Surgery Is Still the Preferred Treatment for Most Skin Cancers

Cancer can be treated with surgery, radiation, and / or chemotherapy. The best treatment(s) will offer the highest cure rates while minimizing side effects. For most skin cancers, surgery remains the best treatment. Traditional radiation therapy can be an important tool in some instances, but is not typically used as monotherapy. Chemotherapy is generally only applicable in limited situations.

What Is Surgery Still the Best Treatment?

Decades of studies have shown that surgery provides higher cure rates than radiation or chemotherapy for most skin cancers. Some of the benefits of surgical treatment include:

1. -Cure rates up to 99% (especially if Mohs micrographic surgery is utilized).
2. -Confirmation of tumor clearance by analyzing the surgical specimen.
3. -Treatment is typically completed in a single day (usually 2-3 hours).
4. -Most surgeries can be performed in-office using local anesthesia (lidocaine).
5. -Post-operative complications, such as infections, are rare (less than 5%).
6. -Most patients are very satisfied with the cosmetic appearance of their scar.

Of course, no treatment is perfect or without risk. There is a small chance that the tumor cannot be removed successfully with surgery. There is some discomfort when the lidocaine is first injected (most people tolerate just fine). And yes, there is a scar from surgery; there is no such thing as a scarless surgery. However, most patients are very satisfied with their surgical outcome. And keep in mind that radiation creates “scars” too: not surgical scars, but discoloration, skin texture changes, and the like.

Where Does Radiation Fit In?

The most common use of radiation for skin cancer is adjuvant therapy. If surgery fails to remove all of the skin cancer, or if there is concern that the tumor has spread beyond the surgical site, then radiation can be used to “clean up” the surrounding area. There are also instances when a tumor cannot be removed surgically without producing significant patient deformity (very large tumors that may be eating into the bone, for example). Finally, some patients may be too frail or surgery phobic for surgery. Some things to keep in mind about radiation:

1. -Radiation requires many visits to the doctor (probably 10-20 days).
2. -Cure rates can be good, but typically not as high as surgery.
3. -Treatments are painless, but there can be post-op discomfort (skin burning or irritation).
4. -There is no pathology confirmation that the cancer is removed.
5. -Post-radiation discoloration / texture changes can be more noticeable than a surgical scar.
6. -Radiation exposure increases the risk of future cancer formation.

What About New Radiation Therapies? Are They As “Gentle” As Advertised?

Superficial radiation therapy (SRT) and electronic brachytherapy are 2 newer technologies being marketed to dermatology offices. They use less radiation than traditional approaches, so they can be safely used in an outpatient office setting. Many cancer specialists have expressed concerns about these treatments, including:

• -There are few long-term studies, so we do not know how cure rates compare to surgery.
• -SRT / electronic brachytherapy may kill the surface of the tumors, but not the roots. In that case, the cancer could come back bigger and more aggressive in the future.
• -Training: radiation therapy is traditionally administered by a radiation oncologist, who is a physician with at least 5 years of residency training. These newer technologies are often being administered by dermatologists, who likely did not receive training on radiation therapy during their residency program.

SRT and electronic brachytherapy are not currently recommended by the National Comprehensive Cancer Network guidelines for skin cancer treatment.

What About Chemotherapy?

Topical chemotherapies can be used for very superficial skin cancers. Oral and IV chemotherapies are used for advanced disease (skin cancer that has spread throughout the body).

Final Thoughts?

There is an old saying among doctors that we treat patients, not disease. Cancer care is a collaborative approach: the role of the physician is to provide high-quality information to the patient so that they can choose the treatment plan that is right for them. In my practice, I perform Mohs micrographic surgery, refer patients to radiation oncology when surgery is not right for them, and prescribe topical chemotherapy for superficial skin cancers when appropriate. Perhaps as medicine advances, non-invasive technologies will prove to be superior to our current treatments. Until that time, surgery will continue to be the preferred treatment for most skin cancers.