Skin Cancer Treatment Options
Treatments
There are a number of different options available for the treatment of skin cancer based on various disease, patient and practice factors. For instance:
Disease Factors:
Type
Size
Location
Invasion into surrounding structures
Previous treatment
Patient Factors:
Age
Health Status
Personal preference
Cost
Previous experience
Practice Factors:
Availability
The decision regarding the best treatment option will be made through a collaborative process between the patient and their Dermatologist taking into account the many factors above.
The practitioners consulting from The Skin Centre are proud to offer the full range of topical therapies, physical therapies - such as cryotherapy, curette and cautery, photodynamic therapy, or surgery including wide local excision or Mohs micrographic surgery. Rarely, your practitioner may have to refer certain cases to their colleagues in radiation oncology or plastic surgery, but this will be discussed and the patient provided with the appropriate referral. Please see the brief overview of the therapies provided by the practitioners we support below:
Topical Treatments (5-Flurouracil -5FU/Efudix, Imiquimod – Aldara, Diclofenac - Solaraze)
In this context, a topical therapy refers to a prescription cream or gel, applied a number of times to a defined lesion over a period of weeks. There are various topical options available for the treatment of pre-cancerous sun spots and certain kinds of superficial skin cancer. The most commonly prescribed products include 5-Fluorouracil (Efudix) – a topical chemotherapy, Imiquimod (Aldara) – a topical immunotherapy or Diclofenac (Solaraze) – a non steroidal anti-inflammatory. The frequency and duration of treatment depends on the topical that is being used and the type of skin cancer that is being treated. The efficacy of these products is considered good, although not the gold standard of care, but some patients prefer this to more invasive physical or surgical options. There may be side effects of treatment including redness, skin irritation, itch, discomfort, blistering and crusting of the skin. Other rarer side effects for some products may include changes in pigmentation and flu like symptoms.
Spot Treatment vs. Field Treatment
When using topical treatments, for precancerous sun spots or certain forms of superficial skin cancer, your Dermatologists may prescribe them as either a spot treatment or a field treatment. A spot treatment is recommended when wanting to treat single or multiple distinct lesions of concern. In this case, your doctor will highlight the site(s) and instruct you on how far around the spot they’d like you to apply the product. On the other hand, a field treatment refers to use of topical creams to treat a defined area of concern. Since many of these areas can be quite large, your Dermatologist may choose to break the treatment into multiple sections to prevent the risk of a widespread adverse reaction to the cream. Particularly if it is your first time using it. Depending on the lesion type and the choice of topical treatment, the frequency and duration of application will vary. It is important to follow the instructions given by your Dermatologist and if you are concerned, please contact your practitioner on (07) 5597 7170) with any concerns.
Physical Therapies
Cryotherapy
Cryotherapy is a long established treatment in which skin lesions are removed by freezing. There are a number of gases that can be used as the freezing agent, but in Australia the most common is liquid nitrogen. Overall, cryotherapy is considered to be a relatively inexpensive, safe and reliable treatment for benign and premalignant lesions such as actinic keratoses, viral warts and seborrhoeic keratoses. In experienced hands, it may also be used to treat small superficial skin cancers such as a superficial multifocal BCC or an intra-epidermal carcinoma. However, since this technique does not involve removing tissue to examine under the microscope, close follow up is recommended. It should never be used to treat pigmented lesions, or lesions suspicious for melanoma. Cryotherapy is quick to perform. The patient may experience some discomfort during the procedure, followed by immediate swelling of the site. In the hours after treated area can blister, forming a scab that will eventually fall away. Healing time depends on the site with the face and upper body healing faster then lower body and legs. Care must be taken during this period to keep the site clean and moist.
Curette and Cautery (C&C)
Curette and Cautery (C&C) is a technique fairly unique to the practice of dermatology. It is a form of electro-surgery, where scrapping and heat are utilised to remove superficial lesions from the surface of the skin. C&C is most commonly used to treat benign and premalignant lesions such as seborrhoeic keratoses, acrochordons and viral warts but can also be used to remove malignant lesions such as basal cell carcinoma, intra-epidermal carcinoma and keratoacanthoma.
After numbing the area with local anaesthetic the tissue is spooned or scrapped using an instrument known as a curette. This tissue is then sent to the pathologist to be looked at under the microscope. The wound bed is then treated with heat via an electrosurgical unit known as diathermy. This heat stops any bleeding but also destroys any remaining tumour cells from where the tissue has been scooped away. This process of scrapping and heating is repeated 2-3 times. Other than the injection for the local anaesthetic, C&C is considered painless. There may be some mild discomfort and swelling in the hours following but this usually resolves quickly. A dressing is applied for the first 48 hours after which care must be taken to keep the wound site clean and moist. Healing times vary depending on the location of the lesion with the upper body healing faster than sites on the lower body.
