Saving face the Mohs way

Tue, Mar 5, 2013, 00:00

When I was told just a few days before Christmas that I had skin cancer, I wasn’t really surprised. I had already had two visual examinations by consultant dermatologists who had put me on notice. Now, after a biopsy, the diagnosis was confirmed.

Thankfully, the type of cancer I had, basal cell carcinoma, or BCC, is seldom life threatening.

It rarely spreads beyond the initial site, but if treatment is delayed, or unsuccessful, it can do a lot of local damage. Compared with other cancers, cure rates are relatively high – and higher for some treatments than others. So I was more hopeful than despondent.

Skin cancer is primarily caused by unprotected exposure to the sun, and I confess to having had lots of that.

You would think we’d know better by now, but the message that sunbathing and sunbeds cause cancer is slow to get through. And fair-skinned Celts are more prone than most, as is evident from the soaring number of new cases.

Most prevalent

According to provisional, and as yet unpublished figures from the National Cancer Registry, 34 per cent – more than one person in every three – of those diagnosed with cancer in Ireland in 2010 had skin cancer, making it by far the most prevalent type of cancer.

The number presenting with melanoma, the worst of all the skin cancers, has more than doubled in the past decade. No other cancer is increasing at anywhere near this rate.

And for every melanoma diagnosed here, there are 10 non-melanoma skin cancers – basal cell and squamous cell carcinomas. BCC is linked to short, intense blasts of sun such as we might experience on holiday, while SCC is more likely in those who are constantly exposed.

The Cancer Registry’s provisional figures show 8,570 new cases of non-melanoma skin cancer in Ireland in 2010, 1,146 more than in 2009, and 3,426 up on 1994 when statistics began.

But even this daunting figure greatly underestimates the full extent of the disease because regardless of how many tumours someone may have in their lifetime, only one per patient is officially counted.

“Non-melanoma skin cancer is not only the most common of all the cancers,” says Dr Aoife Lally, a consultant dermatologist in Dublin, “it is also the most under-recorded and the poorest resourced.

“Our clinics are over-booked, and we face a chronic lack of resources.”

One UK hospital where Dr Lally used to work had nine inhouse consultant dermatologists. “Here,” she says, “we have 30 for the entire population.”

My own BCC started as a small sore on the bridge of my nose that simply wouldn’t heal.

My GP referred me to a consultant dermatologist, but before I could be treated, I had moved home from Dublin to London where my BCC was confirmed.

There are many ways to treat a BCC, from creams to X-rays. But because mine was on my nose – a “high risk” site – I was sent for a particular procedure called Mohs micrographic surgery, named after Frederick Mohs, the American doctor who pioneered it in the 1940s.

Highest cure rate

Mohs surgery is triply advantageous: it is performed under local anaesthetic; it spares a lot more healthy tissue than standard surgery – critical if the operation is on your face – and it has the highest cure rate of all treatments – 98 per cent and upwards.

Mohs is now considered the definitive treatment for non-melanoma skin cancers, most of which appear on the face, neck and head. And in the US it is being applied increasingly to early melanomas as well. But, unfortunately, it is not readily available in Ireland.

Until recently, consultant dermatologist Patrick Ormond at St James’s Hospital in Dublin was the only doctor performing Mohs surgery publicly in the entire country. One other doctor offered it privately in Cork.

Now St James’s has a second public Mohs practitioner, Dr Rupert Barry.

“We manage our waiting list very actively,” says Dr Ormond, “but even so, public patients can still wait nine months or more.”

There are two other consultant dermatologists – one each in Cork and Limerick – who are trained in the Mohs technique but who, Dr Ormond laments, can’t perform it because back-up resources aren’t available.

In the UK, where I am being treated, there are close to 60 Mohs practitioners in the NHS and the maximum waiting time is three months.

The doctor who operated on me at London’s Royal Free Hospital, consultant dermatologist Ed Seaton, explains that the secret of Mohs is in the word “micrographic”.

In standard surgery, he tells me, the doctor will remove the obvious tumour followed by a substantial layer of surrounding skin in the hope of excising all peripheral cancerous tissue.

Analysis

The surrounding skin layer is sent off to a pathologist for analysis, but only about 5 per cent of the critical edges are tested in random sampling, a method that allows room for error.

In Mohs surgery, by comparison, a much thinner layer of surrounding skin is cut out, but thanks to the way it is prepared for examination, Dr Seaton explains, 100 per cent of the edges where cancer cells could be lurking can be seen under the microscope.

What’s more, Dr Seaton himself will inspect this material in a dedicated laboratory on site, while I wait. If any cancerous tissue has been missed, he will remove it straight away, and test another layer until it is all gone. So when I leave hospital it’s in the certain knowledge that I am cancer-free.

My actual surgery takes just a few minutes, and then I’m patched up temporarily and left to wait while Dr Seaton examines my tissue sample which, he tells me, he’ll first map, flatten, sub-divide, freeze, dye and slice, with the aid of a dedicated histologist. This is the essence of Mohs.

As I wait, I can see that the high success rate of Mohs is directly related to its labour and resource intensiveness.

Today, Dr Seaton will operate on four patients, where 10 could be treated using standard surgery.

The payback comes later when virtually no Mohs patients will re-present with a recurrent tumour.

For me, the news is good: within an hour of my operation, Dr Seaton tells me he got rid of all my cancer first time round. Instead of going back under the knife, I’m ready to be stitched up and sent home.

Success all round

A few hours later my nose is swollen and my eyes are black, but when I get the stitches out a week later I’m astonished at how little visible damage has been done.

For me, as for most who experience it, Mohs surgery has been a success all round: cleared of cancer with minimum scarring. It’s a win-win formula, and without doubt one that should be much more accessible in Ireland than it currently is.

“With standard treatments,” says Patrick Ormond, “five or six patients in every hundred will see their tumour recur, and it’s the recurrent tumours that do the worst damage.”

He reckons there are more than 400 such recurring tumours each year here in patients where standard procedures haven’t removed all the cancer.

These patients could benefit enormously if Mohs surgery was available to them.

With the National Cancer Registry predicting that almost 10,000 new non-melanoma skin cancers will be diagnosed in Ireland in 2015, rising to nearly 14,000 by 2025, and with most of these, as well as the worst of them, appearing in the face and head area, it should be obvious that it will require far more than two Mohs surgeons in the public health system to cope.

“What has to be remembered,” says Patrick Ormond, “is that Mohs surgery not only benefits patients by reducing suffering and anxiety, it can also save money and resources in the long run because of its exceptional success rate in preventing tumours from coming back.”

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