Why not Mohs?

[zanzizic]

Don’t get me wrong I think mohs is an essential part of our practice and I’m grateful that my partner does the nasty cases. I just think part of our value as dermatologists (what we can add over the PCPs and midlevels) is distinguishing between those aggressive cancers and not with accuracy and not over-treat.

A year or two ago I heard a Mohs Surgeon (a fairly famous one) at a conference talk and she literally said that every -EVERY- scc should always go to mohs, no exceptions. I almost choked.

One other pet peeve I have is that no one seems to give super-old/sick patients the option of doing nothing for their skin cancers. If they are 90 with a bunch of co-morbid conditions Most of them time I tell them only to come back if something bothers them and after a reasonable first discussion 99% of of them don’t even want biopsies for the dozen apparent cancers on their body anyway.... sure, treatment is safe in this population but if it’s not going to kill them, doesn’t bother them, and they have an average life expectancy of 2 years most don’t want anything at all....

I know General dermatologists feel good about having that “you’re going to die before this BCC or SCC is going to cause you problems” conversation.

Fortunately for them, they don’t have to deal with the ramifications when the patient doesn’t die anytime soon.

Next week I’m excising a BCC on an 88 yo demented woman’s face that extends from just below her lower eyelid margin down to the corner of her mouth. It’s exophytic, ulcerated, and she picks at it constantly. Another few months and maggots may make an appearance. The family is now having to confront this issue now that her nursing home/memory care unit is threatening to charge them more for the frequent bandage changes (that the patient rips off). She won’t sit still for XRT and Erivedge symptoms were too much for her.

I have an ASC so I’m going to do Mohs under general and the oculoplastic surgeon will reconstruct immediately following.

It would have been nice if her dermatologist would have sent her to me for an easy Mohs procedure five years ago when this was manageable and the patient wasn’t uncooperative due to Alzheimer’s.

This isn’t an unusual scenario. I’ve seen horrible cases due to this advice.

I’m not saying that this is never the right thing to do. But the patient better be circling the drain. Often times even dermatologists don’t take the potential morbidity of nonmelanoma skin cancer seriously. Telling 80ish yo people they don’t need to treat is not good medicine. You never know how long these folks will live.

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[doctalaughs]

Fair enough- I can see why a Mohs Surgeon would have that perspective if you get those situations with regularity.

I just don’t think they arise from the low risk tumors that were saucerized and ed&c; rather the lesions either partially sampled or high risk but inadequately treated to start. Maybe our mohs guy isn’t telling me the horror cases I’m generating because I hired him . But I do share an office with him and get all my patient notes so I doubt it. Seems like the terrible ones come from the FPS in town, the farmers who didn’t come to anyone for 10 years and occasionally the plastic surgeon down the he road who excises high-risk stuff even through a couple recurrences.

The end of life stuff is hard — but I would argue doing heroic mohs is not usually the only answer as cure isn’t necessarily the true goal, and if the conversation was that the initial lesion was going to be observed —then the referring doctor should be intimately involved in dealing with the consequences if for some reason family changes their mind. I haven’t found too many patients who can’t tolerate a hedgehog inhibitor if it’s done right (ie pulsed dose protocols).

 

[MOHS_01]

Fair enough- I can see why a Mohs Surgeon would have that perspective if you get those situations with regularity.

I just don’t think they arise from the low risk tumors that were saucerized and ed&c; rather the lesions either partially sampled or high risk but inadequately treated to start. Maybe our mohs guy isn’t telling me the horror cases I’m generating because I hired him . But I do share an office with him and get all my patient notes so I doubt it. Seems like the terrible ones come from the FPS in town, the farmers who didn’t come to anyone for 10 years and occasionally the plastic surgeon down the he road who excises high-risk stuff even through a couple recurrences.

The end of life stuff is hard — but I would argue doing heroic mohs is not usually the only answer as cure isn’t necessarily the true goal, and if the conversation was that the initial lesion was going to be observed —then the referring doctor should be intimately involved in dealing with the consequences if for some reason family changes their mind. I haven’t found too many patients who can’t tolerate a hedgehog inhibitor if it’s done right (ie pulsed dose protocols).

You should really work on not being so damn agreeable - makes it harder to be a jerk to ya

How do you pulse you hedgehog inhibitors?

 

[doctalaughs]

You should really work on not being so damn agreeable - makes it harder to be a jerk to ya

How do you pulse you hedgehog inhibitors?

I usually do the 12/8/12 week intermittent dosing since that seems to have the most literature but if they don’t tolerate, I have a few that are even on 1 week on/ 3 off and it still seems to work pretty well (I think there were a few papers on that a couple years ago?). I haven’t had anyone fail to tolerate that. Most are Bcc Nevus syndrome but a few locally advanced.

 

[Skindoc83]

Correct me if I’m wrong but a lot of tumors lose responsiveness to Erevidge fairly quickly no? Which I feel like just kicks the can down the road for like a year but now you’re left with a multi focal tumor

 

[doctalaughs]

Correct me if I’m wrong but a lot of tumors lose responsiveness to Erevidge fairly quickly no? Which I feel like just kicks the can down the road for like a year but now you’re left with a multi focal tumor

I have a few bcc nevus pts that have been on Vismo since the drug came out and still going great — for what, like 8 years?

Locally advanced /met- likely true, but in my experience I find it’s more like 2-3 years of major improved quality of life and in an end-of-life situation that’s perfect. Haven’t had a situation where we’re back to square one in less than 12 months (assuming they haven’t died from something else). although I guess it could happen. Then again, I’ve never tried it for someone with a life expectancy longer than 2 years from other conditions anyway.