Saturday , December 5 2020

Superficial Radiotherapy Vs. Mohs Surgery:

Which is the better choice for skin cancer treatment?

Recent research places the cure rate for nonmelanoma skin cancer at 97.4% with Superficial Radiotherapy. These results, published in The Journal of Drugs in Dermatology in 2019, demonstrated the actual results of elderly patients in an outpatient clinic, who were treated with Superficial Radiotherapy for skin cancer in the lower extremities. Lower extremity skin cancers are particularly prone to slow healing and infectious complications, when treated with surgery. Since Superficial Radiotherapy is nonsurgical, there is no concern regarding healing or infection. Not to mention that with results this good, nearly matching the cure rates achieved with Moh’s micrographic skin surgery, patients have a viable, nonsurgical option for cure of their skin cancer.

Traditionally considered the gold standard for cure of skin cancer, Moh’s Micrographic Surgery is a procedure that requires proper excision, review of pathology and surgical reconstruction afterwards. An experienced, fellowship trained Moh’s surgeon can provide the cure rates cited in published literature of 99%. However, since there are no restrictions on who performs the procedure, general dermatologists routinely perform Moh’s Surgery, despite lacking fellowship training. This accounts for the less than expected cure rates, poor reconstruction and less than ideal cosmetic results some patients face afterwards. Because of its complexity and tediousness, Moh’s Surgery was originally designed for use only in specific areas of the body that are not amenable to routine excision or for recurrent skin cancers. It has however become overpracticed, with many general dermatologists only recommending Moh’s
when effective alternative therapies could easily be implemented or preferable. Moh’s is one of the many treatment options available to patients with skin cancer, the final treatment decision is based on many factors, including skin cancer type, body area involved, patient age, comorbidities and patient choice.

Dr. Gil Cortes, Dermatologist with NOVU Dermatology mentioned “Many patients come to see me and complain they were never informed about Superficial Radiotherapy as a viable treatment option. They are curious to find out more and want to know how it compares to Moh’s. When I mention the cure rates, many are very surprised and many more relieved that there is an option that doesn’t involve surgery.” Dr. Cortes mentions that although he can do Moh’s surgery, he often finds that it is not necessary and takes time to consider each patients’ needs and preferences. He mentioned “Moh’s definitely has its place in skin cancer treatment, but is undoubtedly overpracticed.” Nonmelanoma skin cancer may be treated with Moh’s micrographic surgery, surgical excision, ED & C, topical creams such as Efudex and Diclofenac as well as Superficial Radiotherapy and more. Of the many nonsurgical options presented, only Superficial Radiotherapy comes close to offering a cure rate comparable to Moh’s surgery.

Although Superficial Radiotherapy is by no means a new treatment method, it has been improved and treatment protocols streamlined, which has led to consistently high cure rates in recent studies. The fact that the radiation involved is nonpenetrating, means side effects are minimal and infection rates close to nonexistent. There is no follow up biopsy or cutting, only clinical monitoring of the treated area by the Dermatologist. Not to be confused with other types of radiation treatments, SRT is different. SRT utilizes low energy X-Rays, or photons, to deliver electromagnetic energy to rapidly dividing cells in order to effectively stop cancer growth.4 This is in stark contrast to the traditional machines used in radiation oncology, which deliver high energy megavoltage photons in the range of 6 to 25mV through the use of a linear accelerator (LINAC).4 The amount of penetration of radiation is very different between high- energy and superficial machines. High-energy machines used in radiation oncology are designed to penetrate, so they can treat internal malignancies and spare the cutaneous structures.4 In contrast, superficial machines spare the deeper structures and target the skin, a quality that is ideal for the irradiation and treatment of skin cancers. Additionally, high energy radiation machines do not offer the cure rates that are seem with superficial radiotherapy, some ranging as low as 75%.

A limiting factor for some patients, is the fact that Superficial Radiotherapy requires multiple treatments. If patients do not complete the treatment protocol, which can range from 7 to 20 treatments, they will not be effectively treated. Per Dr. Cortes, patients experience is usually positive. “Multiple treatments can be an issue for younger patients who have work constraints, but most seniors don’t have an issue with the visits at all. Especially because the actual treatment time is usually less than a few minutes and completely painless.” Because of this, therefore patients should find a provider close to home to ensure ease and comfortably complete the full course. A limiting factor for practicing dermatologists, is the cost of the machine. A modern superficial radiotherapy machine is a significant expense, which also requires training and certification for use. Treatments require physician supervision and more dedication of time and personnel, which makes the offices that offer superficial radiotherapy relatively scarce. However, with improving coverage from Medicare and other insurers, superficial radiotherapy is slowly stepping up as a popular, viable, effective and completely nonsurgical treatment option.

Gil Cortes, MD, FAAD
NOVU Dermatology Practice Owner & Dermatologist
(352) 775-3565
NOVUDERMATOLOGY.COM

Rolling Oaks Professional Plaza
929 N. US Hwy 441 Suite 603
Lady Lake, FL 32159

1.Roth WI, Shelling M, Fishman K. Superficial radiation therapy: A viable nonsurgical option for treating basal and squamous cell carcinoma of the lower extremities J Drugs Dermatol. 2019:18(2):130-134.

2.McGregor S, Minni J et. Al. Superficial radiation therapy for the treatment of nonmelanoma skin cancers. J Clin Aesthet Dermatol. 2015:8 (12):12-14

3. Veness M, Richards S. Radiotherapy. In: Bolognia J, Jorizzo J, and Schaffer J, eds
Dermatology, vol 2 Philadelphia: WB Sauders:2012:2291-2301

4.Barysch M, Eggman N, Beyeler M, et. Al. Long term recurrence rate of large and difficult to treat cutaneous squamous cell carcinomas after superficial radiotherapy. Dermatology. 2012:224:59-65

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