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An Inconvenient Truth about Skin Cancer (over)Treatments.

Dermatologist He’s earning his living Skinning me

~ From the poem “Melanihaiku 1” (“De Natura Melanoma”: poems by Sharad P. Paul, Middle Island Press 2015)

Increasingly we see Mohs Surgery being advertised. What is it? Mohs surgery is named after Frederic Mohs, a general surgeon who developed the technique in 1938. The technique involves shaving away layers of cancerous cells and testing until there is no cancer left. The testing is done during the procedure itself (rather than sent off to the lab) and it

allows to remove cancer completely with narrower margins.

In our clinic, we excise skin cancer and often use dermoscopy to assess margins. Because of the vast experience, we have had in dealing with skin cancers since 1996 (when our clinic opened), we have an extremely low incomplete excision rate. Rarely, we come across difficult tumours where we have to perform complicated closures, and in such cases, follow an approach called slow Mohs surgery i.e. leave the wound open and close the next day after getting a pathologist look at the specimen urgently. This allows us to avoid having to re-do a procedure (except for melanomas where a wider tissue removal is usual practice). Therefore, we rarely use this approach in our clinic.

While Mohs surgery has some advantages, it is much more expensive. New Zealand has some of the highest fees for skin cancer surgery in the world and Mohs surgery is at top of the list.

Tamar Nijsten, MD, PhD, from Erasmus Medical Centre in Rotterdam, the Netherlands spoke at the 26th European Academy of Dermatology and Venereology (EADV) Congress in Geneva recently. He said dermatologists were “following the money” and that the overuse of Mohs surgery was an “inconvenient truth”.

Dr Nijsten's remarks were part of a presentation entitled "Inconvenient Truths in Skin Cancer Care," given here at the 26th European Academy of Dermatology and Venereology (EADV) Congress. As chair of the European Dermato-Epidemiology Network he remarked, “Dermatologists often default to expensive Mohs micrographic surgery to treat primary basal cell carcinomas “he said, “despite evidence that a specific lesion is nonaggressive. Instead, curettage, excision, cryotherapy, or even topical creams should be considered before resorting to Mohs.” Mohs should be reserved for patients with high-risk but the reality is otherwise.

Because of my background of having studied law as well as medicine, I am often asked what the best medico-legal advice is, and I say this: “If you treat your patients as you would treat yourself or your family, things will be OK.” This is my underlying philosophy. This simple philosophy would make us take good care, lower costs and not recommend unnecessary procedures, and would by default define what should be the fundamental paradigm for procedural medicine, but increasingly it isn’t.

Source: Maureen Salamon. Medscape Medical News. 'Follow the Money' in Extreme Skin Cancer Care. Coverage from the 26th European Academy of Dermatology and Venereology (EADV) Congress. Sept 17, 2017

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