I wanted to also include a perspective from one of our long-standing skin cancer patients here at May River Dermatology in order to present the full story on radiation therapy:
Mr. Tomfohrde is an 89-year-old patient here at May River Dermatology with a history of countless skin cancers including basal cell carcinomas, squamous cell carcinomas and malignant melanomas. He has been coming to our practice for years and we have had to operate on skin cancers on his face, scalp, neck chest, back, arms and legs. Justifiably, Mr. Tomfohrde opted to explore other options when diagnosed with yet another SCC on his lower extremity. He had only just healed recently after a large Mohs defect on his lower extremity resulted in protracted wound healing, bandaging, and frequent follow up appointments. So much so that he opted against our recommendation of Mohs surgery, and requested a referral to radiation oncology.
Since I am not a radiation oncologist, I felt like a retrospective interview with Mr. Tomfohrde might greatly assist in clarifying my perspectives on radiation therapy for primary cutaneous malignancies on which our dermatologist had recommended Mohs. I also wanted to find out what Mr. Tomforhde wanted other patients to know who may be considering nonsurgical options.
Now remember, primary XRT is different than SRT in terms of its efficacy, and has been around for years. Radiation oncologists use customized templates that allow for the delivery of radiation therapy only to the treatment sites and restrict dispersion to a minimum. Radiation Oncologists are ACGME-fellowship trained and have trained for years in the safe and effective use of radiation for the treatment of both cutaneous and visceral malignancies. Radiation oncologists do NOT use SRT, but instead have much more well-supported, customizable vehicles and templates that are used for the effective and safe delivery of radiation therapy.
As mentioned previously in the previous section, radiation therapy is a second line treatment option—reserved only for those patients on whom surgery is not possible or advisable. Thus our referral for radiation therapy happens infrequently. This is largely because Mohs surgery offers margin control, while XRT does not. In addition, there are real risks associated with XRT, including textural changes in the skin; radiation dermatitis; and rare cases, skin necrosis and deep infections. Such instances occur very rarely and are usually the result of anatomic variations, improper surveillance by the supervising MD and or restricted vascular supply (e.g., the lower extremities).
This latter scenario was one that Mr. Tomfohrde was not expecting, and was not prepared for, as his treatment with a local radiation oncologist led to extensive radiation dermatitis, culminating in a deep vein thrombosis and large ulcer, much larger than previous Mohs defect; and one that took much longer to heal. At 89 years old, most people would have some element of peripheral vascular disease which results from the gravity-driven dilation of our lower extremity veins and atherosclerotic plaques in our arteries. As such, lower extremity wounds can be an almost predictable challenge to the Mohs surgeon. However, when lower extremity skin cancers are radiated in a patient with significant peripheral vascular disease, the likelihood of skin breakdown, ulceration and much more extensive barriers to wound healing arise. On a cellular level, radiation exposure can cause fibrosis and narrowing of an already compromised arterial supply, causing a restriction in oxygen supply to the entire lower extremity distal to the application site.
And this is not a new story to our team of Mohs surgeons…which is why we don’t recommend it unless surgery is not possible. One of my favorite adages that is neither unique or clever is that when it comes to medical decision-making….”There’s no magic bullet….I wish there were; but there isn’t…” And it’s true, medicine is a balancing act of risk analysis, pros and cons and an informed representation of options to our patients. Just because I am a surgeon, I don’t recommend Mohs surgery until my patients are fully informed about their options. After speaking with Mr. Tomfohrde, I have reaffirmed by belief that Mohs surgery is a safer, more predictable, option with a higher cure rate, as well as a pathology report that ensures the tumor has been microscopically cleared.
I’ll leave readers with this final, very powerful statement: When I asked Mr. Tomfohrde what he would want other dermatologists to learn from his experience with radiation therapy, he said this: “Don’t ever send one of your patients for radiation therapy unless they would die without it.”
Interestingly, and very appropriately, Mr. Tomfohrde unknowingly echoed the very same position on the appropriate use of XRT as the American College of Mohs Surgery and the American Academy of Dermatology. So, to him I will reply, “Well said Mr. Tomfohrde! And thank you for telling your story.”