Derm-it Trotter! Don't Swear About Skincare.
Feeling frustrated or overwhelmed with everything skin? Does the skinformation overload make you want to swear about skincare? Join Dr. Shannon C. Trotter, board certified dermatologist, as she talks with fellow dermatologists and colleagues in skincare to help separate fact from fiction and simplify the world of skin. After listening, you won’t swear about skincare anymore!
Derm-it Trotter! Don't Swear About Skincare.
Skin Cancer Therapy Without Stitches: SRT (Superficial Radiation Therapy)
Skin cancer treatment has come a long way, yet many patients don’t know their options beyond surgery. Dr. Mark Nestor explains how image-guided superficial radiation therapy (IG-SRT) achieves up to 99% cure rates for basal and squamous cell carcinomas.
Using ultrasound to measure and target cancer precisely, IG-SRT offers a non-invasive alternative with excellent cosmetic results—especially for areas like the nose, scalp, or legs. Treatment takes about 15 short sessions with minimal side effects. While not used for melanoma, it’s a highly effective option many patients never hear about.
but also the breadth of skin cancer and see if it's being properly treated during radiation.
Speaker 2:I wanted you to talk a little about. What does that really mean and how does it work to treat skin cancer?
Speaker 1:And a lot of patients come in to me and say you know, I've had so many skin cancers, I've had 50 Mohs surgeries, I've had excisions, etc. An issue where we want to treat the skin cancer cells and do as minimal damage to normal cells as possible.
Speaker 3:Welcome to Dermot Trotter Don't Swear About Skin Care where host Dr Shannon C Trotter, a board-certified dermatologist, sits down with fellow dermatologists and skincare experts to separate fact from fiction and simplify skincare. Let's get started.
Speaker 2:Welcome to the Dermot Trotter Don't Swear About Skincare podcast. So today we've got an exciting show here for you. Today We've got Dr Mark Nestor, who's going to talk with us more about image-guided superficial radiation therapy. But first let's talk a little bit about Dr Nestor. He's a board-certified dermatologist quite accomplished. He serves as director for the Center of Clinical and Cosmetic Research and the Center for Cosmetic Enhancement in Aventura, florida. He's a voluntary professor in the Department of Dermatology, cutaneous Surgery and the Department of Surgery Division of Plastic Surgery at the University of Miami Miller School of Medicine and we're really fortunate to have him a part of the conversation today because he's done the work, he's done the research, he's used these types of devices in radiation therapy before. So I want to welcome you to the podcast. It's great to have you here.
Speaker 1:Thanks, shana, it's really a pleasure to be here.
Speaker 2:I think this is a topic you know we wanted to tackle. You know you and I were chatting about this that it's sort of interesting. In medicine we have a lot more direct-to-consumer advertising. People are seeing advertisements for medicines and treatments on TV, the radio station, and I think that's where a lot of people have heard of radiation therapy in this different way for using it to treat skin cancer. So there's this IG-SRT, or image-guided SRT, or superficial radiation therapy that I wanted you to talk a little about. What does that really mean and how does it work to treat skin cancer? Srt, or image-guided SRT, or superficial radiation therapy, I wanted you to talk a little about. What does that really mean and how does it work to treat skin cancer?
Speaker 1:Great questions.
Speaker 1:So there are a variety of different types of radiation therapy. I think that's very important for people to realize, because I have patients come in all the time and said you know, I am heard about this, but I had an image or I've heard radiation therapy for breast cancer or for prostate cancer and it was a terrible experience. I had all these problems, et cetera, and so it's important to understand that this is a different form of radiation therapy. And what's so interesting is that this was the original form of radiation therapy over 100 years ago and radiation therapy was actually invented by dermatologists. The first cancer to be treated by radiation therapy was a skin cancer, was a basal cell carcinoma. So it's been around for a long time.
