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Right to Know: The Critical Importance of Options and Choices in Skin Cancer Treatment

Doctor examining birthmarks and moles patient. examination of birthmarks and moles.the doctor examines the patient's mole

If there is one thing that Americans have been consistently good at, it is the creation of options and choices in all areas of life.

In the realm of health care, and cancer treatment in particular, presenting patients with available options for treating disease has proven to be key in saving lives and dramatically enhancing the quality of life (QoL).

Nonmelanoma skin cancer (NMSC), which I have been treating for 17 years, is the most common type of cancer in the United States.  Each year, some 5.4 million basal cell and squamous cell carcinomas are diagnosed among 3.3 million people, and 2,000 individuals die from this disease. Traditional treatments for nonmelanoma skin cancer include Mohs surgery, radiation therapy, cryotherapy, and various topical therapies.

In recent years, a newer option has emerged as a superior alternative therapeutic. Image-Guided Superficial Radiotherapy (Image-Guided SRT) uses ultrasound-aided simulation to target the lesion by identifying its breadth, depth, size, and shape. The current third-generation iteration of Image-Guided SRT leads to levels of treatment efficacy not seen with previous generations of SRT technology without image guidance.

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A recent study published in the medical journal Oncology and Therapy evaluated the safety and efficacy of Image-Guided SRT, concluding, “Image-Guided SRT should be considered as a first-line option for treating NMSC tumors in suitable early-stage patients.” [1] Furthermore, the study demonstrated that Image-Guided SRT provides an overall cure rate of over 99 percent for stages 0-II, equaling that of Mohs surgery without the attendant adverse effects.

Further, Image-Guided SRT’s “see as you treat” technology facilitates the adaptive radiotherapy protocol responsible for its high cure rate and provides an added benefit to patients – visible proof that the tumor is shrinking, which contributes to improved patient compliance.

Image guidance requires lesions and normal tissue to be evaluated in an adaptive manner to ensure proper superficial radiotherapy delivery. When using Image-Guided SRT, clinicians can assess in real-time, at each treatment, the exact dimensions and location of the lesion and response during the course of care, contributing to a higher standard of care and better patient outcomes.

Those of us offering Image-Guided SRT as an option for our patients found that they are highly satisfied with this treatment. It is quick; Image-Guided SRT is delivered in stages in the dermatologist’s office – typically involving a series of treatments, three to four times per week, over several weeks. It is efficient; up to three lesions can be treated during a course of care. (On average, around 1.67 lesions are detected at diagnosis.) It works; Image-Guided SRT’s cure rate of 99.3% compares favorably to Mohs surgery cure rates of 98 percent for basal cell carcinoma and 96% for squamous cell carcinoma. And finally, Image-Guided SRT does not produce complications commonly occurring with Mohs procedures, including surgical scarring.

A 2020 study by Fix et al. revealed that 83.2% of patients treated with Mohs micrographic believed that their post-op scars would be half of the actual size. [2] In essence, their Mohs scars were 2.2 times larger than they had expected, suggesting that the consent process for Mohs surgery is often not fully inform patients as to the extent of their surgery.

Today, 230 (and growing) U.S. dermatology practices offer Image-Guided SRT, and they have collectively treated over 45,000 patients and 70,000+ lesions, making Image-Guided SRT a community standard of care that is already accessible to 1 in 4 Americans diagnosed with SCC and BCC. Patient satisfaction scores are equally as impressive, with 99% of patients stating that they were happy with their decision and stating that they would recommend Image-Guided SRT.

The number of dermatology practices offering this patient- and practitioner-favored treatment modality is growing fast, but increased patient education is vitally needed along with a greater focus on “well-balanced informed consent.”

The concept of informed consent has been around for years, defined by the American Cancer Society (ACS) as a process of communication between patient and health care provider that often leads to agreement or permission for care, treatment, or services. [3] Every patient, says ACS, has the right to get information and ask questions before any cancer procedure and treatment.

Per the National Comprehensive Cancer Network (NCCN), the primary goal of the treatment of basal cell cancer is the complete removal of the tumor and the maximal preservation of function and cosmesis. [4] All treatment decisions should be customized to account for the particular factors present in the individual case and for the patient’s preference. Further, surgical approaches often offer the most effective and efficient means for accomplishing cure, but considerations of function and patient preference may lead to choosing radiation therapy (RT) as primary treatment in order to achieve optimal overall results.  [4]

If adult patients are mentally able to make their own decisions, medical care cannot begin unless they give informed consent. This requires that health care providers present their patients with all necessary information about their treatment options, even if the provider does not offer a viable option, like Image-Guided SRT, but can refer the patient to another practice for that care.

