September 9, 2025 • 27 mins
Skin cancer treatment has come a long way, yet many patients don’t know their options beyond surgery. Dr. Mark Nestor explains how image-guided superficial radiation therapy (IG-SRT) achieves up to 99% cure rates for basal and squamous cell carcinomas.
Using ultrasound to measure and target cancer precisely, IG-SRT offers a non-invasive alternative with excellent cosmetic results—especially for areas like the nose, scalp, or legs. Treatment takes about 15 short sessions with minimal side effects. While not used for melanoma, it’s a highly effective option many patients never hear about.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
but also the breadth of skin cancer and see if it's
being properly treated duringradiation.
Speaker 2 (00:07):
I wanted you to talk a little about.
What does that really mean andhow does it work to treat skin
cancer?
Speaker 1 (00:12):
And a lot of patients come in to me and say you know,
I've had so many skin cancers,I've had 50 Mohs surgeries, I've
had excisions, etc.
An issue where we want to treatthe skin cancer cells and do as
minimal damage to normal cellsas possible.
Speaker 3 (00:28):
Welcome to Dermot Trotter Don't Swear About Skin
Care where host Dr Shannon CTrotter, a board-certified
dermatologist, sits down withfellow dermatologists and
skincare experts to separatefact from fiction and simplify
skincare.
Let's get started.
Speaker 2 (00:45):
Welcome to the Dermot Trotter Don't Swear About
Skincare podcast.
So today we've got an excitingshow here for you.
Today We've got Dr Mark Nestor,who's going to talk with us
more about image-guidedsuperficial radiation therapy.
But first let's talk a littlebit about Dr Nestor.
He's a board-certifieddermatologist quite accomplished
.
He serves as director for theCenter of Clinical and Cosmetic
(01:10):
Research and the Center forCosmetic Enhancement in Aventura
, florida.
He's a voluntary professor inthe Department of Dermatology,
cutaneous Surgery and theDepartment of Surgery Division
of Plastic Surgery at theUniversity of Miami Miller
School of Medicine and we'rereally fortunate to have him a
part of the conversation todaybecause he's done the work, he's
done the research, he's usedthese types of devices in
radiation therapy before.
So I want to welcome you to thepodcast.
(01:32):
It's great to have you here.
Speaker 1 (01:34):
Thanks, shana, it's really a pleasure to be here.
Speaker 2 (01:37):
I think this is a topic you know we wanted to
tackle.
You know you and I werechatting about this that it's
sort of interesting.
In medicine we have a lot moredirect-to-consumer advertising.
People are seeingadvertisements for medicines and
treatments on TV, the radiostation, and I think that's
where a lot of people have heardof radiation therapy in this
different way for using it totreat skin cancer.
(01:58):
So there's this IG-SRT, orimage-guided SRT, or superficial
radiation therapy that I wantedyou to talk a little about.
What does that really mean andhow does it work to treat skin
cancer?
Srt, or image-guided SRT, orsuperficial radiation therapy, I
wanted you to talk a littleabout.
What does that really mean andhow does it work to treat skin
cancer?
Speaker 1 (02:09):
Great questions.
So there are a variety ofdifferent types of radiation
therapy.
I think that's very importantfor people to realize, because I
have patients come in all thetime and said you know, I am
heard about this, but I had animage or I've heard radiation
therapy for breast cancer or forprostate cancer and it was a
(02:30):
terrible experience.
I had all these problems, etcetera, and so it's important to
understand that this is adifferent form of radiation
therapy.
And what's so interesting isthat this was the original form
of radiation therapy over 100years ago and radiation therapy
was actually invented bydermatologists.
The first cancer to be treatedby radiation therapy was a skin
(02:54):
cancer, was a basal cellcarcinoma.
So it's been around for a longtime.
Probably in the 70s, 50 yearsago now, more than half of
dermatologists had superficialradiation therapy in their
offices, and what happened wasover the next 20 years or so,
there was no equipment.
You couldn't get equipmentanymore, there was no technology
(03:16):
and where I learned?
I learned as a resident at NYUin the late 80s, early 90s, and
literally the equipment wasstitched together with duct tape
and kicks every once in a while, and so you know it really was
only in the last 10 to 15 yearsthat new technology has really
(03:37):
invigorated this, and so I wantto just look at the difference
between superficial radiationtherapy forgetting a second
frame it's guided and theprimary use by radiation
oncologists, which is electronbeam, because those are two
different forms of radiationtherapy.
When it comes to skin cancer,all the studies show that
(03:59):
superficial radiation therapy ismuch more effective at treating
skin cancers than electron Band it's much more gentle,
meaning you get a bettercosmetic effect.
So these are the two importantdifferentiators between what the
radiation oncologist used totreat skin cancer and other
types of cancer and what thedermatologist used in their
(04:21):
office.
So there's a lot of data, a lotof studies that have been on
this new form of equipment forradiation therapy and it's been
shown to be incredibly effectivefor treating basal cell
carcinomas, squamous cellcarcinomas, et cetera.
And you know, not for alldifferent skin cancers, but
certainly for the vast majorityof basal and squamous cell
(04:44):
carcinoma, squamous cell in situthe effectiveness, you know, is
really equivalent to surgeryand even Mohs in a lot of cases
of the high 90% five-year curate.
And that's the way we talk aboutany cancer.
The way we talk about anycancer is what is the five-year
curate, meaning it's not goingto return, most likely at that
(05:06):
point.
Now what happened was that anumber of a few years ago the
idea came can we make this anybetter?
And the question was in orderto make it better, how do we
pinpoint exactly how deep we go,how wide we go to really take
(05:26):
that 90-something percent, 95,98% curate and try to notch it
up as close as we can to 100%.
Nothing is ever 100%, as weknow that in medicine, or
anything but as close aspossible is what we want to do.
And so what was shown is that ifyou can pinpoint the depth
(05:47):
especially, but also the breadthof skin cancer and see if it's
being properly treated duringradiation, you can actually jack
up those numbers.
And the numbers forimage-guided now are in the 99
plus percent treatment for this.
