An Alternative to Mohs Surgery for Basal Cell Carcinoma

Last summer I started to notice a spot on my nose. It looked a bit like a pimple but it didn’t go away. After a few weeks I went to a dermatologist and had a biopsy. Bad news: basal cell carcinoma, not the worst kind of skin cancer but not to be ignored. Doctors call BSC “the rat cancer” because it burrows under the skin, out of sight; there is no way to tell how much (or even where) it has spread.

The dermatologist told me that I should have Mohs surgery to remove the cancer. The procedure is for the surgeon to shave off skin a layer at a time, testing each layer as she goes, until a cancer-free layer is reached. There is no way to know ahead of time whether the surgeon will remove one layer or seven. In an area as delicate and contoured as the nose, a seven- layer procedure would leave a large wound that would take weeks or months to heal completely and might require plastic surgery. For me, that would mean canceling the annual scuba diving trip and possibly ending up with a permanent, unsightly mess at the end of my nose. Surely, I thought, there must be a better way.

And there is. It’s called superficial radiation therapy and it has become available within the last ten years. It is distinct from an earlier form of radiation therapy that was commonly used before the introduction of Mohs surgery, which became the standard treatment for BSC in the 1970s. SRT is not available everywhere and has advantages and disadvantages compared with Mohs. The experience of having an SRT treatment is similar to having a dental x-ray and takes about as long.

-  SRT is non-invasive, painless, and non-scarring. Like any surgery, Mohs causes bleeding, pain, and an unpredictable amount of scarring.

-  SRT requires 12-15 very short visits for treatment. Mohs surgery requires 2 visits, one of which may last all day. If there are unforeseen complications, further visits may be needed and, possibly, treatment by a plastic surgeon.

-  The cost of both types of treatment is about the same and both are covered by insurance.

-  The cure rate of Mohs is slightly higher, but both are above 90%.

-  SRT may increase the likelihood of getting cancer again, decades in the future. (If I’m around then, I expect that there will be much better forms of treatment available.)

For me, the good news was that SRT is available in Indiana. The bad news is that the best qualified facility is in Muncie, more than 2 hours from my house (more like 2.5, with road construction at both ends). But I did it anyway – 14 round trips between late September and early November of last year. The facility had an oncologist to determine the dosage but the actual treatments were done by a technician. At the time of the last few sessions I had some mild bleeding from my nose but that was the only discomfort. I’m so glad I did this!

 

More Reasons for the Eroding Trust between Patients and Physicians

I’ve just been reading an article by James F. Sweeney, “The Eroding Trust Between Patients and Physicians”, that appeared in the 4/10/2018 issue of Medical Economics. First, I appreciate the fact that Mr. (Dr.?) Sweeney is addressing this issue, which is a serious detriment to effective medical care. Lack of time and of any substantial relationship with the patient are the causes emphasized by Sweeney, but there are a number of others that deserve attention.

Standard of Care imposes constraints that encourage doctors to play it safe and avoid creative thinking. Especially in the field of oncology, the threat of liability intimidates many doctors and may cause them to see each new patient as a potential lawsuit. The treatments endorsed by Standard of Care sometimes reflect out-of-date science rather than the latest and best thinking in the field.

Reliance on randomized controlled trials (in addition to lack of time) means that patients tend to be treated by category. RCTs are useful as an overall indicator, but they don’t tell the physician anything at all about a particular patient.

Medical offices frequently don’t have accurate, long-term medical records for patients. With the advent of electronic records, decades of precious data on individual patients were discarded and lost. Unless the patient herself has kept hard copies, the doctor must make recommendations based on a couple of years of test results. Adding to this problem is the lack of compatibility among EMR systems.

The connection between medical practice and science is becoming more tenuous. Protocols for some tests are not followed correctly. (My favorite example is the taking of blood pressure, when medical offices don’t have you sit quietly for a few minutes beforehand, the correct protocol. Then they tell you that you have high blood pressure.) We hear confident statements that calcium supplements promote heart disease, when the evidence for this is shaky at best. Medical practice tends to cherry pick scientific studies and highlight those that support what it is already doing.

In spite of substantial scientific evidence supporting the role of diet and exercise to good health, many medical practitioners discount their importance. Ads for medical practices and hospitals featuring photos of overweight doctors and nurses are clear evidence of this attitude.

Current medical practice tends to reject, even scorn, any therapy that isn’t part of the conventional canon. After developing painful scar tissue in my shoulder and arms, I was successfully treated by a chiropractor with myofascial therapy (MRT) and active release technique (ART). Conventional medicine’s recommendation? Pain meds or surgery.

