First do no Mohs harm
Weigh the benefits of the procedure against the big picture
Carl F. Schanbacher, M.D., a clinical assistant professor of dermatology at Tufts University School of Medicine and Mohs surgeon, has treated more than 20,000 skin cancer patients.
The importance of deciding not to do Mohs is a lesson that he says has made him a better physician.
“If I’m doing Mohs on everyone, I’m really failing,” Dr. Schanbacher says. “I find that I really need to consider the circumstances of each individual patient.”
There isn’t a quota or predetermined ratio of patients that should be turned away, according to Dr. Schanbacher. Rather, it has to do with understanding each patient’s situation.
“I feel for our frail patients. … sometimes undergoing a Mohs procedure and then a subsequent reconstruction can really set people back. If there’s someone who has a terminal illness or some major medical problem, is it really in their best interest to have Mohs, or could they just sail into the sunset in their final year or two years of life? As long as there are no critical symptoms—the lesion isn’t ulcerated or increasingly painful—I’m inclined to let them keep it [the skin cancer] and inform them of what could take place,” he says.
Dr. Schanbacher, who made this the topic of his talk at last month’s American Academy of Dermatology Summer Scientific Session in Boston, says he didn’t always take this approach. In fact, he has operated on patients who, along with their families, were unhappy about how the recovery impacted their lives. “It was just too much,” according to the dermatologist.
“I thought maybe we’re not doing it right. Maybe we need to properly inform them of the aftermath—the spectrum of activity that they’ll go through,” Dr. Schanbacher says.
For those who might suffer too much, Dr. Schanbacher says he plans a separate consultation with patients and their families. During that time, he graphically explains what patients will go through if they have Mohs, as well as what might happen if they don’t.
Looking beyond skin cancer
Dr. Schanbacher examines not only each patient’s skin cancer but also whether that person’s life can accommodate what might be a difficult recovery from Mohs.
“The first thing we want to know is, does the patient live alone? What is his or her living situation like? Who is going to help with wound care?” he says. “We talk with the families and get each patient’s social situation figured out well ahead of time.”
For dermatologists, that means not looking only at the basal cell coming through the door. It’s also looking at the person who has the skin cancer and whether that he or she is capable of dealing with the aftermath.
“For example, there are patients who are in their 80s and live alone. These patients are on pain medicine post-reconstruction, and they fall and break a hip. Now they’re in the hospital, all for a skin cancer on the tip of the nose that they could have kept,” he says, indicating that these are examples where the circumstances of post-operative care, and the surgery more broadly, can be more detrimental to patient’s health than the actual skin cancer.
There are options
For patients who might be better off not having Mohs surgery, Dr. Schanbacher says he’ll consider radiation therapy or, simply, observation.
For patients who should receive Mohs but might not be able to endure the lengthy procedure because they have Parkinson’s or dementia, for example, Dr. Schanbacher would consider a simpler reconstruction.
“We’ll really abbreviate any sort of medical encounter they have. I’ll use topical adhesive to close the wound and say, if you have a problem, call me. It’s a 20-minute procedure,” he says. “Or I’ll greatly simplify the reconstruction. The dermatologists who send me patients understand; they get it. What I don’t want is the treatment to be worse than the problem.”
Providers who have elderly skin cancer patients with several comorbidities might consider electrodessication and curettage, cryosurgery or topical chemotherapy as suitable alternatives to Mohs.
“I can tell you that I’ve had happier patients over the last few years,” he says. “And the families are surprised because they realize that here’s a surgeon who giving us the option to not to undergo surgery.
While it is an effective course of treatment for many skin cancers, Mohs is not always best for every patient. As physicians, our first obligation in every situation is to do no harm. We must ensure our treatment is never worse than the original issue, and that we thoroughly consider our patients’ values in each case.”