When to Call a Time Out on Mohs Surgery

Jerry Brewer, MD, MS, FACMS, and dermatologic surgeon at the Mayo Clinic in Rochester, Minnesota, shared skin cancer cases of the scalp, neck, and face that ultimately required avoiding Mohs surgery. He explained his process of designing a multidisciplinary plan for patients with tumors extending beyond soft tissue margins during the session “On the Margin: Reasons to Avoid or Discontinue Mohs Surgery” at the 2023 American College of Mohs Surgery Meeting in Seattle, Washington.

Brewer caught up with Dermatology Times® after the session to go over key takeaways to put into Mohs surgery practice.

Dermatology Times: What should Mohs surgeons keep in mind when presented with a complex case, possibly beyond repair?

Brewer: It's kind of a challenge when you have a situation where either the tumor seems too out of control for the day of surgery, or you need to have a multidisciplinary approach to work things out before engaging in surgery. There's a lot of things to navigate. One is patient expectations. If they come in expecting to have the surgery done, it can be a little challenging to navigate that with them. Sometimes it's just challenging to really do the best thing you can with an aggressive tumor that might kill the patient. The people you talk to, the way you interact with the patient—it's all kind of an art and very important.

Sometimes it's hard to tell clinically if it's an okay scenario to operate on or not. Sometimes it's pretty obvious if you look at tumors—just big, bulky, indurated, invading into some important structures. But there are other situations, for example, like cancers on the scalp—kind of hard to tell sometimes. The case that I showed this morning was a tumor that had unfortunately eaten through the bone of the skull, and operating on that wouldn't have not been a good idea. Sometimes, if you're unsure, just taking a step back. Getting a second opinion and imaging can really help you with the best approach.

Dermatology Times: You often see patients in their most vulnerable stage of life. What approaches should be considered with outbursts of frustration?

Brewer: There were a lot of hands that went up in the room of people who had dealt with situations of patients that have come in combative and belligerent, and to the point where it may have put the team at risk and made the situation unsafe for the team to proceed with surgery with situations like the patient maybe grabbing the scalpel or trying to control the the situation too much. That's that's tricky of how to navigate that on multiple levels. I mentioned in the room, I learned a very wise thing from a friend of mine, who reframed in her head instead of saying, "What's wrong with you", she would say, "I wonder what happened to you."

Everybody handles stress in different ways. And sometimes, a patient might come in that just happens to be handling stress in a way where they become belligerent and angry at the team. The hard part is to keep yourself emotionally distant enough to maintain that level of empathy to the patient, but at the same time, know what's right and wrong. In situations like this is I have a huddle with my team. And I say this patient is being angry and belligerent and ask what is the right thing to do. In the [specific] situation I'm thinking of, the team was unanimous that it would not be safe for us to continue with surgery. We went into the room with that whole team backing the entire decision. It wasn't just one person's opinion, and that really made that tough situation go a little bit better. But it can be tricky. It's really tricky.

I guess the last thing I would say is I think it's part of human nature, what I call, jump on the stage and say, "I'm right, you're wrong, and you're being angry and I'm going to put up a wall." One of the challenges, I think, is to maintain that human level of respect for the person that's being belligerent and still see them as a as a human that has needs and is concerned with fears—still maintaining that level of respect, but not going in a place that might be unsafe for you at the team.

Dermatology Times: This is your 18th year attending the ACMS meeting. What keeps you coming back?

Brewer: Oh my gosh, this is what I love. This is the love of my life. I happen to have the best job on Earth. I just love what I do—the opportunity to cure a person's cancer and put them back together. The honor of taking care of somebody during some of their most vulnerable times and the expertise of doing that. It's a gift and I love the Mohs College. I love this meeting because I get to come and learn from colleagues and connect with humans that are extremely thoughtful and insightful and just really good people. It makes me a better person to be here.

Transcript has been edited for clarity