The skin, the body's largest organ, plays a crucial role in protecting us from the environment. However, prolonged exposure to the sun's harmful rays can lead to abnormal growths of skin cells, often resulting in skin cancer.
Skin cancer comes in various forms, with the most common types being basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Melanoma, though less common, is the deadliest form of skin cancer, often developing in a pre-existing mole or appearing as a new, dark spot on the skin.
When it comes to treating skin cancer, two primary options are often considered: Mohs surgery and Superficial Radiation Therapy (SRT). While SRT has gained attention due to aggressive promotion by pharmaceutical companies selling SRT devices to dermatology practices and does not require a doctor to use the device, it is essential to understand why Mohs surgery remains the gold standard in skin cancer treatment. Mohs surgery, which the American Academy of Dermatology supports, is performed by a fellowship-trained Mohs surgeon and board-certified dermatologist.
The Benefits of Mohs Surgery
Mohs surgery is a highly effective treatment for skin cancer, offering several significant advantages over other methods. This precise surgical technique maximizes cure rates, preserves healthy tissue, and promotes faster healing. Here’s a closer look at the key benefits of Mohs surgery.
1. Higher Cure Rates and Lower Recurrence Risk
Mohs surgery is a precise surgical technique that involves removing the skin cancer layer by layer, with each layer being examined under a microscope until no cancerous cells remain. This meticulous process ensures that all cancerous tissue is removed while preserving as much healthy tissue as possible. Mohs surgery boasts an impressive cure rate, reducing the chance of skin cancer recurrence to just 2.5%. In contrast, SRT carries a much higher recurrence rate, with a 15.8% chance of the cancer returning after treatment.
2. Fewer Treatment Sessions
Mohs surgery typically requires only one or two visits to achieve complete cancer removal, making it a time-efficient option for patients. On the other hand, SRT necessitates multiple treatment sessions, often ranging from 5 to 30 visits, which can be both time-consuming and inconvenient for patients.
3. Pathological Confirmation of Cancer Removal
One of the most significant advantages of Mohs surgery is the immediate pathological confirmation that all cancerous cells have been removed. This is not the case with SRT, where there is no pathological confirmation of margin status to ensure the entire cancerous area has been eliminated. This lack of confirmation can lead to incomplete treatment and an increased risk of recurrence.
The Drawbacks of Superficial Radiation Therapy (SRT)
While superficial radiation therapy (SRT) can be a non-invasive option for treating certain skin cancers, it is not without limitations. Patients and physicians should carefully consider its potential downsides before selecting it as a treatment. Below are five crucial drawbacks to consider when evaluating superficial radiation therapy.
1. Higher Costs and Lack of Rigorous Studies
SRT, while non-invasive, comes with higher costs compared to Mohs surgery. Despite its promotion, there is limited published literature on the long-term side effects of SRT. Furthermore, emerging data suggests that SRT may increase the risk of developing secondary skin cancers, a serious concern that undermines its safety profile.
2. Limited Expertise Required
Unlike Mohs surgery, which is performed by fellowship-trained and board-certified dermatologists, SRT does not require a specialist to administer the treatment. The absence of rigorous training and expertise can lead to suboptimal outcomes and raises questions about the overall safety and efficacy of SRT.
3. Not a First-Line Treatment
According to national expert consensus entities, SRT should only be considered a second-line treatment option under special circumstances, such as for patients who are non-surgical candidates. Mohs surgery, on the other hand, is widely recognized as the first-line treatment for many types of skin cancer due to its superior outcomes and safety profile.
4. Lack of Rigorous FDA Approval
SRT devices do not undergo the same rigorous efficacy and safety studies required for specific skin indications through the FDA’s premarket approval pathway. This lack of stringent oversight further calls into question the reliability of SRT as a primary treatment option for skin cancer.
5. Lack of American Academy of Dermatology Approval
As of 2024, the American Academy of Dermatology (AAD) pushed guidelines stating surgical treatment — excision, Mohs surgery, or curettage and electrodesiccation — is the most effective option for most cases of NMSC. In some cases, however, doctors may consider other treatments, such as cryotherapy, radiation or topical therapy. The guidelines do not include recommendations for treating NMSC with laser therapy or electronic brachytherapy, as there was not enough evidence available for the workgroup to make an informed decision.
Board-certified dermatologists have the training, knowledge and experience to provide NMSC patients with the highest-quality care,” says board-certified dermatologist Murad Alam, MD, FAAD, co-chair of the guidelines work group for the AAD. “If you are diagnosed with BCC or SCC, a board-certified dermatologist can work with you to determine the treatment option that’s best for you.”
Why Choose Mohs Surgery Over SRT
While Superficial Radiation Therapy may appear to be a convenient, non-invasive option for treating skin cancer, it falls short in several critical areas compared to Mohs surgery. With its higher cure rates, fewer treatment sessions, and immediate pathological confirmation of cancer removal, Mohs surgery remains the superior choice for patients seeking effective and reliable treatment for skin cancer. Given the higher costs, increased risk of recurrence, and potential for secondary cancers associated with SRT, it is clear that Mohs surgery should be the preferred option for most patients, reserving SRT for cases where surgery is not feasible.
Written by - Daniel Shurman, MD, FAAD, Mohs Surgeon 
