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There is an ever-widening variety of treatments for skin cancers – from lasers and light therapy, to creams, radiation and freezing. But one that is still proving most effective, according to experts, is also the most old-fashioned – and involves ‘mapping’ the tumours using a paper and pencil.
The surgical technique, known as Mohs micrographic surgery, was first developed in the 1930s.
I found out all about it when last year, a few months shy of my 40th birthday, I was diagnosed with a basal cell carcinoma (BCC) that developed in the centre of my forehead.
I had a strange ‘ulcer’ that appeared from nowhere that would scab over but never fully heal. I
was worried about it, so sought the help of my GP. It took a while to get a proper diagnosis because I don’t fit the usual profiling.
The risk of BCCs increases with age, and they most commonly affect those over the age of 60.
I do however have risk factors – I have fair skin and have spent time abroad. A biopsy finally confirmed the result.
After coming to terms with a cancer diagnosis, which did hit me hard though I was quickly reassured that it was not a life-threatening form, I started to research the best treatment options available.
As well as wanting the cancer gone, in truth I was also concerned about the size of the scar I would be left with.
Online, I discovered that during standard surgery, a 4mm margin is cut which would have left a significant mark on my face.
It was during an appointment to discuss this with my GP that Mohs surgery was first mentioned. He had also recently been diagnosed with a BCC, which accounts for 75 per cent of all skin cancers.
Mohs cures about 99 per cent of BCCs when treated for the first time. The success rate drops to about 95 per cent for previously treated BBCs that then return.
And, according to consultant dermatological surgeon Dr Raj Mallipeddi, who heads up the country’s largest Mohs units at St Thomas’ Hospital in London: ‘In areas like the nose, ears and eyelids it will give a better cosmetic outcome.’
The Mohs procedure (it’s named after the surgeon who invented it, Frederic Mohs) begins with the removal of the visible portion of the skin cancer with a scalpel, along with a layer of surrounding skin.
Once a layer of tissue has been removed, a map, or drawing, of it and its orientation to the face is made on paper to serve as a guide to the precise location of the tumour.
The tissue is processed using stains to help highlight any cancerous material, which the surgeon will then examine under the microscope.
If cancer is still present in certain areas, the surgeon will then remove another layer of tissue with a scalpel. The process is repeated until all cancer cells have been removed and only healthy cells remain. It is only then that the wound is closed.
The procedure, is performed using only local anaesthetic, and can take up to six hours, although most of the time is spent waiting for results rather than being operated on.
Not all patients will automatically be put forward for this treatment.
There are only a small number of units performing Mohs in the UK. St Thomas’, the largest provider, treated around 1,000 patients last year.
There are about 113,000 new cases of skin cancer every year in the UK.
The treatment is also suitable for another common type – squamous cell carcinoma, which accounts for 20 per cent of cases. Mohs can even treat certain forms of melanoma, the deadliest skin cancer.
Depending on the diagnosis, the consultant may decide that a standard excision will have a higher chance of success without the long operative time and cost of Mohs.
Other options include radiotherapy, the use of topical creams such as Imiquimod; or Photodynamic Therapy, which combines use of a special cream with exposure to a specific wavelength of light. However topical treatments are usually reserved for low-risk superficial tumours.
High success rate: Using pencil and paper to map out the tumours has proven to be one of the most successful way to treating skin cancer
So what is it like? The operation day itself is a long one.
During my first session, the surgeon removed the lesion and a layer of surrounding tissue, cauterised and bandaged the area while I returned to the waiting room. Once the anaesthetic was injected, the procedure was painless and relatively fast. I had about an hour’s wait, in which I sat and read a magazine before being called back into theatre, where the surgeon explained there were two areas where cancer cells were still present.
The most uncomfortable bit of the whole procedure was when the team cleaned the wound and injected it again ready for more surgery.
The area was again cauterised, burnt with a heated instrument to stem the bleeding, and covered in a large plaster packed with gauze and I returned for my final wait.
After another hour passed flicking through magazines, I was called into theatre by Dr Mallipeddi who said that as the margins were now clear the wound could be closed. It was an indescribable relief to hear that the cancer had gone.
Then I had to get my brave face on for the final bit of surgery.
More anaesthetic and a bit of tugging drew my skin together, and it took about three weeks for the wound to heal properly.
Four months on and the scar is about 3cm long. But people only notice it if I point it out. Make-up and a newly adopted fringe certainly help, but it is a small price to pay for a face free from cancer.
If I have learned anything from the experience it is this: skip the sunbed, wear sunscreen at all times, wear a hat and cover your shoulders in the sun.
And if you notice a patch of skin or an ulcer that doesn’t heal, report it to your GP. The sooner you catch a change, the better your chance of a full cure and less scarring.
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