So the idea here is we useultrasound and the ultrasound
(06:11):
can measure the depth of skincancer and see, essentially, the
volume, so we can morespecifically target exactly what
we want to do.
And that's what Image want todo and that's what image-guided
is.
Image-guided means that we canvisualize the skin cancer and
visualize what we want to treat,where we want to treat it, and
(06:34):
pinpoint the exact essentiallyKV or the energy that we want to
use to treat that skin cancer.
Speaker 2 (06:43):
So with those changes over time, because I think a
lot of people might like oh yeah, I've kind of heard of SRT, or
maybe for some of the healthcare providers listening, they
know of SRT with image guidedkind of added.
Now Are the devices essentiallyall the ones that are out there
now image guided or there'sstill some functioning kind of
in the old fashioned way withoutthat advantage?
Speaker 1 (07:03):
So the answer is image guided.
Is a little separate littledevice on their ultrasound.
And as you know dermatologists,a lot of dermatologists in our
office have ultrasound.
We use ultrasound for fillers,for other things, to measure
things, to measure fat depthsetc.
So it doesn't have to be partof the machine and, as I said,
even without the ultrasound and,as I said, even without the
(07:26):
ultrasound, the cure rates forradiation, superficial radiation
therapy, are in the 98 to 99%anyway.
So this jacks it up a bit.
It certainly does, and it makesboth a physician and patient
(07:53):
feel better because they canactually say I visualized the
tumor.
And one of the tenants ofradiation oncology, which is
really what we're talking abouthere, is that you want to be
able to specifically visualizeand use that information to at
best possible target the skincancer and leave the normal
tissue behind.
So it allows us to do thataspect.
It doesn't mean we have to doimage-guided at each treatment.
Some do and that's fine.
(08:14):
But the idea here is that wewant to be able to use every
tool that we have to be able tooptimize the treatment for
patients.
And you know, obviously thegold standard has been for skin
cancer has been surgery, youknow, and there are different
aspects, whether it's just asimple excision, whether it's
(08:34):
mows, whether it's destruction.
These are all surgical means toget rid of skin cancers.
The downside of surgery is thatyou have scars, and you have
not only do you have scars, incertain cases you don't have a
lot of tissue to close, like onthe scalp and other areas, and
so it becomes a little bit moredifficult to you know figure out
(08:56):
how and what is best for thepatient care.
And a lot of patients come into me and say you know, I've had
so many skin cancers, I've had50 Mohs surgeries, I've had
excisions, et cetera I reallydon't want to go through surgery
anymore.
How can we look at thingsdifferently?
And superficial radiationtherapy, image-guided or not, is
(09:19):
a great alternative, especiallyfor patients who are a little
older.
And again, I've treatedpatients young because they
really don't want to havesurgery from that aspect.
But the older patients are wesee this a lot number one,
number two patients with skincancers on areas that aren't the
easiest to do surgery.
(09:40):
So on the scalp, on the nose,on the lower extremities, those
are some of the primary areaswhere I use superficial
radiation therapy to a greatextent, and the reason is that,
again, those aren't optimal todo surgery.
The other thing that'swonderful about superficial
radiation therapy and again,imageguided will put into this
(10:03):
bucket certainly is that forlarger skin cancers, and I don't
mean necessarily larger interms of death, but larger in
terms of the size.
And very often we see, excuseme, superficial skin cancers
that are larger, especially inareas such as the scalp.
Well, we know as dermatologists, the scalp is something that's
(10:24):
very hard to heal from biggerexcisions because there's no
skin.
You can't push it together veryeasily.
And this is a really wonderfulway of treating that skin cancer
getting rid of it withouthaving to cut out the skin and
it leaves an area without anysun damage whatsoever.
So there are, you know, thesereasons I talked about the lower
(10:46):
extremities.
These reasons I talked aboutthe lower extremities Below the
knees is something historically,that surgery is very difficult
to do because very often youhave a lot of swelling on the
lower extremities number one.
Number two because of the waythe blood supply works there,
the legs don't heal as well.
We know that.
We know that clearly.
So the infection rate in thelower extremities is much higher
(11:07):
.
Know that clearly.
So the infection rate in thelower extremities is much higher
.
The rate where you getdehiscence or you get opening
and you get ulcerations is muchhigher when you do surgery, so
radiation therapy gives usanother tool to use in that area
as well, very, very effectively.
Speaker 2 (11:23):
So I think, when you talk about it being effective
and a great tool, I want to talka little bit.
You know, this elephant sort ofin the room, maybe in the
dermatology community, maybe inthe radiation oncology community
too, about people don'tpotentially support this In
particular.
You know physicians orhealthcare providers that feel
like this is not, you know, areasonable option.
(11:44):
So I think I mentioned to you,you know, one of the questions I
got from a patient is that youknow I went to a dermatologist
who said, hey, you know yournodular basal cell in the nose.
You know you shouldn't reallydo this.
The data is not there.
Guidelines say that it's notreally a good.
You know primary treatmentpotentially for you.
I want to get your take sort ofon this controversy and sort of
(12:05):
the debate, because it ishealthy for us to have debate,
obviously over treatments and ifthey're the right choice, but
sort of maybe where that started, where it's come from and then
kind of where we sit currently,you know, with guidelines or
what you feel like, maybe thedermatologic community, what
we're sort of thinking about itnow as a treatment option.
Speaker 1 (12:20):
It's a great, great point.
Number one I'm a scientist so Igo with studies and data.
Okay, this is what I do.
So if you look at the studies,okay, if you look at the data
from superficial radiationtherapy, especially in the last
10 years okay, because there'sliterally been, you know, I
(12:40):
would say, close to 100 studiesgoing back.
And if you look at the oldstudies, the old studies all
have about a 95% curated basalcell, almost around a 93% for
squamous cell that uses oldequipment and old treatment
guidelines, meaning you know youhave certain parameters that
you use for the old equipment.
It wasn't necessarily optimal,but I got news for you 93% and
(13:03):
95% is very comparable tosurgery, no question about it.
