Why Is Everyone Talking About Radiation for Skin Cancer? Insights from a Mohs Surgeon.
As a Mohs surgeon and cutaneous oncologist specializing in skin cancer treatment, I consider one of the most crucial aspects of my role to be guiding patients through their diagnosis and treatment journey with the most effective and evidence-based care. Recently, I've received numerous questions about infomercials and the hype surrounding radiation as a safe and effective first-line treatment for many skin cancers. This information is being presented in a way that suggests it's simple, superior to surgery, and relatively risk-free. This is dangerous misinformation, and I'd like to clarify the facts and share my experience in this blog.
The risks associated with radiation, along with its significantly lower cure rate in many cases, are not being adequately communicated to patients. While I do recommend radiation in very specific situations in my practice, the gold standard treatment for most skin cancers often involves other modalities, frequently Mohs surgery. Unless patients are unsuitable for surgery (a relatively rare occurrence) or have specific tumor characteristics that make radiation a viable option either after or instead of surgery, the potential harm of using radiation as a first-line treatment can far outweigh any benefits.
The primary goals of skin cancer treatment are accurate diagnosis, stopping the cancer's progression, completely eradicating the tumor, and minimizing risks. In cases where Mohs surgery is appropriate, this treatment allows the surgeon to examine 100% of the tissue margins in real-time, resulting in the highest cure rate and minimal removal of healthy surrounding skin. This limited removal is beneficial for healing and long-term cosmetic outcomes. Many patients worry about facial surgery leading to disfigurement or poor healing. However, with an experienced surgical approach and proper aftercare, most patients heal with a well-concealed, barely perceptible long-term scar. Most importantly, the risk of the skin cancer returning is minimized.
While radiation therapy is sometimes used as a post-surgical treatment for certain high-risk tumors, it is essential to consider its limitations and risks. Radiation may be recommended for non-surgical candidates, but Mohs surgery and other surgical procedures are generally quite safe and can be performed in most cases, even for patients on multiple blood thinners or with other underlying complex medical conditions.
Choosing Between Surgical and Radiation Treatments for Skin Cancer: Understanding the Realities and Risks
I often find that patients seek to avoid surgical treatment in favor of what they perceive as an "easier" option. However, radiation therapy requires frequent visits over several weeks, which can be quite inconvenient and challenging for many people. Additionally, radiation costs are generally much higher than surgery, placing a greater financial burden on patients and our already strained medical system.
Three key risks associated with radiation therapy include:
Higher Recurrence Rate: Radiation as a primary treatment option has a much higher recurrence rate than surgical options like Mohs surgery. This is largely due to the inability to examine all tissue margins under a microscope during treatment. Many tumors have irregular and unpredictable "roots" or “edges” that can be missed without microscopic examination.
Changes to Skin Quality: Radiation alters the topography and quality of the skin, causing thinning, color changes, and hair loss. If a skin cancer recurs in a previously radiated area, surgical removal is more challenging, and achieving an optimal cosmetic result is harder due to these tissue changes. Reconstruction options may also be limited because of the compromised quality of radiated skin, making some skin flaps and other repairs unfeasible.
Heightened Risk of Recurrence and Future Skin Cancer: Monitoring for recurrence is complicated by radiation-induced skin changes. Recurrences after radiation therapy tend to be larger, deeper, poorly defined, and more difficult to excise, often resulting in substantial wounds that necessitate more extensive and complex reconstruction. Additionally, radiation can significantly raise your risk of future skin cancer development in the radiated field.
In summary, here are the risks associated with first-line radiation treatment:
Limited Effectiveness: Radiation therapy may seem to be effective at first, but it does not, in fact, completely eliminate all cancer cells, especially for tumors with aggressive features from the beginning. It can be challenging to achieve full eradication of the tumor while minimizing damage to surrounding healthy tissue.
Risk of Recurrence: Radiation treatment results in higher rates of cancer recurrence compared to surgical approaches like Mohs surgery. Recurrent cancers often present greater challenges in treatment and can lead to more complex outcomes.
Potential for Side Effects: Radiation therapy can cause adverse side effects, such as skin irritation, redness, and long-term damage to the skin and underlying tissue. These effects can impact the patient's quality of life and may require additional management interventions.
Lack of Tissue Examination: Unlike Mohs surgery, which allows for real-time microscopic examination of tissue margins, radiation therapy does not provide immediate feedback on the completeness of tumor removal. This can lead to uncertainty about the effectiveness of treatment and a high psychological burden for many patients.
Precision and Control: Mohs surgery offers precise, controlled removal of cancerous tissue layer by layer, minimizing damage to healthy surrounding tissue. This approach ensures a higher likelihood of complete tumor removal and reduces the risk of recurrence.
Tailored Treatment: Each skin cancer case is unique, and Mohs surgery allows for personalized treatment based on the specific characteristics of the tumor and its location. This tailored approach maximizes effectiveness while preserving cosmetic and functional outcomes.
If you have been diagnosed with skin cancer and are exploring treatment options, I encourage you to schedule a consultation to discuss the best approach for your individual case. Remember, informed decision-making is key to successful skin cancer treatment outcomes.
If you are considering Mohs Surgery or have questions, call our office at 401-415-8586 to schedule a consultation with Dr. Findley.