In addition to patient education, payor education is ongoing for emerging and better procedures requiring coverage. Coverage for Image-Guided SRT services varies as some commercial payors, along with their outsourced precertification vendors, are denying payment for imaging or other commonly rendered and medically necessary services associated with this treatment, each of which is integral to the success of the procedure treatment course.  CMS regulations generally prohibit Medicare Advantage plans from denying coverage where Medicare covers the beneficiary’s services.[5]  However, Medicare Advantage plans have even gone so far as to deny coverage for their members, which may be a violation, as CMS has been providing full coverage for all Image-Guided SRT services since inception. This practice by the payor(s) is clearly not conforming to the informed shared decision-making process between the patient and their physician that some national medical societies have embraced. After all, it is all about the patient and their treatment outcome.

Patients with nonmelanoma skin cancer have a right to know that there are both surgical and non-surgical options, along with a clear explanation of the side effects and risks associated with each, so that they can provide truly informed consent and make the best decision for their treatment journey. Patients should also have confidence as a payor beneficiary to have medically necessary services reimbursed for procedures that are safe and highly effective.

Patients need to know they have a choice, and a voice, in their cancer treatment.

Reference
[1] Yu L, Oh C, Shea CR. The Treatment of Non-Melanoma Skin Cancer with Image-Guided Superficial Radiation Therapy: An Analysis of 2917 Invasive and In Situ Keratinocytic Carcinoma Lesions. Oncol Ther. 2021 Jun;9(1):153-166. doi: 10.1007/s40487-021-00138-4. Epub 2021 Feb 5. PMID: 33547631; PMCID: PMC8140015.
[2] Fix WC, Miller CJ, Etzkorn JR, Shin TM, Howe N, Sobanko JF. Comparison of Accuracy of Patient and Physician Scar Length Estimates Before Mohs Micrographic Surgery for Facial Skin Cancers. JAMA Netw Open. 2020 Mar 2;3(3):e200725. doi: 10.1001/jamanetworkopen.2020.0725. PMID: 32159810; PMCID: PMC7066479.
[3] What Is Informed Consent? American Cancer Society (ACS). Online. Last accessed on August 11, 2022.
[4] Basal Cell Skin Cancer. National Comprehensive Cancer Network. NCCN Guidelines. Online. Last accessed on August 11, 2022.
[5] Medicare Managed Care Manual / Chapter 4 – Benefits and Beneficiary Protection (Rev. 121, Issued: 04-22-16) Online. Last accessed on August 11, 2022.

Featured image: Doctor examining a patient’s birthmarks and moles. Photo courtesy: © 2016 – 2021 Fotolia/Adobe. Used with permission

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Alpesh Desai, DO, is a leading board-certified dermatologist at Heights Dermatology, serving multiple areas in Texas. From the offices in Houston, Rosenberg, Lake Jackson, Portland, Corpus Christi, Palacios, Columbus, Gonzales, Dallas, Mansfield, Beaumont, Bay City, New Braunfels, and San Antonio, Texas, Desai specializes in all aspects of adult and pediatric dermatology, including general, surgical, and cosmetic dermatology. He shares excellent academic and professional credentials, as well as a genuine commitment to sharing knowledge and experience with both his professional colleagues and his patients. It is no surprise that he was named one of Houston’s Best Physicians by Health & Fitness Sports Magazine in 2007, 2008, and 2009. A Houston native, Desai returned to the area after successfully completing a surgical internship and dermatology residency in southern California. In 2006, he was selected among several of his peers to take over one of Houston’s most prestigious dermatology practices. With the help of his brother Tejas Desai, MD he expanded the practice to include Mohs Micrographic Surgery, Cosmetic Procedures, and Clinical Research Trials. At Heights Dermatology, the mission has been to utilize the emerging technology to deliver advanced patient care with a personal and caring touch. Desai’s long list of professional affiliates includes memberships at the local and national levels, including the Texas Medical Association, Harris County Medical Society, and the American Academy of Dermatology. Desai is also a leader in dermatology and conducts many clinical research trials. He also provides free dermatology care to local charities and was recently awarded an Honor of Distinction by the Asian American Physician Association for his contribution and dedication to Southeast Asia Orphanages. Desai has been frequently featured in print and broadcast media as a recognized expert in his field. He has been on numerous radio interviews discussing dermatological issues ranging from psoriasis to cosmetic procedures. Furthermore, he continues to contribute back to his medical community by authoring multiple medical articles, manuscripts, and texts currently in print.