Anyone Familiar with Mohs Micrographic Surgery for Skin Cancer?

[Puckslinger]

I'm scheduled to undergo the procedure on Tuesday, the 9th of September.

I have a couple of concerns; but my anxiety is mounting as the appointment gets nearer.

Here's what's happening:

In January, 2008, I went to the dermatologist about a little bump I had on my left bicep. It was larger than a pea, but smaller than a gumball. Anyway, it had gotten snagged on the zipper of my sleeping bag a couple of times; had bled and then healed both times. But it was clearly growing.

At the dermatologist's office, the doc took one look at it and said, "That is a Squamous Cell carcinoma. And we are going to have to take it off."

I said, "Is it serious?"

He said, "Not if it's treated early. It is the second most common form of skin cancer."

He told me it was a good thing that I came into the office, and didn't put off dealing with it.

"I've seen Squamous Cells grow to the size of a baseball in six weeks", he told me.

I said, "Well, let's take it off then."

They did a procedure called a Shave and Scoop.

A Shave and Scoop does exactly what it sounds like. They have a device that looks something like a disposable razor, with a little doodad on the bottom that looks like the thing you see on the bottom of certain kinds of fishing lures; that causes them to dive underwater.

They give you an injection to freeze the site; then shave it off and scoop it out all in one swift motion.

The doc asked if I had a problem with a scar. I said it really didn't matter to me; so they put a big round band aid on it and sent me home.

A couple of days later, they called my house and said the biopsy showed they had "gotten it all"; and I should start having yearly checkups--sooner if I was concerned about new growths. They also told me how to use antibiotic ointments, and to change the band aid if it got wet.

I ended up with a small circular scar that looks like a small caliber bullet or vaccination scar. I forgot all about it.

So, the next thing you know a year has flown by and I call the dermatologist's office to schedule my 'yearly checkup'. It turns out there is a waiting list of three months. As the three months draw near, the office calls and tell me they have to reschedule; and it will be another couple of months.

Finally, on 11 August, 2009, I go into the office; but the dermatologist isn't there. There is a Nurse Practitioner who is going to check me out.

She has me strip, goes over my entire body, then points to a little bump on my forehead near the hairline.

"I want to biopsy that.", she says.

I said, "What is it? It has gotten snagged on my bike helmet a couple of times and bled; but I just thought it was a little pimple or something."

She says, "That looks like a Basal Cell carcinoma...the most common form of skin cancer"

"Well, let's take it off then."

This time, she tells me that she is going to do the biopsy; but the dermatologist is going to have to "Do a little procedure and put in a couple of stitches". "So you have a neat little linear scar", she says, "Because it's on your face."

So a couple days later the Nurse Practitioner calls and says the biopsy confirmed it is Basal Cell carcinoma, and they will be holding a "Face Clinic" on the 9th of September. They will only be seeing patients with cancer on the face that day. She said I should arrive at 8:30AM and plan on spending the entire day.

She said they will provide coffee and donuts in the morning, and pizza at lunchtime. I should bring something to read.

I"m thinking: 'Can't we just do a Shave and Scoop'? But I agree to be there on the 9th of September.

A couple days later, I get a fat envelope full of forms for me to fill out in the mail; including some releasing the doctor from any liability as a result of my scheduled Mohs Micrographic Surgery. It included a Handbook For Patients that is the size of a small paperback novel.

From what I can make out, it goes something like this:

You arrive at the office, have coffee and donuts, then they take you into an examination room and give you an injection to freeze the site. Then you go back into the waiting room and take your place at the end of the line.

When it is your turn, you go back into the examination room where they will "remove the cancerous tissue in thin, horizontal layers." "Each layer is divided into sections, and each section is carefully identified and "mapped" by the surgeon so it's exact location can be pinpointed on the wound". It goes on:

"After careful preparation in the laboratory, each tissue section is inspected under the microscope. As long as cancer cells are seen within a section, the surgeon continues to remove and examine tissue layers from that part of the wound. Because each layer is examined microscopically, the Mohs surgeon can be highly confident that all of the cancer has been eradicated and no malignant cells are left behind."

Jesus Christ! Does that sound like "a little procedure"?

Here are my main concerns:

Infection. Even though the dermatologist is aware of my HIV status, the Handbook For Patients tells me that a "small percentage of patients develop infections".

My other concern is pain. I had a bad experience with an oral surgeon several years ago, who knew that I had acquired HIV from a shared needle. He broke the bone that makes up the floor of the sinus cavity while pulling one of my upper, back teeth and it left a gaping hole going right into my sinus cavity. The next day I was eating some porridge, and it started coming out my nose. My nose was making fart sounds and was dripping oatmeal.

Anyway, he assumed I was a drug addict, or a recovering drug addict or some damned thing; and he wouldn't write me a prescription for painkillers. He told me to use acetaminophen. (Tylenol); not Tylenol with Codeine; just plain old over-the-counter Tylenol. I ended up having to go to a hospital emergency room after three days of absolutely unbelievable in-your-face pain. It took an entire year to get over that broken bone; but the first six weeks were the worse by far.