Speaker 1:Probably in the 70s, 50 years ago now, more than half of dermatologists had superficial radiation therapy in their offices, and what happened was over the next 20 years or so, there was no equipment. You couldn't get equipment anymore, there was no technology and where I learned? I learned as a resident at NYU in the late 80s, early 90s, and literally the equipment was stitched together with duct tape and kicks every once in a while, and so you know it really was only in the last 10 to 15 years that new technology has really invigorated this, and so I want to just look at the difference between superficial radiation therapy forgetting a second frame it's guided and the primary use by radiation oncologists, which is electron beam, because those are two different forms of radiation therapy. When it comes to skin cancer, all the studies show that superficial radiation therapy is much more effective at treating skin cancers than electron B and it's much more gentle, meaning you get a better cosmetic effect. So these are the two important differentiators between what the radiation oncologist used to treat skin cancer and other types of cancer and what the dermatologist used in their office. So there's a lot of data, a lot of studies that have been on this new form of equipment for radiation therapy and it's been shown to be incredibly effective for treating basal cell carcinomas, squamous cell carcinomas, et cetera. And you know, not for all different skin cancers, but certainly for the vast majority of basal and squamous cell carcinoma, squamous cell in situ the effectiveness, you know, is really equivalent to surgery and even Mohs in a lot of cases of the high 90% five-year curate.
Speaker 1:And that's the way we talk about any cancer. The way we talk about any cancer is what is the five-year curate, meaning it's not going to return, most likely at that point. Now what happened was that a number of a few years ago the idea came can we make this any better? And the question was in order to make it better, how do we pinpoint exactly how deep we go, how wide we go to really take that 90-something percent, 95, 98% curate and try to notch it up as close as we can to 100%. Nothing is ever 100%, as we know that in medicine, or anything but as close as possible is what we want to do.
Speaker 1:And so what was shown is that if you can pinpoint the depth especially, but also the breadth of skin cancer and see if it's being properly treated during radiation, you can actually jack up those numbers. And the numbers for image-guided now are in the 99 plus percent treatment for this. So the idea here is we use ultrasound and the ultrasound can measure the depth of skin cancer and see, essentially, the volume, so we can more specifically target exactly what we want to do. And that's what Image want to do and that's what image-guided is. Image-guided means that we can visualize the skin cancer and visualize what we want to treat, where we want to treat it, and pinpoint the exact essentially KV or the energy that we want to use to treat that skin cancer.
Speaker 2:So with those changes over time, because I think a lot of people might like oh yeah, I've kind of heard of SRT, or maybe for some of the health care providers listening, they know of SRT with image guided kind of added. Now Are the devices essentially all the ones that are out there now image guided or there's still some functioning kind of in the old fashioned way without that advantage?
Speaker 1:So the answer is image guided. Is a little separate little device on their ultrasound.
Speaker 1:And as you know dermatologists, a lot of dermatologists in our office have ultrasound. We use ultrasound for fillers, for other things, to measure things, to measure fat depths etc. So it doesn't have to be part of the machine and, as I said, even without the ultrasound and, as I said, even without the ultrasound, the cure rates for radiation, superficial radiation therapy, are in the 98 to 99% anyway. So this jacks it up a bit. It certainly does, and it makes both a physician and patient feel better because they can actually say I visualized the tumor. And one of the tenants of radiation oncology, which is really what we're talking about here, is that you want to be able to specifically visualize and use that information to at best possible target the skin cancer and leave the normal tissue behind. So it allows us to do that aspect. It doesn't mean we have to do image-guided at each treatment. Some do and that's fine. But the idea here is that we want to be able to use every tool that we have to be able to optimize the treatment for patients. And you know, obviously the gold standard has been for skin cancer has been surgery, you know, and there are different aspects, whether it's just a simple excision, whether it's mows, whether it's destruction. These are all surgical means to get rid of skin cancers. The downside of surgery is that you have scars, and you have not only do you have scars, in certain cases you don't have a lot of tissue to close, like on the scalp and other areas, and so it becomes a little bit more difficult to you know figure out how and what is best for the patient care. And a lot of patients come in to me and say you know, I've had so many skin cancers, I've had 50 Mohs surgeries, I've had excisions, et cetera I really don't want to go through surgery anymore. How can we look at things differently? And superficial radiation therapy, image-guided or not, is a great alternative, especially for patients who are a little older. And again, I've treated patients young because they really don't want to have surgery from that aspect. But the older patients are we see this a lot number one, number two patients with skin cancers on areas that aren't the easiest to do surgery. So on the scalp, on the nose, on the lower extremities, those are some of the primary areas where I use superficial radiation therapy to a great extent, and the reason is that, again, those aren't optimal to do surgery. The other thing that's wonderful about superficial radiation therapy and again, imageguided will put into this bucket certainly is that for larger skin cancers, and I don't mean necessarily larger in terms of death, but larger in terms of the size. And very often we see, excuse me, superficial skin cancers that are larger, especially in areas such as the scalp. Well, we know as dermatologists, the scalp is something that's very hard to heal from bigger excisions because there's no skin. You can't push it together very easily. And this is a really wonderful way of treating that skin cancer getting rid of it without having to cut out the skin and it leaves an area without any sun damage whatsoever. So there are, you know, these reasons I talked about the lower extremities. These reasons I talked about the lower extremities Below the knees is something historically, that surgery is very difficult to do because very often you have a lot of swelling on the lower extremities number one.
