One of my friends told me that she has heard that doctors are overreaching with Mohs for very tiny basal cell cancers. She said I should just treat it with Efudex instead of going through Mohs and plastic surgery to close it. Also, if I do have Mohs and plastic surgery - how long before I can play golf? Maddie
Is Mohs Surgery Overreaching for a Tiny Basal Cell Cancer?
Doctor Answers (8)
Mohs for small basal cell cancers
Mohs is a very specialized surgery which is indicated for treatment of certain skin cancers based on their size, biologic behavior, location, and if they are in high risk areas or are already recurrent. Alternative treatments may be appropriate for a BCC if it does not fit the guidelines. You will need to discuss these with your dermatolgist and make an informed decision based on information received. As much as I love 5FU for treatment of precancerous actinic keratoses I have never been inclined to encourage patients to use 5FU for BCCs unless they are very superficial and in an area where the 5FU can be used for longer periods of time and sometimes under occlusion if it is possible.
Mohs Surgery Necessary for Tiny Basal Cell Cancer?
Thank you for your question. Mohs surgery is typically reserved for squamous cell cancers and basal cell cancers (and some other more rare types of cancers as well) on the face in areas where preserving normal and unaffected tissue. I hope this helps.
Single basal cells should be biopsied and removed surgically to be sure the cancer has been completely excised. MOHs or conventional excision depends on specific indications. If the wound is surgically closed by a plastic surgeon you will be back on the golf course in a few days. Efudex is used for extensive precancerous lesions and extensive superficial basal cell lesions that make surgical excision unfeasible. The problem with treating actual basal cell cancers with Efudex is that you do not know if the cancer is gone after treatment. Yes, there is MOHs abuse, but do not let that deter you from getting the best possible advice from your Board Certified Plastic Surgeon. Best wishes. knowledge is power. Luis F. Villar MD FACS
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Mohs surgery for small basal cell cancers
Mohs surgery is a specialized procedure that enables the surgeon to remove the skin cancer with the highest cure rate and lowest recurrence rate all the while sparing as much normal skin as possible. Having said that, it is not alway indicated for every basal cell cancer. However, it would be helpful to know where your skin cancer is located. Is it located on the face? Specifically on the "mask" area like accross the nose, around the mouth, eyes and the ears. Also, mohs is often chosen for treating skin cancers in young patients, irrespective of the location. There are other treatment options. However, using Efudex may not be appropriate if you basal cell cancer is not superficial and it is not an overnight treatment either and will likely keep you out of commission longer in playing gold since sun exposure becomes a huge issue. I would discuss these options with your dermatologist
Alternative treatments for basal cell skin cancer
There are many alternative treatments to basal cell carcinoma. Generally Mohs is reserved for poorly defined cancers on the face. Alternatives do include excision, EDC, and Aldara. You must rely on your surgeon to recommend best option for you.
Is Mohs necessary?
Mohs is a very specialized surgery that is required for specific types and locations of BCCs. It is not required for all BCCs. Some can be removed with a currette, or other excision, or Efudex, and sometimes you do need Mohs. It depends on what the biospy shows - the location, depth, and width of the BCC. What we think of as a "very tiny BCC" may have roots under the skin; this is when Mohs is used. Efudex is effective only for very superficial BCCs. It cannot penetrate deep enough into the skin to get to the roots of specific types of BCCs. One additional thing - Efudex is great, but also takes weeks of use and can really freak people out as the skin becomes red, gooey, and rather icky for many people. A lot of women, especially, just won't do it. Which then, the BCC isn't treated effectively and keeps on growing! You certainly won't be on the golf course quicker by choosing Efudex, and depending on your biospy, it may not even get to the depths of your BCC. If you have questions about which procedure is being recommended and why - always ask your doctor!
Indications for Mohs Surgery
There are many good indications for Mohs surgery including recurrent skin cancers, locations on areas important for tissue preservation and at higher risk of recurrence (e.g. nose, eyelids, ears, lips), aggressive types of skin cancer (e.g. morpheaform, infiltrative basal cell carcinoma), large size, poorly defined margins, immunosuppressed patients.
Best option is to discuss with your dermatologist what is the best option for you and for your skin cancer and why. Mohs provides the highest cure rate and preserves the greatest amount of healthy tissue, but there may be other options that would be better given other factors.
Most of my patients wait about 1- 1 1/2 weeks before they go back to playing golf. Good luck.
Mohs surgery has a set of criteria that should be met
You ask a very sophisticated question. There are many treatment options for basal cell cancer. Mohs surgery has the highest cure rate of any of the treatment methods but is only appropriate for certain types of Basal Cell Cancers, generally speaking, ones located on a critical area of the face, ones that are over a certain size on the body or ones that have been treated and have come back. The decision to undergo Mohs surgery is one most Mohs surgeons undertake after making sure the patient meets the appropriate criteria and that the patient understands all the other treatment options. Thus, you don't always have to undergo Mohs but you should discuss this with your dermatologist or Mohs surgeon because there may be certain criteria, even if your spot is very tiny, that might make it important to undergo Mohs surgery (ie aggressive histology).
Regarding the closure, if you see an American College of Mohs Surgery member, they have extensive experience in facial reconstruction and most do more reconstructive facial surgery for skin cancers than any other specialist , so it might be something to consider. It is your decision though on who you want to close your hole following Mohs but in my practice, over 99.9% of the closures are done by me. The sheer volume and amount of skin cancer reconstruction is often the most important determinant. If you are seeing a plastic surgeon for the closure, but they spend time doing Breast implants or hand surgery, they might not be doing a whole lot of skin cancer reconstruction. Most importantly though is to make sure you feel comfortable with the person doing your "closure."
In terms of your restrictions, every surgeon is different, but in general you will need to avoid golfing for one to two weeks.