The fact is, I have never been addicted to any drugs. And I only used needles a couple of times.

Anyway, the dermatologist had me sign a Release of Information form; so he could get a copy of my medical records from my Primary Physician; and I'm afraid he will see that I've used needles in the past, and won't give me pain medicine if it is needed.

The Handbook says that some Basal Cell carcinomas can be "rooted" and "branch out in many directions".

If they are going to be taking skin off in layers, I have to imagine pain; plain and simple.

Is anyone familiar with this procedure? I would welcome any information you might offer.

When I told my youngest son (22), who happens to be very much into good nutrition about all this, there was a sudden silence on the phone line; so I said, "What's the matter, Danny?"

He said, "I just think it's interesting that you are going in for cancer surgery, and they are going to give you donuts and pizza."

It got me thinking about this dermatologist, and the entire practice. If I thought I could get away with it, I would just leave it alone and go untreated.

Suggestions?

[skeebo1969]

  Suggestion:

  Don't mess around with skin cancer....  get it cut out for sure. 

[Inchlingblue]

I am not familiar with the procedure but your description of it sounds like it is very thorough, which is a good thing (see below).

There is absolutely no way you can "get away" with not treating skin cancer.

Try and not dwell on what happened with the oral surgeon. I recommend going into this with a good frame of mind, this is a good thing that you caught it and it's being removed, the news could be much worse.

One final reminder: September 9th is a Wednesday, not a Tuesday.

I looked up Mohs micrographic surgery and here's what it says:

Mohs micrographic surgery is the most effective and state-of-the-art procedure for skin cancer today, which offers the highest potential for recovery - even if the skin cancer has been previously treated by another method and recurred.

LINK:

http://www.mohscollege.org/about/

[sdguyloveslife]

This is just a "wild guess" so, I could be dead wrong here, but it sounds like there's a company or sales rep trying to sell or lease to your dermatologist this "Mohs" equipment. 

It's a rather "big deal" to transport all of this highly sophisticated medical equipment to his office and set it up, which is why it sounds like an "assembly line" set up on that particular day. 

Since they are now bringing in "another party" to your medical care, it would make sense that you have to sign new release forms, etc. 

The donuts and pizza are probably furnished by the sales rep of the "Mohs" equipment company and aren't being supplied by your doc. 

Not a bad deal, since you get a "state of the art" treatment to which you might not have had access to otherwise. 

[Puckslinger]

Thanks for the advice, Skeebo! I think I'm just going to do it.

Inch:

 I appreciate you taking the time to provide the excellent link. And thanks for the heads up about the 9th falling on Wednesday. I would have looked pretty silly showing up bright and early on Tuesday morning looking for donuts.

I think you and Skeebo are right about just doing it. I would like to postpone it indefinitely; but I know that is not the smart thing to do.

I'm hoping that when it comes to pain, they will be more compassionate than the oral surgeon was.

sdguyloveslife:

I share some of your cynicism; but I am going to show up on the 9th with a semi-positive attitude, and hope for the best. Bar the whole scenario appearing wonky when I show up, I'm going to let them proceed. Thanks for the reply. I think you are right about it not being a bad deal regarding 'state of the art' treatment. We will find out Wednesday.

I will let you all know how it turns out.

[edfu]

I had Mohs surgery done on the tip of my nose for basal-cell carcinoma.  It's state of the art, because they are able to check via microscope each layer that is removed.  Thus, they know if they have removed all of the cancer or not.  They will keep removing another layer until the microscopic investigation reveals completely non-cancerous tissue.  Bottom line:  They are certain to get ALL of it, and simultaneously they do not remove MORE than is essential.  You will have to wait a period of time after each layer is removed while they look at it under the microscope.  (I had to have three layers removed.)    

They numb the area quite thoroughly with a local anesthetic shot, like with Novocaine for dental work, and I didn't feel any pain, even afterward.  (Because mine was on the tip of my nose, I had to go immediately from the Mohs operating room--which was in a different location from my dermatologist's office--to a plastic surgeon's office.)    

I also experienced a large number of patients waiting for the same prodecure the morning I went.  I think they set it up like an assembly line.  I noticed three people sitting behind microscopes in addition to the dermatology surgeon.  Given the manner in which this is done, it does seem to make sense that they would schedule a number of people for the procedure at around the same time.   Basically, they are doing additional biopsies while you wait in the next room--extremely efficient and beneficial.  

There is no question:  It's absolutely essential you have this done ASAP.  My dermatologist scheduled me for it as soon as possible after the initial biopsy came back.  

[Puckslinger]

Thanks for sharing the details of you personal experience with the Mohs surgical procedure, Edfu.

I'm feeling much more confident and at ease after reading your post. It's one of those things that I wouldn't have even mentioned to a physician; and I have to give credit to that hawk-eyed Nurse Practitioner for spotting it. As I stated in my initial post, it  looked like a little pimple or something to me. But it had bled and healed a couple times, after getting roughed up by my bike helmet.