If you look at the new data,okay, which is over the last,
you know, 15, 10, 15 years,forgetting right now about
image-guided you know the datais, as I said, 98% to 99%
long-term curates.
(13:23):
That is not only at least asgood, but that is better than
surgery.
So a lot of the issue comes,number one, from not
understanding the data.
You know it's not.
People don't look at it.
Number two it's a whether it'spolitics, whether it's the issue
(13:45):
of I do surgery, that's all Ido.
I think it's better.
Therefore, et cetera.
This comes into play no matterwhat happens.
People have their own way oflooking at things.
I do both.
I do surgery.
I do, you know, radiation.
Many, many radiation people whodo superficial radiation
(14:07):
therapy are most surgeons, sothey do both.
So, again, I think it's aquestion of education from there
, but it's also a question ofeverybody, and the guidelines
now really say that superficialradiation therapy is in there
for the choice and everybodyshould be given the full
(14:29):
education and choice of what'savailable, and I think that's
really very, very important.
Patients need to be essentiallycounseled that, hey, you have a
skin cancer on your nose.
As you said, you have a pain inyour nose.
Here are the options we havesurgery, we have radiation, we
have other things, other thingssuch as topicals.
(14:51):
They may not work as well, butit's still an option.
From that perspective, I'mgoing to educate you.
You're the patient, you canmake the choice.
I'm your guy, basically.
So I think that you know, asnumber one, as people really
begin to understand this,understand the science,
(15:12):
understand the data, includingphysicians, they will be more
comfortable with it.
I think that the idea somehowthat it's not a reasonable
option makes no sense becausethe data is so sense, because
the data is so clear from thatperspective.
So, again, I think patientsneed to be armed with education,
(15:37):
and sometimes you get that fromyour physician.
Sometimes the patients have togo out on their own, and that's
what's happening now to go outon their own, and that's what's
happening now.
As you said, there is certainlya lot of information being put
out there about superficialradiation therapy is
specifically image guidedsuperficial radiation therapy.
(15:59):
So patients are learning aboutthis and you know that Dr Google
is very, very powerful or nownow Dr Pat GPT is even more
powerful about learning aboutwhat the options are.
And patients need to beempowered, you know, to learn
about what my options are andthen speak to the doctor and if
(16:23):
they have to get another opinion, and if they have to get
another opinion, I have very,very many patients coming to me
asking for other opinions, etcetera, to say my doctor said
this, tell me about this, etcetera.
And I'll give them theinformation and I'll always say
you have choices.
You have choices of surgery, ofdestruction of topicals and of
(16:43):
superficial radiation therapy,and I'll give them the pluses
and minuses.
Speaker 2 (16:52):
No, I think that's good because you want patients
to have sort of an honestpicture of that.
And I think the one thing Ialways remember when a patient
had a different treatment choice, they maybe came to see me and
I gave them multiple options andlike, hey, nobody ever gave me
those options before.
I thought this was just theonly thing I could do.
It is really important.
I think we owe it to patients togive them options and the risk,
benefits and pluses and minuses, of course, with all of that.
But they are in the driver'sseat and it's our job, like you
(17:15):
said, just to give them thatinformation and our opinion on
what we think might be the bestWith SRT.
You know, I think you know Ihad a patient come in asking,
you know they had a melanoma andthey're like, hey, can we just
get our SART on this?
Can I treat this withsuperficial radiation therapy?
So I think one of the things Iwanted you to kind of go over is
you know, when is it reallyappropriate?
I know we kind of talked abouta few instances, but high level
(17:36):
again, where you think the casesare most appropriate and in
cases where, like, probably notthe best treatment option as
well.
Speaker 1 (17:41):
Okay, yeah, I missed that last part.
You're a little bit fuzzy there.
But yes, certain things, Ishould say certain types of skin
cancers, are not forsuperficial radiation therapy,
image-guided or not.
Melanoma is not for SRT,Certain types of squamous cell
carcinomas and even certaintypes of basal cell carcinomas
(18:03):
where it's very, very aggressive, etc.
I don't necessarily recommendSRK, except in certain
circumstances.
I had patients coming in to seeme in their old, late 90s, let's
say, or early 90s, whatever itmight be, who are not in good
shape and who wouldn't toleratesurgery number one.
(18:23):
So we can use superficialradiation therapy to essentially
, you know, either palliate,either make these skin cancers
much more, I guess, timeeffective, and they're not going
to be bothered by it.
From that perspective They'llunfortunately pass away from
something else or do somethingalong the lines of using this in
(18:49):
a way that makes it better forthe patient.
But certainly, you know, Irefer patients to radiation
oncologists.
There's something calledperineural invasion for squamous
cell carcinoma.
I don't use SRT, I refer thoseout for electron beam, because
electron beam is more aggressive, it gets deeper.
(19:18):
There's a type of cancer calledDFSP and again I send those to
a radiation oncologist as well.
Merkel cell there are a numberof different types of skin
cancers that aren't ideal forSRT from that perspective.
A lot of patients come in witha small basis of carcinoma on
the chest, on the arm, et cetera.
I don't do SRT on thosepatients, I'll scrape it off,
I'll cut it out, et cetera.
So there are.
(19:40):
You know, part of our job is tosay this is not ideal for you
and that's okay.
Speaker 2 (19:50):
Because I do think that's important.
You know, I think some patientsthink, oh again, I should have
been given this option and maybeit just wasn't the right option
, you know, at the time for themto kind of pursue.
And just having that viewpointI think is helpful too.
So if somebody is going toundergo SRT in your office, how
do you explain to them what youexpect maybe for a number of
treatments or potential sideeffects, kind of that risk
(20:11):
benefit?
What's the conversation looklike when you talk with people?
Speaker 1 (20:14):
That's a great question.
So essentially, we cut theradiation up into bits.
That's the way radiationtherapy works.
There is an issue where we wantto treat the skin cancer cells
and do as minimal damage tonormal cells as possible and
(20:34):
that, you know, this curve iscritical to doing that.
And in order to do that, wechop it up in what's known as
fractions.