Speaker 1:Number two because of the way the blood supply works there, the legs don't heal as well. We know that. We know that clearly. So the infection rate in the lower extremities is much higher. Know that clearly. So the infection rate in the lower extremities is much higher. The rate where you get dehiscence or you get opening and you get ulcerations is much higher when you do surgery, so radiation therapy gives us another tool to use in that area as well, very, very effectively.
Speaker 2:So I think, when you talk about it being effective and a great tool, I want to talk a little bit. You know, this elephant sort of in the room, maybe in the dermatology community, maybe in the radiation oncology community too, about people don't potentially support this In particular. You know physicians or healthcare providers that feel like this is not, you know, a reasonable option. So I think I mentioned to you, you know, one of the questions I got from a patient is that you know I went to a dermatologist who said, hey, you know your nodular basal cell in the nose. You know you shouldn't really do this.
Speaker 2:The data is not there. Guidelines say that it's not really a good. You know primary treatment potentially for you. I want to get your take sort of on this controversy and sort of the debate, because it is healthy for us to have debate, obviously over treatments and if they're the right choice, but sort of maybe where that started, where it's come from and then kind of where we sit currently, you know, with guidelines or what you feel like, maybe the dermatologic community, what we're sort of thinking about it now as a treatment option.
Speaker 1:It's a great, great point. Number one I'm a scientist so I go with studies and data. Okay, this is what I do. So if you look at the studies, okay, if you look at the data from superficial radiation therapy, especially in the last 10 years okay, because there's literally been, you know, I would say, close to 100 studies going back. And if you look at the old studies, the old studies all have about a 95% curated basal cell, almost around a 93% for squamous cell that uses old equipment and old treatment guidelines, meaning you know you have certain parameters that you use for the old equipment. It wasn't necessarily optimal, but I got news for you 93% and 95% is very comparable to surgery, no question about it. If you look at the new data, okay, which is over the last, you know, 15, 10, 15 years, forgetting right now about image-guided you know the data is, as I said, 98% to 99% long-term curates. That is not only at least as good, but that is better than surgery.
Speaker 1:So a lot of the issue comes, number one, from not understanding the data. You know it's not. People don't look at it. Number two it's a whether it's politics, whether it's the issue of I do surgery, that's all I do. I think it's better. Therefore, et cetera. This comes into play no matter what happens. People have their own way of looking at things. I do both. I do surgery. I do, you know, radiation. Many, many radiation people who do superficial radiation therapy are most surgeons, so they do both. So, again, I think it's a question of education from there, but it's also a question of everybody, and the guidelines now really say that superficial radiation therapy is in there for the choice and everybody should be given the full education and choice of what's available, and I think that's really very, very important.
Speaker 1:Patients need to be essentially counseled that, hey, you have a skin cancer on your nose. As you said, you have a pain in your nose. Here are the options we have surgery, we have radiation, we have other things, other things such as topicals. They may not work as well, but it's still an option. From that perspective, I'm going to educate you. You're the patient, you can make the choice. I'm your guy, basically. So I think that you know, as number one, as people really begin to understand this, understand the science, understand the data, including physicians, they will be more comfortable with it. I think that the idea somehow that it's not a reasonable option makes no sense because the data is so sense, because the data is so clear from that perspective. So, again, I think patients need to be armed with education, and sometimes you get that from your physician. Sometimes the patients have to go out on their own, and that's what's happening now to go out on their own, and that's what's happening now.
Speaker 1:As you said, there is certainly a lot of information being put out there about superficial radiation therapy is specifically image guided superficial radiation therapy. So patients are learning about this and you know that Dr Google is very, very powerful or now now Dr Pat GPT is even more powerful about learning about what the options are. And patients need to be empowered, you know, to learn about what my options are and then speak to the doctor and if they have to get another opinion, and if they have to get another opinion, I have very, very many patients coming to me asking for other opinions, et cetera, to say my doctor said this, tell me about this, et cetera. And I'll give them the information and I'll always say you have choices. You have choices of surgery, of destruction of topicals and of superficial radiation therapy, and I'll give them the pluses and minuses.