Photodynamic Therapy (PDT)
Photodynamic Therapy (PDT) is technique that uses photosensitising creams, oxygen and light to create a localised reaction to destroy superficial cancer cells. In Australia, PDT is approved for the treatment of actinic keratoses, superficial multifocal and nodular basal cell carcinoma and off label is sometimes used in facial rejuvenation and for mild-moderate acne. The process of PDT is two stage. It first involves preparation of the site and application of the photosensitising cream. This photosensitising cream absorbs selectively into cancer cells over a period of 3-4 hours. During this period, the treatment site is covered by a bandage and the patient is able to undertake normal indoor activities. The second stage, which happens later that day, involves the activation of the cream with a special wavelength of light over several minutes. This part of the process can be uncomfortable and local anaesthetic is used to numb the area. In some instances, your Dermatologist may suggest daylight PDT. This involves a similar process, but harnesses sunlight rather than artificial light to activate the cream. Once completed the treatment site will be dressed and should remain dry for 48 hours. After that, care must be taken to keep the wound clean and moist. Depending on the type of lesion that has been treated, this two stage process may need to be repeated a fortnight later.
Wide Local Excision (WLE), Local Flaps and Skin Grafts
In many cases, the surgical removal of a lesion will be recommended by your Dermatologist. Surgery is considered the most efficacious of the treatment options for skin cancer, with Mohs micrographic surgery the gold standard offering the highest cure rate overall. The way in which a skin cancer is removed depends on the cancer itself, the site and certain other patient factors. The first stage is to identify the edges of the lesion after which an appropriate margin is drawn around. The size of the margin depends on the skin cancer that is being treated. For instance, the margin for a melanoma is generally larger than that of a basal cell carcinoma. Ideally the wound that is created by this process will be closed as a straight line, with the scar hidden in the natural skin creases. However, there are certain circumstances when a flap or a skin graft must be used, for instance, when the wound that has been created by the removal of the skin cancer is too large for the edges to brought together nicely. A local flap involves moving skin from an adjacent area to cover the site. The flap uses its original blood supply and remains attached to the area from which it came. A graft on the other hand, involves the removal of a portion of skin from a distant site, which is then placed onto the wound, requiring the blood supply at the recipient site to heal. All are excellent options for closure and when booked for surgery, your Dermatologist will discuss with you which approach suits your case best.
Mohs Micrographic Surgery (MMS) (Mohs Surgery)
Named for its inventor, Dr Frederick Mohs, it was first established in the 1930s but has only been widely practiced since the 1960s, when the process was modernised by Dr Perry Robins of New York. Mohs Micrographic Surgery is considered the gold standard in the treatment of certain skin cancers including basal cell carcinoma and squamous cell carcinoma. These are contiguous tumours and the two most common skin cancers in Australia.
Mohs surgery is a unique staged procedure that involves your doctor performing both the surgery and the pathology. Your Dermatologist (if qualified to perform Mohs Micrographic Surgery) will first remove the lesion as close as possible to its margins and then examine that section under the microscope. If cancer cells are seen at any of the edges, the Dermatologist will then remove a further layer of tissue, but only where it is needed. This process is repeated until all of the cancer has been removed.
Overall, 70% of patients will be clear on the first stage. Once clear, your Dermatologist will then repair the wound that has been left by removal of the cancer. As only the minimum amount of healthy tissue has been removed using the Mohs procedure, there is a better chance that the wound will be able to be closed as a straight line (primary closure) giving a more cosmetically pleasing scar. If this isn’t possible, your Dermatologist may use a local flap or a graft. Occasionally they may work in combination with an oculoplastic or plastic surgeon.
Whilst standard excision with a wide surgical margin is a perfectly acceptable treatment option, there are certain circumstances in which Mohs surgery is best. For instance, in the removal of basal cell carcinoma and squamous cell carcinoma in cosmetically and functionally important areas such as the eyes, nose, lips, ears, scalp, fingers, toes or genitals. It is also useful for rapidly growing tumours that have indistinct edges, or have recurred after previous treatment.
Overall Mohs surgery offers the highest cure rate, up to 99% for a primary skin cancer and 94% for a skin cancer that has recurred after previous treatment. It is precise, allowing same day results with close to 100% of the margins examined, compared to standard excision where only 1% of the tumour is examined under the microscope. It is convenient and cost effective, performed in the day surgery suites of the adjacent hospital, requiring only local anaesthetic.
Dermatologist, Dr Andrew Freeman, is currently the only practitioner on the Gold Coast offering Mohs Micrographic Surgery. This service can be accessed with or without a referral, but will require a pre-surgical consultation for planning.
Laser Vermilionectomy vs Surgical Vermilionectomy (Lip Resurfacing)
A vermilionectomy refers to the resurfacing of the lip. Resurfacing is undertaken when lips have been damaged by the sun and where pre-cancerous sun spots or changes have occurred. Removing the top layers of skin may prevent the development of a more invasive skin cancer. Resurfacing can be undertaken surgically by a plastic surgeon, or by a Dermatologist using laser therapy. There are also other topical treatments or photodynamic therapy, but these latter options tend to be less effective in this site.
The practitioners consulting from The Skin Centre, offer two laser treatments for the lip depending on the degree of sun damage that has occurred. Both involve a period of downtime, where attention must be paid to wound care and time away from normal activities may be required. In addition to the reduced risk of progression to skin cancer, the unexpected bonus of this procedure is an improvement in peeling and cracking of the lips as well as more even skin tone.
Identifying pre-cancerous or cancerous skin conditions early assists in achieving the best possible patient outcomes. To discuss treatments, have a skin check or to discuss a particular area of concern with your practitioner, please call (07) 5597 7170 or email reception@skincentre.com.au