It’s that time of the year when summer memories resurface. Those carefree days on the beach in our itsy bitsy teeny weeny yellow polka dot bikinis (or reasonable facsimiles). Remember how we used to slather baby oil all over our bodies and lie in the sun, working on that “perfect tan” or until we were burnt to a crisp and/or it was time to run home to watch “American Bandstand”?
Well, ladies - and the gentlemen in your lives - it’s payback time. All the sun damage you did to your body years ago has been hiding out. Who knew that all those sun tans and - worse - sunburns were actually our skins’ DNA attempts to repair the skin damage the sun’s UVA rays were causing? Now we learn, those repairs can cause gene defects that can eventually lead to skin cancer. I was 59 when my skin cancer reared its ugly head. I was not alone. Skin cancer is the most common form of cancer in the United States. More people have had skin cancer - basal cell, squamous, and melanoma, each named for the cell within the skin from which the cancer originates - than all other cancers combined.
Basal cell skin cancer is the most common, and lucky for me, the least formidable. It rarely metastasizes (spreads) to other parts of the body, but it does grow larger and deeper, destroying nearby parts of the body in its path and causing disfigurement if not immediately addressed.
I let my skin cancer languish for about three – OK, maybe it was six - months. I had self-diagnosed the “thing” on the right side of my nose as “just a small pimple.” Then: “Just a small pimple that won’t go away.” Then: “A small pimple that won’t go away and that forms a scab in the center and bleeds when the scab comes off.” (If there’s something similar on your face, it’s probably not a pimple either.)
I was encouraged by the fact that it didn’t appear to be getting bigger. (I later learned that infiltrating skin cancer tumors like mine form hidden roots or “fingers” of diseased tissue. So, what you’re seeing is just the tip of the iceberg, especially if it’s located in cosmetically sensitive or functionally critical areas around the eyes, nose, lips, and scalp.) Though I considered mine at the side of my nose, its true location was at the medial canthus (the arc at the inner eye area), perilously close to my eye. This location and its histology (i.e. its aggressive, infiltrating tissue structure) were indicators that I needed Mohs surgery. That’s what my dermatologist called to tell me when she received the biopsy report.
Mohs surgery, also known as Mohs micrographic surgery, was invented by Frederic Mohs, is not just for excising skin cancer (primarily basal cell and squamous), but also for color-coding tissue specimens and creating a mapping process to accurately – and immediately (no waiting two weeks for results) - identify microscopically the exact location of remaining cancerous cells.
Mohs developed the technique in 1936, when he was a medical student at the University of Wisconsin. But it wasn’t put into practice until the early 1970s. “Mohs surgeons must not only be surgeons, they must also be pathologists,” says Boca Raton, FL Mohs surgeon Larry Garland. Mohs surgeons have on-site laboratories, and specially-trained technicians who take the pieces of tissue that the surgeon excises, cut and dye them, and turn them into microscopic slides for the Mohs surgeon to map and examine under the closest scrutiny.
A Mohs surgeon first removes the visible tumor, then takes a thin slice of tissue that, once prepared by the technician, will be scrupulously studied under the microscope for remaining cancer. Because the tissue is cut into sections – anywhere from two to 20 (depending on the circumference of the tissue removed) – and mapped, the surgeon can determine exactly where any remaining cancer might be. Then, he returns to the patient, removes only that section of cancerous tissue he’s identified, and repeats the process - one stage at a time, until the slides are “clean.”
It’s definitely an intense, time-consuming procedure, but it’s not the removal of the tissue that‘s time-consuming; that can take as little as five minutes. It’s the preparation and studying of the tissue. That can take as long as an hour. So, if you have cancerous cells in, say, three layers (stages) of tissue, you can be in the surgeon’s office for a good three hours – the majority of the time spent in the waiting room, waiting – with a pressure bandage on the wound. That’s why patients are advised to bring reading material with them.
In about 75 percent of Mohs surgeries, only one or two stages of tissue removal is necessary. In part, that’s because skin cancer is slow growing. It may also be because the public is better educated about skin cancer. About 20 percent involve three or four stages. About five percent of the cases involve more than four stages.
Dr. Steven Garrett, a Mohs surgeon in Mashpee, Massachusetts, performed my Mohs surgery. He calls Mohs surgery “the gold standard .” That’s because it offers the highest cure rate (up to 99 percent); has the lowest chance of regrowth; minimizes the potential for scarring and disfigurement because it removes the least amount of healthy tissue, and is the most exact and precise means of removal, dramatically reducing the chance of requiring additional surgery because it doesn’t remove too little of the cancerous cells.
I found the procedure to be surprisingly painless. The area was numbed, of course, and thanks to the tranquilizer I requested, instead of going to the waiting room and reading a book, I slept on the examining table while Garrett examined my tissue. He found cancer in one of the two first-stage slides; so, he removed a thin second layer of tissue, but only from that one area. When he examined that tissue microscopically, it was “clean.” He had warned me that I would need to have a skin graft, and that he would do it himself. Some Mohs surgeons prefer that cosmetic surgeons do the repair work.
Like any other type of surgery, there are always risks, including excessive pain, bleeding, wound infection, scarring, nerve damage. Depending on where the tumor is, other complications can arise. In my case, Garrett warned me that it was possible, although not probable, that the infiltrating “roots” could have reached my tear ducts. Or come close enough to impact on them during surgery. Luckily, that didn’t happen. But a couple of weeks after surgery, I developed some nerve damage and could not close my eyelids all the way. The problem disappeared in less than a month. The skin graft didn’t look nearly as bad as I thought it would look. And after about six months, it was less visible than that pimple that wouldn’t go away.
Here are five reasons to consider Mohs surgery:
You have been diagnosed with basal or squamous cell cancer, and one or more of the following apply:
The cancer is large.
The edges of the cancer cannot be clearly defined.
The cancer is in an area of the body (eyelids, nose, ears, lips) where it’s important to preserve healthy tissue for the maximum functional and cosmetic results, or is likely to recur if treated by other method.
The cancer is in an area where the preservation of normal skin is critical. This includes fingers, toes, and even genitals.
Prior treatment has failed.
To find a Mohs surgeon, call the American College of Mohs Micrographic Surgery and Cutaneous Oncology: 800-500-7224 www.mohscollege.org or the American Society for Mohs Surgery, 800-616-2767 www.mohssurgery.org.
Associates of the American College of Mohs Micrographic Surgery and Cutaneous Oncology are physicians – usually dermatologists – who have completed one or two years of training at a Mohs College-approved training center and have participated in or observed at least 500 Mohs surgery cases; Fellows of the American College of Mohs Micrographic Surgery and Cutaneous Oncology have been Associates for at least three years, plus have performed at least 300 Mohs surgery cases. Members of The American Society for Mohs Surgery, who must be board-certified dermatologists; performed at least 75 Mohs surgery cases as the primary surgeon; submitted letters of recommendation to the society; and passed a written and practical application examination.
WARNING: It's not easy to stay out of the sun, but please note: No matter how high the SPF (Sun Protection Factor) in your sunscreen, it’s not enough. You need a broad spectrum sunscreen that also provides UVB protection.
Dale Koppel, PhD is the author of "THE INTELLIGENT WOMANS GUIDE TO ONLINE DATING: And She Lived Happily Ever After." Available on amazon and www.theintelligentwomansguide.com.