There are several effective methods for treatment (removal) of skin cancer. The method chosen will depend upon several factors such as the location, size and previous therapy. We will discuss only basal- (BCC) and squamous-cell (SCC) skin cancers in this section. Melanoma is a completely different topic and will be discussed in a separate subsection.

Tiny skin cancers USUALLY grow in the shape of a ball and may respond well to traditional less-accurate surgical methods. However, skin cancers that occur in special areas, such as the nose, lips, eyes, ears and on porous skin, may require more accurate removal methods. In addition, skin cancers may take different forms in which the less accurate surgeries may fail frequently, because tiny roots of skin cancer will remain behind if removal is incomplete. See Basal-Cell Carcinoma and Squamous-Cell Carcinoma.

Somewhat less accurate methods of removing skin cancers include deep freezing with LIQUID NITROGEN and or scraping and burning, i.e., CURETTAGE and DESICCATION (C&D). They are considered less accurate because they generate no specimen for microscopic examination and rely solely on a doctor's experience and guesswork. Keep in mind that a small cancer contains millions of cancer cells. Comparing the size of an individual cancer cell to the size of a curette (scraping knife) is similar to compare an ant to a bulldozer. Could your doctor successfully send a bulldozer down an anthill to catch an ant? It would depend on how much destruction your doctor would want to do to get the ant (tumor root). When liquid nitrogen (air) at -200 C freezes a tumor, different levels of freezing result. Freezing the deepest tumor may scar the surface skin!

SCRAPING and BURNING (C&D) skin cancers usually results in sores that take weeks to months to heal and will scar, if the treatment is properly performed deeply enough into the leather layer or dermis. Scraping and burning may properly be done only lightly in the most superficial or tiniest of tumors. Any larger tumor requires a deep treatment that will scar and take some time to heal from an ulcer. The deeper the treatment is performed, the longer it takes to heal and greater the chance that the final result will be a white, porcelain-like scar. Doctors should make patients aware that scars can result from the scraping and burning type of treatment, especially if the treatments are to the face.

DERMABRASION is the sanding of skin by hand and can be used to treat precancers. It rarely can treat anything but the most superficial of skin cancers. A refrigerant known as Freon" is required to perform dermabrasion. Unfortunately, it is virtually impossible to get Freon".

Cancer treatment with TOPICAL (the surface or top of the skin) FLUOROUACIL (5-FU, Efudex, Floroplex) is effective if applied as it was studied for FDA (United States Food and Drug Administration) approval, with SIX weeks of treatment. Unfortunately, foregoing proper treatment with fluorouracil, many doctors, including dermatologists, have modified treatment to periods of two weeks or less, even with steroid creams to quench the burning sensation. This "undertreatment" is done to avoid the severe reactions and possible scarring that naturally occur when all the cancerous cells in a large area are destroyed with fluorouracil. Undertreating actinic keratosis or skin cancers with any treatment, including fluorouracil, can result in a normal-appearing surface skin while abnormal cells grow and mutate below, e.g., in a hair pore. These deeper "missed" cells can then mutate into deep squamous-cell cancer that can be released into the blood stream, to spread to other parts of the body and cause death. Driving precancers deeper with fluorouracil is not an uncommon event, as the late, well-respected skin-cancer surgeon Dr. Henry Menn of the University of Miami frequently noted when addressing medical meetings. Dr. Menn stated that inappropriate (under) treatment with fluorouracil on the face causes the death and serious disease for many patients. See Treating Precancers.

Efudex (5-FU) has been reported to be effective against the multicentric (superficial) form of basal-cell carcinoma (BCC). If applied perfectly and properly and to the correct histology of tumor, 5-FU is likely 95% effective. However, "perfectly" and "properly" are rarely attained because 5-FU is being used most frequently as a spot treatment. Not all BCC's are of a single histology, i.e., multicentric may be mixed with nodular. The author does not believe that fluorouracil should be used by most patients for "spot" treatment. Imagine that a target cancer, the width of a pencil eraser, is located about an inch above the patient's nose. If the patient correctly applies the fluorouracil cream for one week the spot will start to fade. In the second week of treatment the patient incorrectly applies the cream as little as one-half inch off target. The patient is unaware because the target cancer has started to fade and normal skin usually has no reaction to fluorouracil. The cancer will be undertreated the same as if the patient used fluorouracil for too few days. In some cases like that of an infiltrating basal-cell cancer, which appear to the untrained eye like a precancer, the patient may drive the cancer deeper with spot treatment. The patient's incorrect treatment of the target location will cause the cancer to initially fade. However, the cancer is moving deeper into the skin and this will leave an untreated infiltrating basal-cell cancer that the patient or doctor can't see.

Fluorouracil is a great medicine if used properly in the right patients. If we recommend fluorouracil to our patients, we want them to cover a larger area than the target area so it will be hard to miss the targeted tumor. Also, because we live in Florida where the heat and sun cause patients to react more severely to six weeks of fluorouracil, as well as to develop staphylococcus infections of the eroded skin, we recommend the medicine only cautiously and allow our patients the option to choose from among many other treatments.