And in doing this, what we'redoing is we're giving enough
radiation to treat the cancercells because they're more
essentially fragile to radiation, and it allows the normal cells
(20:56):
to recuperate and remain fine,basically from that perspective.
So in my office I do essentiallyan average of about 15
treatments, generally two orthree times a week.
Okay, so you know, somewherebetween five and seven weeks.
Some image guided centers do 20treatments.
Fine, they they divided up alittle bit more from that
(21:18):
perspective.
But that's what we're talkingabout.
We're talking about and thatand that.
By the way, that is one of themain differences of what we know
now for optimization versuswhat was 20, 30, 40 years ago.
They used smaller numbers offractions and they didn't get
necessarily the optimal effectand they got more localized
(21:40):
destruction, so they didn't getsuch a good cosmetic benefit,
and I want to stress that.
You know, one of the bestthings about image-guided or
superficial radiation therapy iscosmetic benefit is wonderful.
Essentially, you have someredness and you asked about what
you're going to expect duringthe treatment.
So we're going to do 15treatments.
(22:01):
The treatments themselves onlylast 30 seconds.
It takes a while to seteverything up, et cetera, but
the treatments only last 30seconds.
It takes a while to seteverything up, et cetera, but
the treatments only last 30seconds.
After three, four treatments youget some redness.
If it's on your nose, whateverredness and peeling from that
perspective, and that's normal.
There really aren't many otherside effects and that's the
(22:24):
beauty of this.
Depending upon the area, ifyou're going to treat the nose,
I put a little shield inside thenose to prevent the mucous
membrane from getting damaged.
Same thing in the lip if we dothat, but that's about it.
After we're done, we treat it.
By the way, we don't treat thearea of radiation with topicals
(22:47):
when we're doing it, because wewant the skin to react.
The inflammation that you get,the redness, the radiation
dermatitis, is one of the keyfactors that treats the skin
cancers, so we don't want toaffect that.
After the treatment, Igenerally use something called
EpiSerum, which is somethingdermatologists know very well.
It's a barrier repair thattends to work very well from
(23:14):
that perspective, but that's it.
When it comes to side effects,there really aren't much On the
lower legs you can like withsurgery.
Every once in a while get anarea that takes a while to heal.
A little ulceration takes awhile to heal.
That's certainly we tellpatients's a possibility, much
less than with surgery, but itcan happen from that perspective
and the patients healeventually from there.
Speaker 2 (23:36):
One of the side effects.
A patient came in and again, Idon't know if they were Dr
Googling it, of course, but theymentioned you know well, I
heard if I get SRT it increasesmy risk for skin cancer in that
area later on.
So I wanted you to kind of talkthrough what we know about that
, because it is something that'sfloated around.
That seems to be a genuineconcern, you know, for patients
(23:56):
coming in, whether they found itonline or through a
conversation, you know, withtheir healthcare provider.
Speaker 1 (24:01):
Great question there is absolutely no evidence
whatsoever that you get anincreased risk of future skin
cancers.
In fact, you know, in areas wetreat which is so interesting,
like on a scalp, where inaddition to skin cancer what we
normally see is tons of actinicdamage and actinic keratosis,
the skin after we're done issmooth as a baby's behind.
(24:24):
It's very, very smooth becauseall that sun damage is gone.
A baby's behind.
It's very, very smooth becauseall that sun damage is gone.
So we don't see that at all andin fact that's a misnomer with
radiation therapy in general isthat it promotes skin cancer in
the future.
So it does not do that.
Speaker 2 (24:41):
Because I do think that's some of the hesitation.
You know that's kind of beenpushed out there, you know, for
patients.
Speaker 1 (24:46):
That's the idea of lumping all radiation therapy
together.
Exactly, yeah, it's different.
Superficial radiation therapyis certainly different from that
perspective.
Speaker 2 (24:56):
So I think from your perspective, as we're wrapping
up, you know we've given kind ofa nice overview.
Is there anything else that youwould kind of want patients to
be aware of with SRT good, bad,the ugly or ugly or anything
else that we didn't touch uponthat you think is really
important for them?
Speaker 1 (25:10):
to be aware of.
So right now there's a bigbattle with essentially with
Medicare, with CMS, about whatthe reimbursement is going to be
for radiation therapy, andthey're trying to cut it down.
And the problem with that isit's not reimbursed anywhere
near what radiation oncologistsget for treating skin cancers
and it's not reimbursed anywherenear what radiation oncologists
get for treating skin cancersand it's expensive.
(25:32):
We do a number of treatments,et cetera.
The equipment is expensive tomaintain and they're looking to
cut it dramatically.
If that happens, it's going tolimit the amount of superficial
radiation therapy available topatients and that will be a
shame from that perspective.
So this is a battle that bothpatients and physicians are
taking up now to stop the cuts,so to speak, which seem to be
(25:56):
very common across medicine fromhere.
But it's been something thathopefully they'll listen to,
because I think this issomething that's incredibly
valuable for our patients.
Speaker 2 (26:11):
Well, thank you so much.
I appreciate you going over allthat today because we're
getting a lot of questions and,like I said before we went on, I
had a patient today that justbasically said to me, hey, what
about SRT, Is this going to bean option?
And I thought, oh, I'lldefinitely talk with you about
it.
But you got to tune in becauseI'm going to have a true expert
in this field.
That's going to be on mypodcast and will air later on
this fall.
(26:31):
So thank you so much for comingon the podcast, Mark.
I really appreciate your timeand expertise.
Speaker 1 (26:36):
If anybody has questions.
You know I'm in Aventura,florida.
We treat a lot of patients, soyou know that would be.
They can call my office etcetera from there if they have
questions about this, and thankyou so much for having me on.
Speaker 2 (26:51):
Of course it's a pleasure and for those of you
listening or watching, pleaseremind, a friendly reminder to
please hit, like and subscribeand stay tuned for the next
episode of Dermot Trotter.
Don't Swear About Skin Care.
Speaker 3 (27:04):
Thanks for listening to Dermot Trotter.