Speaker 2:No, I think that's good because you want patients to have sort of an honest picture of that. And I think the one thing I always remember when a patient had a different treatment choice, they maybe came to see me and I gave them multiple options and like, hey, nobody ever gave me those options before. I thought this was just the only thing I could do. It is really important.
Speaker 2:I think we owe it to patients to give them options and the risk, benefits and pluses and minuses, of course, with all of that. But they are in the driver's seat and it's our job, like you said, just to give them that information and our opinion on what we think might be the best With SRT. You know, I think you know I had a patient come in asking, you know they had a melanoma and they're like, hey, can we just get our SART on this? Can I treat this with superficial radiation therapy? So I think one of the things I wanted you to kind of go over is you know, when is it really appropriate? I know we kind of talked about a few instances, but high level again, where you think the cases are most appropriate and in cases where, like, probably not the best treatment option as well.
Speaker 1:Okay, yeah, I missed that last part. You're a little bit fuzzy there. But yes, certain things, I should say certain types of skin cancers, are not for superficial radiation therapy, image-guided or not. Melanoma is not for SRT, Certain types of squamous cell carcinomas and even certain types of basal cell carcinomas where it's very, very aggressive, etc. I don't necessarily recommend SRK, except in certain circumstances.
Speaker 1:I had patients coming in to see me in their old, late 90s, let's say, or early 90s, whatever it might be, who are not in good shape and who wouldn't tolerate surgery number one. So we can use superficial radiation therapy to essentially, you know, either palliate, either make these skin cancers much more, I guess, time effective, and they're not going to be bothered by it. From that perspective They'll unfortunately pass away from something else or do something along the lines of using this in a way that makes it better for the patient. But certainly, you know, I refer patients to radiation oncologists. There's something called perineural invasion for squamous cell carcinoma.
Speaker 1:I don't use SRT, I refer those out for electron beam, because electron beam is more aggressive, it gets deeper. There's a type of cancer called DFSP and again I send those to a radiation oncologist as well. Merkel cell there are a number of different types of skin cancers that aren't ideal for SRT from that perspective. A lot of patients come in with a small basis of carcinoma on the chest, on the arm, et cetera. I don't do SRT on those patients, I'll scrape it off, I'll cut it out, et cetera. So there are. You know, part of our job is to say this is not ideal for you and that's okay.
Speaker 2:Because I do think that's important. You know, I think some patients think, oh again, I should have been given this option and maybe it just wasn't the right option, you know, at the time for them to kind of pursue. And just having that viewpoint I think is helpful too. So if somebody is going to undergo SRT in your office, how do you explain to them what you expect maybe for a number of treatments or potential side effects, kind of that risk benefit? What's the conversation look like when you talk with people?
Speaker 1:That's a great question. So essentially, we cut the radiation up into bits. That's the way radiation therapy works. There is an issue where we want to treat the skin cancer cells and do as minimal damage to normal cells as possible and that, you know, this curve is critical to doing that. And in order to do that, we chop it up in what's known as fractions. And in doing this, what we're doing is we're giving enough radiation to treat the cancer cells because they're more essentially fragile to radiation, and it allows the normal cells to recuperate and remain fine, basically from that perspective.
Speaker 1:So in my office I do essentially an average of about 15 treatments, generally two or three times a week. Okay, so you know, somewhere between five and seven weeks. Some image guided centers do 20 treatments. Fine, they they divided up a little bit more from that perspective. But that's what we're talking about. We're talking about and that and that. By the way, that is one of the main differences of what we know now for optimization versus what was 20, 30, 40 years ago. They used smaller numbers of fractions and they didn't get necessarily the optimal effect and they got more localized destruction, so they didn't get such a good cosmetic benefit, and I want to stress that. You know, one of the best things about image-guided or superficial radiation therapy is cosmetic benefit is wonderful.
Speaker 1:Essentially, you have some redness and you asked about what you're going to expect during the treatment. So we're going to do 15 treatments. The treatments themselves only last 30 seconds. It takes a while to set everything up, et cetera, but the treatments only last 30 seconds. It takes a while to set everything up, et cetera, but the treatments only last 30 seconds.
