos, MD, DrPH, reminded us in an article published in 2013 that in the United States most skin cancers are treated surgically even at the end of life.1 It was a groundbreaking expose. The dermatologic community spoke volumes and much of that speech was less than complimentary. It is the standard of care to treat nonmelanoma skin cancers (NMSC) and there are no guidelines to inhibit that march to intervention. It is probably telling that her article was published in a primary care journal. 

In Dr Fromowitz’s cookbook, I would add a box for “sometimes the best surgery is no surgery.” I believe Dr Linos is correct in saying that we in dermatology, particularly the Mohs community of which I am a card-carrying member, often default to surgery. We are badly equipped by temperament and training to do nothing. Doing something always feels right. It seems to be the correct choice. But, is it? 

I would argue that all of us in our conversations with patients need to step back and look not at an absolute number as indicative of end of life but a functional estimation that includes, but is not defined by, birthdays. Various indices can be used, such as the Charlson Comorbidities Index that is validated with predictive power for 1-year mortality.2 Much of what is measured is common among our patients, including diabetes, chronic kidney disease, history of myocardial infarction, liver disease, history of cancer or underlying metastatic disease, use of anticoagulants, and pulmonary disease. I frequently quote recurrence rates, as published by Dr Rowe and colleagues, when speaking to patients regarding their basal cell cancers, with 5-year recurrence rates as follows: Mohs surgery 1.0%, surgical excision 10.1%, curettage and electrodesiccation 7.7%, radiation 8.7%, and cryosurgery 7.5%.3 I am also honest if I think their likelihood of having serious complications from their basal cell cancers are low before they have ended this life’s journey. 

Treating Skin Cancer

I also, like Dr Fromowitz, discuss the use of topicals for superficial disease including photodynamic therapy, though with less enthusiasm unless red light is available. My experience with superficial radiation therapy (SRT) is limited by its prohibition to all but trained radiation oncologists in the state in which I practice. I also reflect on the position statement from the American Academy of Dermatology4 that suggests “that additional research is needed on superficial radiation therapy, particularly on long-term outcomes.” I am aware of the position statement from Kaiser Permanente5 that states that SRT (electronic brachytherapy [EBT]) has “insufficient published evidence to determine whether the safety and efficacy outcomes of EBT for non-melanoma skin cancer (NMSC) are as good or superior to the outcomes of alternative treatment options. There are no published randomized or non-randomized control trials that compare EBT to an alternative therapy for the treatment of NMSC.” In fairness, however, there are few trials that directly compare one modality say, Mohs surgery to excisional surgery, that are not compromised by some selection bias or are of insufficient size and power to overcome published recurrence rates within single-treatment modality. A review of SRT by Sean McGregor, DO, PharmD,6 states that SRT may be a “viable alternative for a select group of patients though additional studies need to be conducted to further delineate its role.”

While there are many good dermatologists that use this modality, likely well and with good outcomes, it would be remiss not to mention the article by Jack Resnick, MD, and colleagues in JAMA Dermatology7 that details a marked increase in the use of commercial devices by dermatologists without much in the way of training and a dramatic increase in Medicare payments, some exceeding $24,000 for the treatment of 1 cancer. Most of those payment excesses have been corrected by the Center for Medicare and Medicaid Services. So, I would leave the use of SRT/EBT in the hands of those with more experience and training than myself. 

Conclusion

In closing, I appreciate Dr Fromowitz’s admonition to all of us to empower our patients to be informed sufficiently to make decisions on care that best fit their tumor, their need, and their unique comorbidities. If we, as a specialty, can achieve that, then we will indeed be the better mousetrap. 

Dr Williford

Dr Williford is a professor of dermatology at Wake Forest University School of Medicine in Winston-Salem, NC.

References

1. Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Landefeld CS, Chren MM. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer. JAMA Intern Med. 2013;173(11):1006-1112.

2. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-383.

3. Rowe DE, Carroll RJ, Day CL Jr. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol. 1989;15(3):315-328.

4. American Academy of Dermatology. Position statement on superficial radiation therapy for basal cell carcinoma (BCC) and squamous cell carcinomas (SCC). https://www.aad.org/Forms/Policies/Uploads/PS/PS%20Superficial%20Radiation%20Therapy.pdf. Updated August 9, 2014. Accessed August 28, 2018.

5. Kaiser Permanente. Clinical review criteria superficial radiation therapy (electronic brachytherapy for non-melanoma skin cancer). https://provider.ghc.org/all-sites/clinical/criteria/pdf/electronic_brachytherapy_nmsc.pdf. Published 2014. Accessed August 28, 2018.

6. McGregor S, Minni J, Herold D. Superficial radiation therapy for the treatment of nonmelanoma skin cancers. J Clin Aesthet Dermatol. 2015;8(12):12-24.

7. Linos E, VanBeek M, Resneck JS Jr. A sudden and concerning increase in the use of electronic brachytherapy for skin cancer. JAMA Dermatol. 2015;151(7):699-700.