I consider myself lucky to have an opportunity to have it treated before it goes from bad to worse.

Thanks again.

[edfu]

My basal cell also presented itself like a pimple, except it was very awkwardly on the very tip of my nose.  I had attempted for months to dry it up with alcohol, Noxzema, etc., to no avail before I showed it to my dermatologist, who immediately thought it was basal cell and did a biopsy.  I spent over forty summers at the beach, and now I have to have a complete skin exam every six months, because I have so many potential problem areas.  My dermatologist wanted me to get a complete detailed photographic record of my entire body so he could more easily detect any worrisome changes, but insurance stupidly won't cover it, and I can't afford the $1,000. 

In fact, I just had another biopsy done last Monday, behind my ear, and luckily it has turned out OK.   

Good luck with your procedure. 

[Stone]

Your risk of infection is actually quite low because of the location.  Your scalp and face are really vascular (which is why you bleed like crazy even with small cuts) so there is a good supply of all of the cells needed to prevent infection and heal wounds.  As far as the company rep bringing pizza and donuts to help sell the equipment, this is also highly unlikely.  Due to all of the abuse that occured when HMO's first came into play this practice is no longer allowed by any drug reps or medical equipment reps because it falls under conflict of interest.  Most facilities even ban reps from bringing office supplies (pens etc) with company names now.  As for pain control, they will have your records and there are certain activities that show up as a red flag.  Having a history as an IV drug user is not one of them and that oral surgeon was an idiot.  Mainly what sets the alarms off are multiple ER visits for soft complaints like headaches, back pain, or abdominal pain without having any type of diagnosed condition or follow through.  Other things that are looked for are multiple phone calls looking for pain medication refills (yes all of your phone calls are logged in your chart), seeing multiple doctors, going to multiple hospitals, or having multiple occaisions of excessive pain complaints (ie every time you have pain it is a 10 on the 0 -10 pain scale with 10 being the worst pain you have ever had) for no identified reason.  Pain is a JCAHO regulation that is being looked at and facilities / doctors are being fined for not properly treating pain so I expect yur experience will be much different now.  Hope this helps ease some of your anxiety

[Puckslinger]

Hello Everybody,

I'm feeling very frustrated and embarrassed after a fruitless visit to my dermatologist this morning.

Some of you know, I was scheduled to have Mohs Micrographic Surgery this morning; to remove a small tumor on my forehead.

Surgery has been rescheduled for the 24th of September. My bad!

I failed to read the following in the patient handbook; under 'How Should I Prepare for Surgery:

" "Blood thinners" such as Coumadin, Ticlid, Plavix and Persatine should be discontinued several days before surgery as directed by the physician that prescribed them. Avoid aspirin and medications that contain aspirin (Anacin, Bufferin, Excederne, Alka-Seltzer, ect.) for at least ten days prior to and 1 week following surgery. Also avoid anti-inflamatory medications (Advil, Aleve, ibuprofen, Nuprin, indometacin, Naprocin, ect.) for the same time period. These medications tend to increase and prolong bleeding during surgery and may interfere with wound healing."

I take a couple aspirin every day for cardio-vascular reasons. And I should have read every word in the Handbook For Patients the dermatologist's office provided.

I will give an update after I undergo the procedure on 24 September.


Stone:

Thanks for your input. You provided some useful information.  About the donuts and pizza: They are provided by the dermatologist's office; not any sales reps. Sdguyloveslife was speculating about that; but there is really nothing sinister or untoward about it.

Thanks, again, to everyone who has taken an interest. I'll keep you updated.

[Stone]

It really wasn't your fault so please don't be embarassed about what happened.  When they scheduled your appointment (and I assume called to confirm?) this information should have been reviewed orally with you as it is very important.  Written information should only be used for back up patient education not as a substitute for face to face teaching as often patients don't even look at it.  Your doctors office messed up, you didn't

[Puckslinger]

Thanks for the support, Stone.

They mailed me the Handbook For Patients awhile ago and they left a message on my machine reminding me about my appointment; and telling me to notify them 24 hours in advance if I would not be able to keep my appointment.

When I got to the office, this morning, they asked me if anything has changed with my medical insurance; and they asked: "Has anything changed with your medicines since your last appointment?"

"No."

"Have you been taking any blood thinners, aspirin, or products containing aspirin during the last ten days?"

I said "I take aspirin every day."

The receptionist, who was doing the questioning, then produced a copy of the Handbook For Patients, opened to the section I quoted from in my last post, pointed to it, and said, "We will have to reschedule."

I felt like a complete idiot for not having read that information before.

But, as I stated in my initial post: The Handbook For Patients is as thick as a small novel; and I doubt that every person who is scheduled for the procedure reads everything it covers.

At least I was spared any unnecessary bleeding or other complications.

The only real downside is: I now have two more weeks to obsess about how 'rooted' the tumor may be, and whether or not they are going to adequately relieve any pain I might experience.

Anyway, thanks again for the interest and support.