Speaker 1:After three, four treatments you get some redness. If it's on your nose, whatever redness and peeling from that perspective, and that's normal. There really aren't many other side effects and that's the beauty of this. Depending upon the area, if you're going to treat the nose, I put a little shield inside the nose to prevent the mucous membrane from getting damaged. Same thing in the lip if we do that, but that's about it.
Speaker 1:After we're done, we treat it. By the way, we don't treat the area of radiation with topicals when we're doing it, because we want the skin to react. The inflammation that you get, the redness, the radiation dermatitis, is one of the key factors that treats the skin cancers, so we don't want to affect that. After the treatment, I generally use something called EpiSerum, which is something dermatologists know very well. It's a barrier repair that tends to work very well from that perspective, but that's it. When it comes to side effects, there really aren't much On the lower legs you can like with surgery. Every once in a while get an area that takes a while to heal. A little ulceration takes a while to heal. That's certainly we tell patients's a possibility, much less than with surgery, but it can happen from that perspective and the patients heal eventually from there.
Speaker 2:One of the side effects. A patient came in and again, I don't know if they were Dr Googling it, of course, but they mentioned you know well, I heard if I get SRT it increases my risk for skin cancer in that area later on. So I wanted you to kind of talk through what we know about that, because it is something that's floated around. That seems to be a genuine concern, you know, for patients coming in, whether they found it online or through a conversation, you know, with their healthcare provider.
Speaker 1:Great question there is absolutely no evidence whatsoever that you get an increased risk of future skin cancers. In fact, you know, in areas we treat which is so interesting, like on a scalp, where in addition to skin cancer what we normally see is tons of actinic damage and actinic keratosis, the skin after we're done is smooth as a baby's behind. It's very, very smooth because all that sun damage is gone. A baby's behind. It's very, very smooth because all that sun damage is gone. So we don't see that at all and in fact that's a misnomer with radiation therapy in general is that it promotes skin cancer in the future. So it does not do that.
Speaker 2:Because I do think that's some of the hesitation. You know that's kind of been pushed out there, you know, for patients.
Speaker 1:That's the idea of lumping all radiation therapy together. Exactly, yeah, it's different. Superficial radiation therapy is certainly different from that perspective.
Speaker 2:So I think from your perspective, as we're wrapping up, you know we've given kind of a nice overview. Is there anything else that you would kind of want patients to be aware of with SRT good, bad, the ugly or ugly or anything else that we didn't touch upon that you think is really important for them?
Speaker 1:to be aware of. So right now there's a big battle with essentially with Medicare, with CMS, about what the reimbursement is going to be for radiation therapy, and they're trying to cut it down. And the problem with that is it's not reimbursed anywhere near what radiation oncologists get for treating skin cancers and it's not reimbursed anywhere near what radiation oncologists get for treating skin cancers and it's expensive. We do a number of treatments, et cetera. The equipment is expensive to maintain and they're looking to cut it dramatically. If that happens, it's going to limit the amount of superficial radiation therapy available to patients and that will be a shame from that perspective. So this is a battle that both patients and physicians are taking up now to stop the cuts, so to speak, which seem to be very common across medicine from here. But it's been something that hopefully they'll listen to, because I think this is something that's incredibly valuable for our patients.
Speaker 2:Well, thank you so much. I appreciate you going over all that today because we're getting a lot of questions and, like I said before we went on, I had a patient today that just basically said to me, hey, what about SRT, Is this going to be an option? And I thought, oh, I'll definitely talk with you about it. But you got to tune in because I'm going to have a true expert in this field. That's going to be on my podcast and will air later on this fall. So thank you so much for coming on the podcast, Mark. I really appreciate your time and expertise.
Speaker 1:If anybody has questions. You know I'm in Aventura, florida. We treat a lot of patients, so you know that would be. They can call my office et cetera from there if they have questions about this, and thank you so much for having me on.
Speaker 2:Of course it's a pleasure and for those of you listening or watching, please remind, a friendly reminder to please hit, like and subscribe and stay tuned for the next episode of Dermot Trotter. Don't Swear About Skin Care.
Speaker 3:Thanks for listening to Dermot Trotter. For more about skin care, visit Dermot Trotter. For more about skincare, visit Dermot Trottercom. Don't forget to subscribe, leave a review and share this podcast with anyone who needs a little skincare sanity. Until next time, stay skin smart.