For more about skin care, visitDermot Trotter.
For more about skincare, visitDermot Trottercom.
Don't forget to subscribe,leave a review and share this
podcast with anyone who needs alittle skincare sanity.
Until next time, stay skinsmart.
but also the breadth of skin cancer and see if it's
being properly treated duringradiation.
Speaker 2 (00:07):
I wanted you to talk a little about.
What does that really mean andhow does it work to treat skin
cancer?
Speaker 1 (00:12):
And a lot of patients come in to me and say you know,
I've had so many skin cancers,I've had 50 Mohs surgeries, I've
had excisions, etc.
An issue where we want to treatthe skin cancer cells and do as
minimal damage to normal cellsas possible.
Speaker 3 (00:28):
Welcome to Dermot Trotter Don't Swear About Skin
Care where host Dr Shannon CTrotter, a board-certified
dermatologist, sits down withfellow dermatologists and
skincare experts to separatefact from fiction and simplify
skincare.
Let's get started.
Speaker 2 (00:45):
Welcome to the Dermot Trotter Don't Swear About
Skincare podcast.
So today we've got an excitingshow here for you.
Today We've got Dr Mark Nestor,who's going to talk with us
more about image-guidedsuperficial radiation therapy.
But first let's talk a littlebit about Dr Nestor.
He's a board-certifieddermatologist quite accomplished
.
He serves as director for theCenter of Clinical and Cosmetic
(01:10):
Research and the Center forCosmetic Enhancement in Aventura
, florida.
He's a voluntary professor inthe Department of Dermatology,
cutaneous Surgery and theDepartment of Surgery Division
of Plastic Surgery at theUniversity of Miami Miller
School of Medicine and we'rereally fortunate to have him a
part of the conversation todaybecause he's done the work, he's
done the research, he's usedthese types of devices in
radiation therapy before.
So I want to welcome you to thepodcast.
(01:32):
It's great to have you here.
Speaker 1 (01:34):
Thanks, shana, it's really a pleasure to be here.
Speaker 2 (01:37):
I think this is a topic you know we wanted to
tackle.
You know you and I werechatting about this that it's
sort of interesting.
In medicine we have a lot moredirect-to-consumer advertising.
People are seeingadvertisements for medicines and
treatments on TV, the radiostation, and I think that's
where a lot of people have heardof radiation therapy in this
different way for using it totreat skin cancer.
(01:58):
So there's this IG-SRT, orimage-guided SRT, or superficial
radiation therapy that I wantedyou to talk a little about.
What does that really mean andhow does it work to treat skin
cancer?
Srt, or image-guided SRT, orsuperficial radiation therapy, I
wanted you to talk a littleabout.
What does that really mean andhow does it work to treat skin
cancer?
Speaker 1 (02:09):
Great questions.
So there are a variety ofdifferent types of radiation
therapy.
I think that's very importantfor people to realize, because I
have patients come in all thetime and said you know, I am
heard about this, but I had animage or I've heard radiation
therapy for breast cancer or forprostate cancer and it was a
(02:30):
terrible experience.
I had all these problems, etcetera, and so it's important to
understand that this is adifferent form of radiation
therapy.
And what's so interesting isthat this was the original form
of radiation therapy over 100years ago and radiation therapy
was actually invented bydermatologists.
The first cancer to be treatedby radiation therapy was a skin
(02:54):
cancer, was a basal cellcarcinoma.
So it's been around for a longtime.
Probably in the 70s, 50 yearsago now, more than half of
dermatologists had superficialradiation therapy in their
offices, and what happened wasover the next 20 years or so,
there was no equipment.
You couldn't get equipmentanymore, there was no technology
(03:16):
and where I learned?
I learned as a resident at NYUin the late 80s, early 90s, and
literally the equipment wasstitched together with duct tape
and kicks every once in a while, and so you know it really was
only in the last 10 to 15 yearsthat new technology has really
(03:37):
invigorated this, and so I wantto just look at the difference
between superficial radiationtherapy forgetting a second
frame it's guided and theprimary use by radiation
oncologists, which is electronbeam, because those are two
different forms of radiationtherapy.
When it comes to skin cancer,all the studies show that
(03:59):
superficial radiation therapy ismuch more effective at treating
skin cancers than electron Band it's much more gentle,
meaning you get a bettercosmetic effect.
So these are the two importantdifferentiators between what the
radiation oncologist used totreat skin cancer and other
types of cancer and what thedermatologist used in their
(04:21):
office.
So there's a lot of data, a lotof studies that have been on
this new form of equipment forradiation therapy and it's been
shown to be incredibly effectivefor treating basal cell
carcinomas, squamous cellcarcinomas, et cetera.
And you know, not for alldifferent skin cancers, but
certainly for the vast majorityof basal and squamous cell
(04:44):
carcinoma, squamous cell in situthe effectiveness, you know, is
really equivalent to surgeryand even Mohs in a lot of cases
of the high 90% five-year curate.
And that's the way we talk aboutany cancer.
The way we talk about anycancer is what is the five-year
curate, meaning it's not goingto return, most likely at that
(05:06):
point.
Now what happened was that anumber of a few years ago the
idea came can we make this anybetter?
And the question was in orderto make it better, how do we
pinpoint exactly how deep we go,how wide we go to really take
(05:26):
that 90-something percent, 95,98% curate and try to notch it
up as close as we can to 100%.
Nothing is ever 100%, as weknow that in medicine, or
anything but as close aspossible is what we want to do.
And so what was shown is that ifyou can pinpoint the depth
(05:47):
especially, but also the breadthof skin cancer and see if it's
being properly treated duringradiation, you can actually jack
up those numbers.
And the numbers forimage-guided now are in the 99
plus percent treatment for this.
So the idea here is we useultrasound and the ultrasound
(06:11):
can measure the depth of skincancer and see, essentially, the
volume, so we can morespecifically target exactly what
we want to do.
And that's what Image want todo and that's what image-guided
is.
