Best Practices

Best practices for surgery for skin cancer vary based on the histologic type of cancer, clinical features of the cancer, and patient-specific factors. Still, there are some common elements in appropriate care ( Box 1 ).

Before surgery, key data pertaining to the case are obtained, collated, and reviewed. Relevant information includes the biopsy reports and any other laboratory tests or diagnostic imaging. Unusual findings on diagnostic tests may suggest the need for additional tests, or confirmatory reads of existing raw data by additional specialized authorities (eg, dermatopathology, radiology). Staging of the tumor, if appropriate, is performed in accordance with American Joint Committee on Cancer criteria and other clarifying literature. Reference to clinical practice guidelines, including those promulgated by the National Comprehensive Cancer Network and relevant specialty societies (eg, American Academy of Dermatology, American Society for Dermatologic Surgery), is considered. Aspects of care where guidance is unavailable or ambiguous can be determined by consideration of patient-specific factors; discussion with the patient, patient’s family, and other members of the medical team; and if appropriate, via a formal ethics board or tumor board consultation. When care in addition to dermatologic surgery may be necessary, additional referrals may be made to other specialists (eg, surgical oncology, plastic surgery, head and neck surgery, urogynecological surgery, transplant medicine or surgery, medical oncology, and radiation oncology). After surgery, appropriate follow-up care to monitor for recurrence or new primary tumors is implemented. Dysfunction or disfigurement resulting from prior surgeries is managed (eg, treatment of hypertrophic or symptomatic scars, treatment of functional asymmetry).

Current Practice

Current practice is variable. Treatment of primary and recurrent basal cell carcinomas and squamous cell carcinomas of small to moderate size and low to moderate risk is consistent at many centers. Higher risk lesions are addressed by Mohs surgery, with lower risk tumors treated by excision, electrodessication and curettage, or other methods. In general, National Comprehensive Cancer Network guidelines are observed.

Treatment of higher risk tumors, including locally advanced or metastatic basal cell carcinoma; high-risk, locally advanced, or metastatic cutaneous squamous cell carcinoma; Merkel cell carcinoma; melanoma; and rare nonmelanoma skin cancers is less consistent across centers. The rates at which other services are consulted and interdisciplinary plans are initiated regarding the management of higher risk tumors range from low to high. Rates of adjuvant treatment are also different. Some centers are more prepared to provide surgical treatment of higher risk skin cancers, and other centers are more likely to refer these to other dermatologic surgery centers.

Gaps and their Classification

Current gaps include differential access and availability of other specialty services that may be required to manage complex or aggressive skin cancers. Additionally, there are no guidelines of care for several rare nonmelanoma skin cancers because of the extreme rarity of these. Emerging useful treatment options, such as 100% margin controlled excision for melanoma-in-situ of the head and neck, are variably used. For some cancers, there are no well-established follow-up treatment plans, including a lack of recommendations regarding future surveillance and testing.

The limited degree of interdisciplinary care transcends the range of categories from knowledge, to skill, to attitude, to specific practices. Practitioners may not be aware of usual and customary practices at major treatment centers, or recommended practices in recent clinical guidelines. For example, the use of sentinel lymph node biopsy and PET/computed tomography for Merkel cell carcinoma, both of which have been shown strong prognostic value for Merkel cell carcinoma, is highly variable. In terms of skill and attitude, practitioners may have a preference for managing even complex tumors entirely in-house, or may not have active referral or consulting relationships with other specialists. The gaps pertaining to limitations or omissions in current guidelines, or the absence of practice guidelines for certain tumor types, are primarily gaps in knowledge.

Barriers and How They May Be Overcome

Principal barriers include the atomized nature of dermatology practice, where many practitioners practice in solo or small specialty-specific groups that are not in physical proximity to referral centers or other specialists’ offices. The outstanding, convenient, and patient-friendly personalized service that dermatologists can offer patients in their private offices paradoxically limits the ease of collaboratively managing with other specialists the few patients who may benefit from interdisciplinary care. Affiliations with local academic medical centers or multispecialty practices may help overcome this barrier. Provisions for such alliances will likely need to overcome financial and regulatory disincentives to collaboration.

Barriers to development of more detailed practice guidelines and guidelines for the management of rare circumstances include limitations in the medical evidence. Development of large prospective databases documenting patient care parameters by the American Academy of Dermatology and the American College of Mohs Surgery will result in copious data on management of aggressive and rare skin cancers. These outcomes data can then be used by consensus groups to develop preliminary practice guidelines for these circumstances. Several years of data collection will likely be required before the data are sifted and analyzed in this manner.

As these and other new data are developed they need to be efficiently and rapidly disseminated to providers. Internet-based educational resources provide a ready means to effectively communicate information and have shown to be effective modifiers of physician practice. As medical practice becomes ever more complex, these types of self-paced “on-demand” educational interventions may prove to have a higher impact than traditional means of distributing medical knowledge (such as journals or conventions.) An additional advantage of the World Wide Web is the ability to connect the aforementioned atomized dermatology providers and their patients with expertise that may be otherwise geographically remote and unavailable to them.