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    Electronic brachytherapy allows collaboration between dermatologists, radiation oncologists


    Fast treatments

    Because treatments are quick, the radiation oncologist who visits his office can do 10-plus treatments daily, Dr. Werschler says.

    “Ten or more Mohs cases is a very long, busy day for a dermatologist. And the radiation oncologists can do this every day, without fatigue. That’s not the case in Mohs surgery,” he says.

    In radiation oncology offices and integrated cancer centers, Dr. Werschler says, electronic brachytherapy equipment can run virtually 24-7.

    “It’s a very different, and very patient-friendly model, whereas I do Mohs surgery one or two days weekly,” he says. “If you can’t come in on those days, I probably can’t treat you without significantly rearranging the clinic schedule.”

    The only downside to electronic brachytherapy is that patients must undergo usually eight to 10 treatments, versus one for Mohs surgery, says Kavita Mariwalla, M.D., a Mohs surgeon in West Islip, New York who refers patients to a nearby radiation oncologist for electronic surface brachytherapy. Electronic brachytherapy also results in some crusting, redness and irritation, which she says resolve in a few days.

    Electronic surface brachytherapy may result in hypopigmentation and possibly permanent hair loss in the treatment area, Dr. Baron says, but older men — the prime demographic of NMSC — don’t much mind the latter.

    Tussling for turf?

    The fact that radiation oncologists and integrated cancer centers are marketing electronic surface brachytherapy for skin cancer treatment “raises a very interesting political, economic and scope of practice issue going forward,” Dr. Werschler adds. Dermatologists need radiation oncologists to perform the treatment, he explains. However, “Radiation oncologists don’t need a dermatologist.”

    As a dermatologist or Mohs surgeon evaluating electronic surface brachytherapy, Dr. Werschler asks, “Do you embrace a competing technology and incorporate it into your practice as part of the spectrum of comprehensive skin cancer care offered in the dermatology office? Or do you fight it, ignore it, delay it, even demean it? I’ve seen all that happening, and heard it in personal conversations.”

    Whenever that happens, he says, “I’m thinking to myself, ‘It’s not my choice. It’s my patient’s choice, after the risks and benefits of the procedure are fully explained.”

    Dermatologists who instead seek to guard their NMSC turf one day could find that “most skin cancers are being treated by radiation therapy — not in the dermatologist’s office, but in the radiation oncologist’s office or comprehensive cancer center,” Dr. Werschler says.

    As a specialty, “Organized dermatology needs to make a decision how they’re going to approach this. You don’t want to be the guy who’s still championing carburetor technology in the world of electronic fuel injection.”

    According to an American Academy of Dermatology (AAD) position paper approved in late 2013, the academy considers surgical treatment (e.g., excision, Mohs, destruction) the optimal primary intervention for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Moreover, the paper raises the concern that the rapid growth in utilization of temporary current procedural terminology (CPT) codes related to superficial radiation therapy and electronic surface brachytherapy may “draw scrutiny from private payers, federal agencies, including the Centers for Medicare and Medicaid Services, members of Congress, and federal watchdogs.”

    Presently, the paper states, “The academy believes additional research is needed on superficial radiation therapy (SRT) and electronic surface brachytherapy.”

    Next: Derms v. radiation oncologists


    John Jesitus
    John Jesitus is a medical writer based in Westminster, CO.


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