Image-guided means that we canvisualize the skin cancer and
visualize what we want to treat,where we want to treat it, and
(06:34):
pinpoint the exact essentiallyKV or the energy that we want to
use to treat that skin cancer.
Speaker 2 (06:43):
So with those changes over time, because I think a
lot of people might like oh yeah, I've kind of heard of SRT, or
maybe for some of the healthcare providers listening, they
know of SRT with image guidedkind of added.
Now Are the devices essentiallyall the ones that are out there
now image guided or there'sstill some functioning kind of
in the old fashioned way withoutthat advantage?
Speaker 1 (07:03):
So the answer is image guided.
Is a little separate littledevice on their ultrasound.
And as you know dermatologists,a lot of dermatologists in our
office have ultrasound.
We use ultrasound for fillers,for other things, to measure
things, to measure fat depthsetc.
So it doesn't have to be partof the machine and, as I said,
even without the ultrasound and,as I said, even without the
(07:26):
ultrasound, the cure rates forradiation, superficial radiation
therapy, are in the 98 to 99%anyway.
So this jacks it up a bit.
It certainly does, and it makesboth a physician and patient
(07:53):
feel better because they canactually say I visualized the
tumor.
And one of the tenants ofradiation oncology, which is
really what we're talking abouthere, is that you want to be
able to specifically visualizeand use that information to at
best possible target the skincancer and leave the normal
tissue behind.
So it allows us to do thataspect.
It doesn't mean we have to doimage-guided at each treatment.
Some do and that's fine.
(08:14):
But the idea here is that wewant to be able to use every
tool that we have to be able tooptimize the treatment for
patients.
And you know, obviously thegold standard has been for skin
cancer has been surgery, youknow, and there are different
aspects, whether it's just asimple excision, whether it's
(08:34):
mows, whether it's destruction.
These are all surgical means toget rid of skin cancers.
The downside of surgery is thatyou have scars, and you have
not only do you have scars, incertain cases you don't have a
lot of tissue to close, like onthe scalp and other areas, and
so it becomes a little bit moredifficult to you know figure out
(08:56):
how and what is best for thepatient care.
And a lot of patients come into me and say you know, I've had
so many skin cancers, I've had50 Mohs surgeries, I've had
excisions, et cetera I reallydon't want to go through surgery
anymore.
How can we look at thingsdifferently?
And superficial radiationtherapy, image-guided or not, is
(09:19):
a great alternative, especiallyfor patients who are a little
older.
And again, I've treatedpatients young because they
really don't want to havesurgery from that aspect.
But the older patients are wesee this a lot number one,
number two patients with skincancers on areas that aren't the
easiest to do surgery.
(09:40):
So on the scalp, on the nose,on the lower extremities, those
are some of the primary areaswhere I use superficial
radiation therapy to a greatextent, and the reason is that,
again, those aren't optimal todo surgery.
The other thing that'swonderful about superficial
radiation therapy and again,imageguided will put into this
(10:03):
bucket certainly is that forlarger skin cancers, and I don't
mean necessarily larger interms of death, but larger in
terms of the size.
And very often we see, excuseme, superficial skin cancers
that are larger, especially inareas such as the scalp.
Well, we know as dermatologists, the scalp is something that's
(10:24):
very hard to heal from biggerexcisions because there's no
skin.
You can't push it together veryeasily.
And this is a really wonderfulway of treating that skin cancer
getting rid of it withouthaving to cut out the skin and
it leaves an area without anysun damage whatsoever.
So there are, you know, thesereasons I talked about the lower
(10:46):
extremities.
These reasons I talked aboutthe lower extremities Below the
knees is something historically,that surgery is very difficult
to do because very often youhave a lot of swelling on the
lower extremities number one.
Number two because of the waythe blood supply works there,
the legs don't heal as well.
We know that.
We know that clearly.
So the infection rate in thelower extremities is much higher
(11:07):
.
Know that clearly.
So the infection rate in thelower extremities is much higher
.
The rate where you getdehiscence or you get opening
and you get ulcerations is muchhigher when you do surgery, so
radiation therapy gives usanother tool to use in that area
as well, very, very effectively.
Speaker 2 (11:23):
So I think, when you talk about it being effective
and a great tool, I want to talka little bit.
You know, this elephant sort ofin the room, maybe in the
dermatology community, maybe inthe radiation oncology community
too, about people don'tpotentially support this In
particular.
You know physicians orhealthcare providers that feel
like this is not, you know, areasonable option.
(11:44):
So I think I mentioned to you,you know, one of the questions I
got from a patient is that youknow I went to a dermatologist
who said, hey, you know yournodular basal cell in the nose.
You know you shouldn't reallydo this.
The data is not there.
Guidelines say that it's notreally a good.
You know primary treatmentpotentially for you.
I want to get your take sort ofon this controversy and sort of
(12:05):
the debate, because it ishealthy for us to have debate,
obviously over treatments and ifthey're the right choice, but
sort of maybe where that started, where it's come from and then
kind of where we sit currently,you know, with guidelines or
what you feel like, maybe thedermatologic community, what
we're sort of thinking about itnow as a treatment option.
Speaker 1 (12:20):
It's a great, great point.
Number one I'm a scientist so Igo with studies and data.
Okay, this is what I do.
So if you look at the studies,okay, if you look at the data
from superficial radiationtherapy, especially in the last
10 years okay, because there'sliterally been, you know, I
(12:40):
would say, close to 100 studiesgoing back.
And if you look at the oldstudies, the old studies all
have about a 95% curated basalcell, almost around a 93% for
squamous cell that uses oldequipment and old treatment
guidelines, meaning you know youhave certain parameters that
you use for the old equipment.
It wasn't necessarily optimal,but I got news for you 93% and
(13:03):
95% is very comparable tosurgery, no question about it.
If you look at the new data,okay, which is over the last,
you know, 15, 10, 15 years,forgetting right now about
image-guided you know the datais, as I said, 98% to 99%
long-term curates.
(13:23):
That is not only at least asgood, but that is better than
surgery.
So a lot of the issue comes,number one, from not
understanding the data.
You know it's not.
People don't look at it.
