Outpatient radiotherapy: Mohs vs. radiation

Mohs surgery is the gold standard for many head and neck skin cancers, but Mohs is not ideal for all patients. Patients who are older, on blood thinners, have multiple medical
co-morbidities, or have lesions on difficult-to-repair locations may not be good candidates for surgery. Some patients prefer nonsurgical treatment options. For those patients, superficial radiation treatment (SRT) is a valuable, yet seldom used, alternative.

“In a limited number of select lesions on select patients, radiation may be as good as, or better than, Mohs,” said Armand Cognetta, MD, professor and chief of dermatology at the Florida State University College of Medicine and founding partner of Dermatology Associates of Tallahassee. “Even though Mohs has a slightly better cure rate, it might not be the better choice for an older, infirm patient. And for areas that are difficult to repair cosmetically, such as the rim of the nostril, radiation may be superior because the cosmetic result is often better.”

Dr. Cognetta discussed the indications and limitations of SRT Friday during “Outpatient Radiotherapy of Skin Cancer: Back to the Future” (F033).

Mohs surgery has an outstanding cure rate, approaching 98 percent, he said. A 10-year study of superficial X-ray treatment for basal and squamous cell carcinomas showed about a 95 percent cure rate.

At present, relatively few dermatologists have access to a superficial X-ray platform, although state-of-the-art units are now readily available. Mohs surgery has been so successful that many dermatologists and dermatology teaching programs have abandoned other treatment modalities, or, in the case of radiation, relegated
it to radiation oncology specialists.

Dr. Cognetta said that he sees good results using a fractionated five-treatment schedule for most patients.

The most appropriate patients for radiation are those who are not good candidates for surgery or those who have nonaggressive tumors and prefer nonsurgical treatment. Radiation oncology referral and electron beam treatment are more appropriate for deep, aggressive, or unresectable basal and squamous cell tumors, and those that exhibit large caliber nerve perineural invasion, Dr. Cognetta said.

See the AAD position statement on SRT at www.aad.org/superficialradiation.

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