He was a typical patient for my small-town clinic. A bit overweight perhaps, but hardworking, spending a lot of time outdoors. No, he didn’t normally wear a big floppy hat. Instead, his skin exhibited the usual signs of solar wear & tear: a reddish, tanned complexion; small, diffuse telangiectasia of the face and ears; and a lesion of the forehead — one that had been there for a year or more (maybe much more).
The lesion was pearly. It had borders that were somewhat ill-defined. It was almost certainly a basal cell carcinoma. It needed to be evaluated and treated.
So, what was the best treatment plan for this patient?
Determining the Next Step
Step one is to get a biopsy. Then what? Does it need to be excised? Does it need Mohs micrographic surgery? Would an electrodessication and curettage (ED&C) be adequate? What does the evidence say?
Mohs almost certainly would have the highest response rate for clearing such a tumor. Recurrence rates after Mohs surgery of a basal cell carcinoma — particularly a relatively uncomplicated lesion like this one — are excellent.
Excisional surgery would give a good response rate, too. While the data are equivocal, it seems that excisional surgery might be more cost-effective than Mohs surgery for removal of this lesion.
Topical treatment with imiquimod (Aldara) might be effective, too — particularly if the patient expressed a need to avoid surgery.
ED&C isn’t as effective as the other surgical approaches. Some might say that ED&C scars are the least attractive, as well.
Evidenced-based decision-making probably would say forget ED&C, and choose from among the other options.
Letting the Patient Choose
Rather than choose the treatment for the patient, I educated him about all of these options.
Mohs might be least convenient, but it would give the best chance of cure. Excision isn’t too difficult and would be highly effective. ED&C gives a decent chance of cure, but the evidence says it is not as effective.
Treating Patients, Not Problems
The evidence favoring excision over Mohs (or vice versa) may be equivocal, but the patient wasn’t. He chose ED&C without hesitation, preferring the convenience of getting the lesion treated at the same time the biopsy was done to confirm the diagnosis.
The quality of medical care is important to all physicians. I hear that quality must be less than optimal because there is so much variation in patterns of care.
Conventional thinking holds that there must be one best way of solving a medical problem. However, the fact that there is variation means things could be better.
This way of thinking is based on the idea that we are treating problems. We are actually treating patients.
Isn’t it far better to tailor the care to suit our individual patients’ goals and preferences?
Steven R. Feldman, M.D., Ph.D.
Chief Medical Editor
He was a typical patient for my small-town clinic. A bit overweight perhaps, but hardworking, spending a lot of time outdoors. No, he didn’t normally wear a big floppy hat. Instead, his skin exhibited the usual signs of solar wear & tear: a reddish, tanned complexion; small, diffuse telangiectasia of the face and ears; and a lesion of the forehead — one that had been there for a year or more (maybe much more).
The lesion was pearly. It had borders that were somewhat ill-defined. It was almost certainly a basal cell carcinoma. It needed to be evaluated and treated.
So, what was the best treatment plan for this patient?
Determining the Next Step
Step one is to get a biopsy. Then what? Does it need to be excised? Does it need Mohs micrographic surgery? Would an electrodessication and curettage (ED&C) be adequate? What does the evidence say?
Mohs almost certainly would have the highest response rate for clearing such a tumor. Recurrence rates after Mohs surgery of a basal cell carcinoma — particularly a relatively uncomplicated lesion like this one — are excellent.
Excisional surgery would give a good response rate, too. While the data are equivocal, it seems that excisional surgery might be more cost-effective than Mohs surgery for removal of this lesion.
Topical treatment with imiquimod (Aldara) might be effective, too — particularly if the patient expressed a need to avoid surgery.
ED&C isn’t as effective as the other surgical approaches. Some might say that ED&C scars are the least attractive, as well.
Evidenced-based decision-making probably would say forget ED&C, and choose from among the other options.
Letting the Patient Choose
Rather than choose the treatment for the patient, I educated him about all of these options.
Mohs might be least convenient, but it would give the best chance of cure. Excision isn’t too difficult and would be highly effective. ED&C gives a decent chance of cure, but the evidence says it is not as effective.
Treating Patients, Not Problems
The evidence favoring excision over Mohs (or vice versa) may be equivocal, but the patient wasn’t. He chose ED&C without hesitation, preferring the convenience of getting the lesion treated at the same time the biopsy was done to confirm the diagnosis.
The quality of medical care is important to all physicians. I hear that quality must be less than optimal because there is so much variation in patterns of care.
Conventional thinking holds that there must be one best way of solving a medical problem. However, the fact that there is variation means things could be better.
This way of thinking is based on the idea that we are treating problems. We are actually treating patients.
Isn’t it far better to tailor the care to suit our individual patients’ goals and preferences?
Steven R. Feldman, M.D., Ph.D.
Chief Medical Editor
He was a typical patient for my small-town clinic. A bit overweight perhaps, but hardworking, spending a lot of time outdoors. No, he didn’t normally wear a big floppy hat. Instead, his skin exhibited the usual signs of solar wear & tear: a reddish, tanned complexion; small, diffuse telangiectasia of the face and ears; and a lesion of the forehead — one that had been there for a year or more (maybe much more).
The lesion was pearly. It had borders that were somewhat ill-defined. It was almost certainly a basal cell carcinoma. It needed to be evaluated and treated.
So, what was the best treatment plan for this patient?
Determining the Next Step
Step one is to get a biopsy. Then what? Does it need to be excised? Does it need Mohs micrographic surgery? Would an electrodessication and curettage (ED&C) be adequate? What does the evidence say?
Mohs almost certainly would have the highest response rate for clearing such a tumor. Recurrence rates after Mohs surgery of a basal cell carcinoma — particularly a relatively uncomplicated lesion like this one — are excellent.
Excisional surgery would give a good response rate, too. While the data are equivocal, it seems that excisional surgery might be more cost-effective than Mohs surgery for removal of this lesion.
Topical treatment with imiquimod (Aldara) might be effective, too — particularly if the patient expressed a need to avoid surgery.
ED&C isn’t as effective as the other surgical approaches. Some might say that ED&C scars are the least attractive, as well.
Evidenced-based decision-making probably would say forget ED&C, and choose from among the other options.
Letting the Patient Choose
Rather than choose the treatment for the patient, I educated him about all of these options.
Mohs might be least convenient, but it would give the best chance of cure. Excision isn’t too difficult and would be highly effective. ED&C gives a decent chance of cure, but the evidence says it is not as effective.
Treating Patients, Not Problems
The evidence favoring excision over Mohs (or vice versa) may be equivocal, but the patient wasn’t. He chose ED&C without hesitation, preferring the convenience of getting the lesion treated at the same time the biopsy was done to confirm the diagnosis.
The quality of medical care is important to all physicians. I hear that quality must be less than optimal because there is so much variation in patterns of care.
Conventional thinking holds that there must be one best way of solving a medical problem. However, the fact that there is variation means things could be better.
This way of thinking is based on the idea that we are treating problems. We are actually treating patients.
Isn’t it far better to tailor the care to suit our individual patients’ goals and preferences?
Steven R. Feldman, M.D., Ph.D.
Chief Medical Editor