Number two it's a whether it'spolitics, whether it's the issue
(13:45):
of I do surgery, that's all Ido.
I think it's better.
Therefore, et cetera.
This comes into play no matterwhat happens.
People have their own way oflooking at things.
I do both.
I do surgery.
I do, you know, radiation.
Many, many radiation people whodo superficial radiation
(14:07):
therapy are most surgeons, sothey do both.
So, again, I think it's aquestion of education from there
, but it's also a question ofeverybody, and the guidelines
now really say that superficialradiation therapy is in there
for the choice and everybodyshould be given the full
(14:29):
education and choice of what'savailable, and I think that's
really very, very important.
Patients need to be essentiallycounseled that, hey, you have a
skin cancer on your nose.
As you said, you have a pain inyour nose.
Here are the options we havesurgery, we have radiation, we
have other things, other thingssuch as topicals.
(14:51):
They may not work as well, butit's still an option.
From that perspective, I'mgoing to educate you.
You're the patient, you canmake the choice.
I'm your guy, basically.
So I think that you know, asnumber one, as people really
begin to understand this,understand the science,
(15:12):
understand the data, includingphysicians, they will be more
comfortable with it.
I think that the idea somehowthat it's not a reasonable
option makes no sense becausethe data is so sense, because
the data is so clear from thatperspective.
So, again, I think patientsneed to be armed with education,
(15:37):
and sometimes you get that fromyour physician.
Sometimes the patients have togo out on their own, and that's
what's happening now to go outon their own, and that's what's
happening now.
As you said, there is certainlya lot of information being put
out there about superficialradiation therapy is
specifically image guidedsuperficial radiation therapy.
(15:59):
So patients are learning aboutthis and you know that Dr Google
is very, very powerful or nownow Dr Pat GPT is even more
powerful about learning aboutwhat the options are.
And patients need to beempowered, you know, to learn
about what my options are andthen speak to the doctor and if
(16:23):
they have to get another opinion, and if they have to get
another opinion, I have very,very many patients coming to me
asking for other opinions, etcetera, to say my doctor said
this, tell me about this, etcetera.
And I'll give them theinformation and I'll always say
you have choices.
You have choices of surgery, ofdestruction of topicals and of
(16:43):
superficial radiation therapy,and I'll give them the pluses
and minuses.
Speaker 2 (16:52):
No, I think that's good because you want patients
to have sort of an honestpicture of that.
And I think the one thing Ialways remember when a patient
had a different treatment choice, they maybe came to see me and
I gave them multiple options andlike, hey, nobody ever gave me
those options before.
I thought this was just theonly thing I could do.
It is really important.
I think we owe it to patients togive them options and the risk,
benefits and pluses and minuses, of course, with all of that.
But they are in the driver'sseat and it's our job, like you
(17:15):
said, just to give them thatinformation and our opinion on
what we think might be the bestWith SRT.
You know, I think you know Ihad a patient come in asking,
you know they had a melanoma andthey're like, hey, can we just
get our SART on this?
Can I treat this withsuperficial radiation therapy?
So I think one of the things Iwanted you to kind of go over is
you know, when is it reallyappropriate?
I know we kind of talked abouta few instances, but high level
(17:36):
again, where you think the casesare most appropriate and in
cases where, like, probably notthe best treatment option as
well.
Speaker 1 (17:41):
Okay, yeah, I missed that last part.
You're a little bit fuzzy there.
But yes, certain things, Ishould say certain types of skin
cancers, are not forsuperficial radiation therapy,
image-guided or not.
Melanoma is not for SRT,Certain types of squamous cell
carcinomas and even certaintypes of basal cell carcinomas
(18:03):
where it's very, very aggressive, etc.
I don't necessarily recommendSRK, except in certain
circumstances.
I had patients coming in to seeme in their old, late 90s, let's
say, or early 90s, whatever itmight be, who are not in good
shape and who wouldn't toleratesurgery number one.
(18:23):
So we can use superficialradiation therapy to essentially
, you know, either palliate,either make these skin cancers
much more, I guess, timeeffective, and they're not going
to be bothered by it.
From that perspective They'llunfortunately pass away from
something else or do somethingalong the lines of using this in
(18:49):
a way that makes it better forthe patient.
But certainly, you know, Irefer patients to radiation
oncologists.
There's something calledperineural invasion for squamous
cell carcinoma.
I don't use SRT, I refer thoseout for electron beam, because
electron beam is more aggressive, it gets deeper.
(19:18):
There's a type of cancer calledDFSP and again I send those to
a radiation oncologist as well.
Merkel cell there are a numberof different types of skin
cancers that aren't ideal forSRT from that perspective.
A lot of patients come in witha small basis of carcinoma on
the chest, on the arm, et cetera.
I don't do SRT on thosepatients, I'll scrape it off,
I'll cut it out, et cetera.
So there are.
(19:40):
You know, part of our job is tosay this is not ideal for you
and that's okay.
Speaker 2 (19:50):
Because I do think that's important.
You know, I think some patientsthink, oh again, I should have
been given this option and maybeit just wasn't the right option
, you know, at the time for themto kind of pursue.
And just having that viewpointI think is helpful too.
So if somebody is going toundergo SRT in your office, how
do you explain to them what youexpect maybe for a number of
treatments or potential sideeffects, kind of that risk
(20:11):
benefit?
What's the conversation looklike when you talk with people?
Speaker 1 (20:14):
That's a great question.
So essentially, we cut theradiation up into bits.
That's the way radiationtherapy works.
There is an issue where we wantto treat the skin cancer cells
and do as minimal damage tonormal cells as possible and
(20:34):
that, you know, this curve iscritical to doing that.
And in order to do that, wechop it up in what's known as
fractions.
And in doing this, what we'redoing is we're giving enough
radiation to treat the cancercells because they're more
essentially fragile to radiation, and it allows the normal cells
(20:56):
to recuperate and remain fine,basically from that perspective.
So in my office I do essentiallyan average of about 15
treatments, generally two orthree times a week.
