A nod to you Trekkies out there! When I say beam me up, I’m referencing the use of radiation for the treatment of skin cancer. What you might not realize is this is not a novel concept. Dermatology has had a long love affair with radiation dating back to the late 19th century. Not only was radiation used to treat cutaneous malignancies but also acne, hirsutism and fungal infections. Can you even imagine? But if you think about it, choosing radiation makes sense. Back then, our understanding of the pathophysiology of acne and infections was limited and so were effective treatment options. Radiation was a new technology and as a hot, novel treatment, it made sense to try it on various skin conditions. Sound familiar? We do that now all the time with new medications…Ah hem…have you ever gone off-label?
So here is a little history…In 1895, Wilhelm Roentgen discovered X-rays and the first successful treatment of a rodent ulcer (basal cell carcinoma) was reported by Thor Stenbeck and Tage Sjogen in 1899. In the 1960’s and early 1970’s, skin cancer radiotherapy was practiced widely by dermatologists and many had X-ray machines in their offices. By 1975, over half of dermatology practices in North America either had superficial radiation therapy or Grey Renz Devices available for use, and around 44% of dermatologists reported regularly using them in their offices. Back then, future dermatologists received training in radiation like we would get with phototherapy today. As our understanding of dermatologic disease improved and pharmaceutical options grew, radiation gradually fell out of favor as a primary treatment. As for skin cancers, surgical removal, especially Mohs Micrographic Surgery, became the gold standard for care. By the 1980s, radiation in dermatology started to decline and virtually disappeared over the next 20 years.
But now it’s making a comeback as a primary treatment for nonmelanoma skin cancer. Dermatologists often recommend radiation as adjuvant therapy, palliative therapy or primary therapy. Adjuvant radiation therapy is when radiation is added on as treatment after a primary treatment, such as surgery has been completed. Adjuvant radiation therapy might be considered in a high-risk cutaneous SCC that was successfully treated with Mohs surgery but showed perineural invasion. Palliative radiation is often done to alleviate symptoms like pain or to scar down a friable tumor and is not designed to achieve a cure. Primary treatment with radiation can include different radiation types but superficial radiation therapy (SRT) has taken center stage.
Superficial radiation therapy (SRT) has come a long way since it first hit the medical scene over a 100 years ago. SRT delivers low energy X-rays to the skin to treat nonmelanoma skin cancer like basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Unlike deeper forms of radiation, SRT penetrates only a few millimeters into the skin, limiting damage to underlying healthy tissues. In addition to SRT, there is also Image-Guided Superficial Radiotherapy (IG-SRT), which enhances standard SRT by adding real-time imaging, often with ultrasound. The imaging technology allows for more accurate identification of the treatment area and for the monitoring of the tumor throughout treatment.
Some of the advantages of SRT include fast treatments, little restrictions or down time and excellent cosmesis. The cons of SRT include multiple treatments, side effects like alopecia, redness and burning at the treatment site. While both SRT and Mohs micrographic surgery report high cure rates, the rates reported for SRT are on superficial NMSC while Mohs also includes invasive and other aggressive tumor types. Opponents of SRT also cite that more robust, prospective studies are needed to compare SRT and Mohs for similar tumor types before drawing direct comparisons on outcomes. SRT has also received criticism for high reimbursement rates and concern that utilization is motivated by financial gain over appropriate care. As for guidelines, the National Cancer Center Network (NCCN) recommends surgery as first line treatment for skin cancer, but states radiation therapy can be considered for nonsurgical candidates. Overall, deciding between SRT and Mohs should be a share-decision making process that includes consideration for your type of skin cancer, ability to tolerate surgery, patient co-morbidities and patient preferences.
Trotter’s Take: Radiation has long been a part of the dermatologists’ repertoire for treatment and can be considered for those who are not good surgical candidates or prefer a nonsurgical treatment option.
Want to boldly go where some have gone before? Then check out Dr. Mark Nestor as he talks about the role of SRT in treating nonmelanoma skin cancer.