These are all features of medical practice today that are causing physicians to lose credibility in the eyes of their patients.

Foot Surgery the Easy Way

I was born with curly little toes on both feet. That never bothered me until the past year, when the left one decided to curl out a bit more and started rubbing against the insides of formerly comfortable shoes and boots. For a while, I babied it along with band aids and pads but finally it was time for a visit to my wonderful podiatrist Dr. Hoffman (introduced in Respect the Feet).

“What have you done this time?” he asked. I explained that I thought I was getting a bunion. Instead, he identified it as a type of hammer toe, a condition that is often treated by breaking the toe and inserting a wire; big incision, lots of pain, weeks of recovery time. Instead, Dr. H proposed a minimally invasive 10 minute procedure in which a tiny incision is made, the tendon is nicked, and the patient goes back to normal life immediately.

So I did that. The worst part of it was the shots to numb the foot. After that, I really felt no pain at all, either during the procedure or later. Dr. H offered an antibiotic and suggested an over the counter pain med, but I said “No, thanks” to both of those. The only real hassle was keeping the dressing dry for a few days, which meant showering with a towel and a plastic bag around my foot. Now I’m back to wearing my regular shoes and boots. Dr. Hoffman scores again!

Got IBS D? This Probiotic Yeast Could Be Your NBF.

In 2014 my doctor at the time ordered tests in an attempt to find the cause of my longtime gut problems (discussed in Trouble Down Below). The tests came back negative except for the observation that a few Blastocystis hominis (BH) organisms were seen. At some point later on, I mentioned this to a GI specialist and he said, “Oh, that’s nothing!”

In general, this seems to be true. In 2000, approximately 23% of the US population was infected with this protozoan, most with no symptoms at all. (In less developed countries, the percentage is much higher.) BH tends to run with IBS and with colorectal cancer but the relationship is not clear. For a few unlucky people, it can cause major digestive upsets lasting weeks or months.

During a trip last month I started to have diarrhea, acid reflux, and intermittent queasiness. Since I do sometimes have digestive upsets when I travel, I didn’t think much about it. When I got home, the other symptoms went away; the diarrhea got worse­­—many, many trips to the bathroom, often in the middle of the night. Before calling my nurse practitioner to see about ordering tests, I did some online research to see what treatments were likely to be. One word: antibiotics.

I’m not totally against these medications; if I have a life-threatening bacterial infection, an antibiotic is certainly what I want to be taking. In my present situation, though, I had reservations. Antibiotics don’t always work for bowel problems. They can also do long-term damage to the immune system by killing off good bacteria in the gut and they may have unpleasant side effects, like diarrhea and yeast infections.

I started looking around for other options and came upon a yeast called Saccharomyces boulardii (SB). This probiotic is a veritable Swiss Army knife of beneficial functions and has been studied for decades. It has repeatedly been shown to work well against diarrhea, sometimes as well as or better than antibiotics. SB is believed to be a strain of baker’s yeast (S. cerevisiae) and is completely safe and without side effects, except for people who are allergic to yeasts. SB can be combined with antibiotic treatment to help support bowel function; since it’s not a bacterium, antibiotics won’t kill it. SB has been shown in some studies to be effective against Candida albicans, ironic because they are both yeasts. There are also researchers who are looking at various uses of SB for cancer patients.

I started taking SB 250 mg. three times a day. The tests came back showing—you guessed it—Blatocysitis hominis! After a few days with not much change, I went online again and discovered a French study from 1996 about diarrhea in 30 people with AIDS (under Clinical Studies in PWAs). The subjects took 3000 mg of SB per day, six times the normal daily dose. After two days, they saw significant improvement, at eight days their bowel function was normal.

I started taking 3000 mg per day of SB and also saw significant improvement after two days. For me, it took about three weeks to get back to normal. I plan to continue at the same dose for another couple of weeks, then gradually reduce it. Given the possibility of an allergic reaction, I think it was just as well that I tried the lower dose first.

SB is sold under the brand name Florastor, $20 for 20 250 mg capsules, cheaper on Amazon and Ebay. CVS has a generic version that is sometimes on sale. Swanson, the online supplement store, sells its own version, $5.99 for a bottle of 30. Are they as good as the brand name, or better? I don’t know but I plan to experiment later on. Given my gut situation, I expect to be taking SB indefinitely, and happily too!