Fluorouracil has been injected into squamous-cell carcinoma to effect cures reported to be as high as 95%. Little scarring results. However, the author personally does not like a 5% chance (5 in 100) that a potentially deadly tumor could return or spread.

The author favors the use of a LIQUID-NITROGEN FREEZE in certain cases of skin cancer. (This differs from the treatment of precancers, where in skilled hands the odds of scarring is low.) However, when a doctor treats a cancer properly and according to "the book," scarring must occur. This is because the cancer treatment must effect a freeze or ice-ball formation for 90 seconds (thaw time) into the dermis (leather layer) of the skin. Healing may take weeks to months. The chance of depigmenting (permanently lightening) is great and depends upon the depth, width and location of the cancer being treated. If a skin cancer treated by liquid nitrogen or curettage and desiccation (C & D) fails to heal after one month, this non-healing may be a bodily sign or hint that the cancer was deeper than the treatment and that the area requires another biopsy for further evaluation. The hint should alert the patient or surgeon to biopsy the area and test the biopsy in the lab, to reveal any remaining cancer, which can then be treated properly. The author prefers to give patients the choice of surgical removal (either standard excision or Mohs) versus destruction. The author will tell patients that "Freezing to kill skin cancers has a failure rate of about 5%. Patients' treatment sites should be monitored annually after freezing or C & D to see if any cancer has returned." Unfortunately, this kind of visual clinical examination (follow-up) is crude, and cancer may grow hidden beneath the scar, causing destruction that will not become apparent for years. In the end, patients should be able to make an informed choice about which option they want.

A somewhat more accurate method of tumor removal than scraping and burning or freezing is STANDARD SURGICAL EXCISION. Most dermatologists, surgeons and all plastic surgeons use this technique. Although we know that, in many cases, the tumor we see on the surface is only the tip of the iceberg, this technique has many good uses. In fact, we use standard surgical excision as often as possible when it does not jeopardize the patient's future health. However, even standard surgical excision is not completely accurate. First, the surgeon must guess, by looking at the surface of the skin, where the tumor begins and ends. Then the surgeon must mark off and cut out an extra amount of bordering normal-appearing skin, usually in the shape of a cylinder or an ellipse (football). Then the surgeon sends the removed tissue to a pathology lab. Labs may use different methods to determine whether the tumor has been completely removed. This is where the difficulty lies. For example, the most common laboratory method is "breadloafing." Just like Holsum® Bread, the specimen is cut into slices. However, instead of 30 slices, which would cost hundreds of dollars, usually only three to five slices are cut from the tissue specimen. Since the pathologist can look at only these few individual slices of tissue, he may miss a tumor in one of the remaining portion of the specimen. So when the doctor or pathologist says, "It's out," he/she really means to say, "It's out to the best of our knowledge using a particular method." Unfortunately, with standard surgical excision, that knowledge is limited.

Standard surgical excision is an example of vertical sectioning and its pitfalls. Vertical sections involve the "breadloafing" method of testing a specimen to see if tumor or another kind of growth is still present in the edges. The principle at work is the following: If a tumor process involves the edges of the tested specimen, then it is highly likely that the process, be it tumor or abnormal growth, involves the edges of the tissue that remained behind in the body where the specimen was taken. Vertical sections test only a small segment of the edge of a specimen and therefore have an inherent failure or uncertainty rate. Most surgeons actually do not know this important fact, as you will see if they are properly questioned. Vertical sections were the cause of the plastic surgeon's having missed the basal-cell skin cancer on President Reagan's nose the first time. Again, there is an inherent failure rate with vertical sections. This is different from horizontal (Mohs) section testing.

Cutting and sewing (see Standard Surgical Excision above) is a mainstay treatment for skin cancer. However, the author believes that cutting and sewing is rarely justified in treating precancers. Deep treatments, like cutting and sewing, and the definite resulting scar, are acceptable for actual cancers only if the procedures are performed properly to remove a skin cancer that would result in further scarring and possibly death. In the old days, cutting and sewing usually paid the doctor more money than other treatments, but in the days of managed care, this has reversed and been discouraged. Therefore, payment can also become an issue.

Mohs Surgery is one of the fastest-growing types of skin-cancer surgery. Mohs Surgery is essentially the use of highly accurate and specialized horizontal sectioning rather than the error-prone vertical sectioning of standard surgical excision. Mohs Surgery has the highest cure rate and definitely leaves the smallest hole, which can be then sewn using plastic surgical techniques. The author prefers the combination of Mohs surgical removal and plastic surgical repair for appropriate skin cancers.

A Mohs Surgeon takes horizontal sections of skin on a tangent (parallel to and just below the surface of the skin) to the surface, tests the specimen with specified cellular stains and examines the processed material with a microscope. A thin horizontal section could be considered a shave excision and a thicker one could, if processed properly with correct edge orientation and staining, be considered Mohs Surgery. Horizontal sections can show the specimen's entire contact edge with the tissues that surround the area where the specimen was taken. The acting principle is the following: If a process (tumor or abnormal growth) is present in the edges of the tested specimen, then it is highly likely that that same process is also present in the edges of the tissue that remained behind in the skin where the specimen was taken. Fortunately, Mohs horizontal sections can be made to test the entire edge of a specimen and therefore have low failure or uncertainty rates. If processed properly by the Mohs method, horizontal sections can be a highly accurate two-dimensional representation of a three-dimensional problem or defect. Extensive material on Mohs Surgery is presented elsewhere in this Web site. See Mohs Surgery.