Okay, so you know, somewherebetween five and seven weeks.
Some image guided centers do 20treatments.
Fine, they they divided up alittle bit more from that
(21:18):
perspective.
But that's what we're talkingabout.
We're talking about and thatand that.
By the way, that is one of themain differences of what we know
now for optimization versuswhat was 20, 30, 40 years ago.
They used smaller numbers offractions and they didn't get
necessarily the optimal effectand they got more localized
(21:40):
destruction, so they didn't getsuch a good cosmetic benefit,
and I want to stress that.
You know, one of the bestthings about image-guided or
superficial radiation therapy iscosmetic benefit is wonderful.
Essentially, you have someredness and you asked about what
you're going to expect duringthe treatment.
So we're going to do 15treatments.
(22:01):
The treatments themselves onlylast 30 seconds.
It takes a while to seteverything up, et cetera, but
the treatments only last 30seconds.
It takes a while to seteverything up, et cetera, but
the treatments only last 30seconds.
After three, four treatments youget some redness.
If it's on your nose, whateverredness and peeling from that
perspective, and that's normal.
There really aren't many otherside effects and that's the
(22:24):
beauty of this.
Depending upon the area, ifyou're going to treat the nose,
I put a little shield inside thenose to prevent the mucous
membrane from getting damaged.
Same thing in the lip if we dothat, but that's about it.
After we're done, we treat it.
By the way, we don't treat thearea of radiation with topicals
(22:47):
when we're doing it, because wewant the skin to react.
The inflammation that you get,the redness, the radiation
dermatitis, is one of the keyfactors that treats the skin
cancers, so we don't want toaffect that.
After the treatment, Igenerally use something called
EpiSerum, which is somethingdermatologists know very well.
It's a barrier repair thattends to work very well from
(23:14):
that perspective, but that's it.
When it comes to side effects,there really aren't much On the
lower legs you can like withsurgery.
Every once in a while get anarea that takes a while to heal.
A little ulceration takes awhile to heal.
That's certainly we tellpatients's a possibility, much
less than with surgery, but itcan happen from that perspective
and the patients healeventually from there.
Speaker 2 (23:36):
One of the side effects.
A patient came in and again, Idon't know if they were Dr
Googling it, of course, but theymentioned you know well, I
heard if I get SRT it increasesmy risk for skin cancer in that
area later on.
So I wanted you to kind of talkthrough what we know about that
, because it is something that'sfloated around.
That seems to be a genuineconcern, you know, for patients
(23:56):
coming in, whether they found itonline or through a
conversation, you know, withtheir healthcare provider.
Speaker 1 (24:01):
Great question there is absolutely no evidence
whatsoever that you get anincreased risk of future skin
cancers.
In fact, you know, in areas wetreat which is so interesting,
like on a scalp, where inaddition to skin cancer what we
normally see is tons of actinicdamage and actinic keratosis,
the skin after we're done issmooth as a baby's behind.
(24:24):
It's very, very smooth becauseall that sun damage is gone.
A baby's behind.
It's very, very smooth becauseall that sun damage is gone.
So we don't see that at all andin fact that's a misnomer with
radiation therapy in general isthat it promotes skin cancer in
the future.
So it does not do that.
Speaker 2 (24:41):
Because I do think that's some of the hesitation.
You know that's kind of beenpushed out there, you know, for
patients.
Speaker 1 (24:46):
That's the idea of lumping all radiation therapy
together.
Exactly, yeah, it's different.
Superficial radiation therapyis certainly different from that
perspective.
Speaker 2 (24:56):
So I think from your perspective, as we're wrapping
up, you know we've given kind ofa nice overview.
Is there anything else that youwould kind of want patients to
be aware of with SRT good, bad,the ugly or ugly or anything
else that we didn't touch uponthat you think is really
important for them?
Speaker 1 (25:10):
to be aware of.
So right now there's a bigbattle with essentially with
Medicare, with CMS, about whatthe reimbursement is going to be
for radiation therapy, andthey're trying to cut it down.
And the problem with that isit's not reimbursed anywhere
near what radiation oncologistsget for treating skin cancers
and it's not reimbursed anywherenear what radiation oncologists
get for treating skin cancersand it's expensive.
(25:32):
We do a number of treatments,et cetera.
The equipment is expensive tomaintain and they're looking to
cut it dramatically.
If that happens, it's going tolimit the amount of superficial
radiation therapy available topatients and that will be a
shame from that perspective.
So this is a battle that bothpatients and physicians are
taking up now to stop the cuts,so to speak, which seem to be
(25:56):
very common across medicine fromhere.
But it's been something thathopefully they'll listen to,
because I think this issomething that's incredibly
valuable for our patients.
Speaker 2 (26:11):
Well, thank you so much.
I appreciate you going over allthat today because we're
getting a lot of questions and,like I said before we went on, I
had a patient today that justbasically said to me, hey, what
about SRT, Is this going to bean option?
And I thought, oh, I'lldefinitely talk with you about
it.
But you got to tune in becauseI'm going to have a true expert
in this field.
That's going to be on mypodcast and will air later on
this fall.
(26:31):
So thank you so much for comingon the podcast, Mark.
I really appreciate your timeand expertise.
Speaker 1 (26:36):
If anybody has questions.
You know I'm in Aventura,florida.
We treat a lot of patients, soyou know that would be.
They can call my office etcetera from there if they have
questions about this, and thankyou so much for having me on.
Speaker 2 (26:51):
Of course it's a pleasure and for those of you
listening or watching, pleaseremind, a friendly reminder to
please hit, like and subscribeand stay tuned for the next
episode of Dermot Trotter.
Don't Swear About Skin Care.
Speaker 3 (27:04):
Thanks for listening to Dermot Trotter.
For more about skin care, visitDermot Trotter.
For more about skincare, visitDermot Trottercom.
Don't forget to subscribe,leave a review and share this
podcast with anyone who needs alittle skincare sanity.
Until next time, stay skinsmart.
Popular Podcasts
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
The Joe Rogan Experience
The official podcast of comedian Joe Rogan.