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    Electronic brachytherapy allows collaboration between dermatologists, radiation oncologists


    Derms versus radiation oncologists

    Mark S. Nestor, M.D., Ph.D., says he shares Dr. Werschler’s concern about dermatology losing NMSC treatments to radiation oncology — not necessarily due to brachytherapy, but due to radiation therapy in general. He is a voluntary associate professor, department of dermatology and cutaneous surgery, University of Miami Miller School of Medicine.

    Dr. Nestor performs SRT for NMSC in his office. He says he understands radiation oncologists treating skin cancer because cancer treatments are what they do. However, “Almost all radiation oncologists use electron beam therapy to treat skin cancers, which has been shown to be less effective and have more side effects than SRT. Additionally, where I have an issue is that there are some in the dermatologic community who look at radiation therapy as a conflict or encroachment on Mohs surgery, which is ridiculous.”

    Many of the dermatologists performing SRT for skin cancers are Mohs surgeons, he says.

    “Mohs is still utilized on certain tumors; radiation therapy is utilized on certain tumors,” Dr. Nestor says. “They’re both choices that patients should have.”

    Compared to electronic surface brachytherapy, he says, “SRT has much more data and behind it at this point. It was developed by dermatologists, and it is being embraced more by dermatologists” who, with proper training, can perform the procedure without radiation oncologists.

    Dr. BhatnagarAjay Bhatnagar, M.D., author of the longest study of electronic surface brachytherapy for NMSC to date, says electronic surface brachytherapy is “a new modality. We need more follow-up to establish the long-term results. But the current short-term results are highly encouraging, and very comparable to traditional brachytherapy.”

    Among 277 patients treated with the new modality, no recurrences have occurred during follow-up that ranged from one to 51 months (mean: 13 months) post-treatment (Bhatnagar A. AAD 72nd Annual Meeting. March 21-25, 2014. Denver, Colorado). He is medical director of 21st Century Oncology of Arizona, practicing radiation oncology in Scottsdale, and Casa Grande, Arizona; and an adjunct assistant professor of radiation oncology at the University of Pittsburgh, Pennsylvania.

    Coexisting peacefully?

    Going forward, most sources say, the NMSC landscape is large enough to accommodate electronic surface brachytherapy, Mohs surgery and other existing treatment options. Dr. Bhatnagar says that while researchers including himself are currently establishing the role of brachytherapy — including electronic brachytherapy — as a viable option for NMSC for a specific subset population, “The majority of NMSCs will be treated by surgery,” Mohs or otherwise.

    Dr. BaronDermatologists who offer electronic brachytherapy are “not trying to replace Mohs surgery, which will remain the gold standard for most NMSC,” Dr. Baron says. “We’re just trying to have another option” for patients who may not be candidates for Mohs surgery or who have lesions in cosmetically sensitive or anatomically challenging locations.

    Dr. Mariwalla adds that with the epidemic of skin cancer in the United States, “I don’t believe that treating all skin cancers with radiation will be something patients want.

    “I don’t believe radiation oncologists are going to start treating only skin cancers,” Dr. Mariwalla says. “They have many other types of cancers to deal with. For the number of skin cancers out there, I don’t believe electronic surface brachytherapy is such a threat.”

    Skin cancer treatments make up about 30 percent of Dr. Bhatnagar’s practice, which he says is atypically high for a radiation oncologist.

    The bottom line is that in terms of safety and efficacy for NMSC, “There’s never been a challenge to Mohs,” Dr. Werschler says. “In my opinion, we now have an alternative therapy. Whereas traditionally patients with skin cancer on the face, hands or legs or with high risk of recurrence generally chose Mohs surgery, now they have a credible choice. So you explain the risks and benefits of the procedure and let them make their decision.”

    Disclosures: Dr. Bhatnagar is a consultant and principal investigator for iCAD and has received research funding from the company. Dr. Nestor is a consultant and advisory board member for Sensus Healthcare and has received research grants from the company. Drs. Baron, Werschler and Mariwalla use the Xoft system but report no financial interests in iCAD.

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


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