As a profession, doctors are determined and cautious. We are determined to do our best and provide the best care for our patients. But we can be quite cautious about trying out new treatments or technologies to help provide that “best care.”
Some hesitation makes sense. Countless treatments that sounded promising at the time fell by the wayside because they didn’t measure up — or caused harm. One example: Fifty years ago, dermatologists often used radiation to treat acne. It seemed to work, but researchers later learned that it increased the risk for thyroid, skin, and other cancers.
Yet I worry that doctors too often play it safe, which can discourage the development of new treatments that would help our patients. Our desire to “do no harm” plus factors from insurance forms to extreme cost consciousness can make us resist innovation.
My field of dermatology offers an example. When it comes to diagnosing and treating skin cancer, surgery is the well-entrenched standard of care. But this one-weapon arsenal often leaves patients with physical scars that are visible to all — and psychic scars only they know about.
There are other options. For the past 10 years, I have carefully introduced noninvasive diagnostic and treatment techniques to help my patients. This journey began with a woman whose Irish skin and years of sun exposure had set her up for multiple skin cancers. I saw her after she had already undergone several biopsies and cancer-removal surgeries. She was desperate to avoid further procedures and their subsequent disfiguring scars.
Knowing I needed to come up with a better approach for her, I began examining her skin with a dermoscope. This hand-held device, which was widely used in Europe at the time, can tell benign lesions from cancerous ones. Not taking biopsies of suspicious areas was a risk we were both willing to take, given that my patient’s many basal cell carcinomas tend to grow slowly.
We also explored the use of a noninvasive treatment using a chemotherapy cream that she applied directly to each skin cancer. Five years later, she remains cancer-free without biopsies or surgery.
Since then, I have gradually expanded my diagnostic and therapeutic repertoire. I now use two devices, optical coherence tomography and reflectance confocal microscopy, to more accurately diagnose skin cancer without surgery. These devices let me look deep into the skin without needing to slice into it. For treatment, I have added lasers and pills such as the so-called Hedgehog pathway inhibitors to chemotherapy creams.
Another patient of mine, a woman in her 60s, had a basal cell cancer removed from her nose more than 20 years ago. She still feels disfigured and psychologically traumatized by the original surgery and the several reconstructive surgeries she has since had done on her nose. Understandably, she will do anything to avoid surgery. I see her regularly and use optical coherence tomography to detect her cancers so early that we can treat them quickly, with no visible scars.
One of my most memorable patients had been a physician in Vienna. When he was growing up in the 1930s, he and other youths were given radiation treatments to their faces. At the time, the medical profession thought that was a good way to help them make more vitamin D. While the treatment may have accomplished that mission, decades later it created multiple skin cancers on his face. He wanted them all removed, so he underwent surgery to remove them. During his follow-up care, I was able to detect an early recurrence of skin cancer without having him undergo another operation.
My early successes with noninvasive ways to detect and treat skin cancer gave me confidence to push the boundary of care while always weighing the benefits and risks for each patient.
I’m not the only dermatologist following this course. Optical coherence tomography and reflectance confocal microscopy have been used in Europe for years to detect skin cancer, and a small but growing number of doctors in the US are using these tools as well. In fact, the Centers for Medicare and Medicaid Services recently approved reflectance confocal microscopy for reimbursement as an alternative to a biopsy for skin cancer, meaning that Medicare and insurance companies will pay doctors when they use it for that purpose.
Experimenting with diagnostic and treatment strategies isn’t for the faint of heart. It begins with a need that can’t be met by clinical care and a careful evaluation of the benefits and risks. Successes, even small ones, can inform the next iterations, gradually providing the evidence to apply the innovation to larger and broader groups of patients.
Like my colleagues, I’m determined and cautious. But I believe that being a thoughtful, evidence-based innovator is another quality that benefits my patients and the wider dermatology community.
Orit Markowitz, MD, is the director of Pigmented Lesions and Skin Cancer at Mount Sinai Medical Center in New York City, chief of dermatology at Queens General Hospital in Jamaica, N.Y., and assistant professor of dermatology at the Icahn School of Medicine at Mount Sinai. Markowitz has received payments from Leo Pharmacueticals, which develops and markets drugs for skin conditions.
This article was edited to update the author’s disclosures.