INTERFERON INJECTIONS offer patients the potential benefits of no cutting and little scarring. This may sound good for a 25-year-old fashion model with a small basal-cell cancer on the nose, if and only if the fashion model is told quite clearly that interferon has one of the poorest cure rates of any skin-cancer treatment. Interferon fails 20% of the time to cure the even simplest basal-cell carcinomas. It is the author's opinion that interferon should never be used to treat complicated basal-cell carcinomas such as biopsy- proven infiltrative lesions. Interferon treatment requires repeat visits, and is extremely expensive. Back to the case of the fashion model: if he/she can tolerate the one-in-five chance that the treatment could fail, resulting in a deeper tumor that could destroy the nose before being discovered, then the treatment may be acceptable.

LASER can be used on skin cancers and surrounding tissues with similar effects to C&D, standard surgical excision, and Mohs horizontal sections depending upon how the laser beam is focused. In a diffused firing mode, a laser can create a wound similar to a C&D site. Lasers can be used instead of scalpels to cut specimens for standard surgical excision for vertical section testing. Alternatively, lasers can be used to cut tissue specimens for the horizontal processing methods of Mohs Surgery. The author believes that lasers CURRENTLY offer no advantage over scalpel surgery in the hands of a skilled surgeon. Instead, lasers today may unnecessarily heat damage tissue edges and fail to coagulate blood vessels while causing excess burning to surrounding tissues. In the author's opinion, lasers frequently are marketed inappropriately to patients, playing upon the public's ignorance regarding skin cancer. Today, costs soar and benefits are rarely even equivalent to those of scalpel surgery. However, in the future lasers will likely improve skin-cancer surgery. The author does not believe that that day has yet come.

......PHOTODYNAMIC THERAPY (PDT) offers patients the option of treatment without surgery. Some researchers cite minimal pain. PDT for skin cancer and precancer treatment is still awaiting FDA approval, which is presumed. While great for treating precancers (see Treating Precancers), PDT, tested extensively at major medical schools, has been found to have extremely poor cure rates for cancers and, therefore, a high failure rate. PDT may be useful in treating skin cancers that are otherwise inoperable (best not treated by surgery), though the author believes that radiation therapy is probably a better approach with current technology. The author sees a bright future for PDT in skin precancer treatment, but little or no use currently for this expensive treatment in treating skin cancer.

RADIATION THERAPY, also called Roentgen therapy, offers patients little pain with no surgery. It involves the beaming of invisible energy rays or particles or both into the tumor and surrounding tissues into which the radiation therapist thinks the tumor may have spread. The radiation poisons and kills cells in the area receiving the concentrated beam by altering genetic and cellular processes. Radiation may be applied to superficial or to deep layers of the skin. Usually, the cells/tissues most affected by radiation are the fastest growing ones, e.g., squamous-cell cancer cells. Unfortunately, normal tissue may be altered or damaged as well, resulting in fibrosis or scarring or even the formation by genetic mutation of new skin cancer years hence. Radiation therapy usually does not scar within the first year following the treatment; however, a white scar usually does appear later. Radiation therapy has a failure rate somewhere between those of C&D and standard surgical excision. Radiation therapy is very expensive, sometimes requiring multiple visits over many weeks under vast, costly machinery. There is a significant risk of developing a second and separate skin cancer in the area of the radiation treatment 10 to 30 years after the treatment. Therefore, strong consideration should be given to avoiding the use of radiation to treat skin cancers in younger patients. It is the author's opinion that radiation is a great treatment for inoperable skin cancers, especially in patients who can not stand or do not want any more surgery, and in those who have other medical problems. A good example of someone for whom radiation therapy would be appropriate is an elderly patient at risk of heart failure, who has had heart operations in the past, who is not expected to live more than one year, who has a squamous-cell cancer eating through his skull into the ear canal and surrounding tissues.

BLEOMYCIN, a chemotherapy drug, can be electronically driven into a skin cancer. The treatment is new and merits many further studies on its effects against different skin-cancer subtypes. However, it does have a high failure rate.

......With each treatment comes a failure rate. This is a topic that doctors rarely like to discuss with patients or with each other. Many a surgeon's favorite line to a patient after surgery or upon reading a biopsy report is "It's all out," when that couldn't be further from the truth. Failure is not a nice concept when it comes to cancer, but the public should have access to the numbers. Here they are, for treating BCC's:

Regardless of location on the body, BCC's larger than 6mm (two pencil erasers) fail treatments more often than smaller BCC's. Size does make a difference. The larger the cancer, the more likely it is to have formed roots that can regrow a cancer, if they are missed.

 

Paul J. Weber, M.D., P.A. 5353 North Federal Highway, Suite 400 Fort Lauderdale, FL 33308 Tel: 954-489-9800 | Fax: 954-489-0401