Skin cancer patients to benefit from 'gold standard' surgery coming to N.S.

Mel Briand's face bears the evidence of how she used to spend her summers.

Sun damage has required her to have cancer surgery on her face. She has scars above her lip and on her nose from surgeries to cut away basal cell carcinoma.

If it comes back, it threatens to burrow into her bones.

At 64, the Halifax woman has been fighting the disease for a nearly a decade, and with each recurrence and subsequent surgery there's the risk of disfigurement.

She wishes her treatment could be different. Changes are on the horizon in Nova Scotia that will make that happen.

Briand's cancer is the result of being part of a generation of sun worshippers who slathered on baby oil to "bake yourself and burn" under the sun.

"We damaged our skin terribly and as you get older [cancer] starts to come out," she said while sitting under the shade in her backyard last week. 

Her nostril is still healing after surgery earlier this month to dig out a chunk of cancerous skin. There's also a scar along her ear from where skin was removed to create a graft to close the wound on her nose.

She underwent basic surgery that removes a larger piece of tissue with the hope that it removes all the cancer.

Lab results usually take about a month to determine whether any cancer was visible along the tissue's edges. But the removal and detection are imprecise.

This is the second treatment to that same spot on Briand's nose, where skin is already thin. Each recurrence gets closer to the bone.

"I worry about, will I notice if something starts up again that doesn't feel normal to me now." 

What rubs salt in her wound is that there's a specialized treatment that's standard care in many provinces, including New Brunswick.

Mohs surgery has been offered in Saint John since 2006, and at a new clinic in Moncton opened in February. But it's not available in Nova Scotia, even though her dermatologist has the necessary training.

The micrographic surgery uses a microscope to detect cancer during the surgical appointment. There's no waiting for weeks to determine whether all the cancer has been removed. 

In the Mohs method, the dermatologist cuts away the cancerous tissue, creates a tumour map and divides the tissue into sections.

It's then shaved into thin layers and stained with a dye so the cancer shows up under a microscope. Layers of tissue continue to cut away until it's clear of cancer. A patient leaves the appointment knowing the cancer has been removed.

Its precision means the smallest amount of healthy tissue is removed. It eliminates the need to wait weeks for lab results to indicate whether the additional surgery is needed.

With a high cure rate, it's a cost-saver to the health-care system.

'We need it, just get it done'

There's no reliable data available on the rate of basal and squamous cell skin cancers in Nova Scotia, according to the Canadian Cancer Society.

But it's known that the province has among the highest rates of melanoma skin cancers in the country, which have similar risk factors, so the rates of skin carcinomas are also likely high, said the organization.

Despite the high incidence, Mohs surgery is not well known in Nova Scotia. Briand has spoken to skin cancer patients who are unaware of the procedure.

"We need it, just get it done," Briand said, about her recent letter to the health minister, pushing for a Mohs clinic in Nova Scotia. 

The topic is timely.

Dr. Robert Strang, Nova Scotia's chief medical officer of health, travelled to New Brunswick two weeks ago for the treatment. He was absent from his regular COVID-19 briefings because of the mandatory 14-day isolation period after a trip out of the province.

On June 10, Strang said his cancer had been removed but he needed "another type of surgery that can relook at things and make sure the margins of where it was removed are clear." 

He's not the only Nova Scotian who's travelled across the border for the treatment. A spokesperson for the Department of Health said in an email about 40 Nova Scotians were referred to New Brunswick for Mohs surgery in 2017-2018.

Mohs surgery has been approved

That trip may soon be unnecessary.

Mohs surgery was approved last fall, according to a spokesperson for the Department of Health, and since then work has begun to get the province's first micrographic surgery clinic off the ground.

It's estimated that about 1,000 Nova Scotians a year will benefit from the treatment.

The Nova Scotia Health Authority said in a statement a billing code was created earlier this year, and it's working on an operational plan, which includes equipment and resources.

It's the result of a campaign by the medical community, led by Dr. Michael Stevens, Briand's dermatologist.

He's been paving the way to bring this service to Nova Scotia, his home province.

Stevens got his first introduction to Mohs surgery while he was a Dalhousie University medical student on a rotation in Saint John.

He then pursued a dermatology residency at University of Toronto and stayed an extra year to complete training in Mohs surgery in 2018. 

'It's been a long time coming'

While in Toronto, Stevens gathered the support of Nova Scotia's top doctors in dermatology, plastic surgery and related specialities to lobby the Health Department to develop the service, which included overcoming hurdles such as creating a new billing code. 

But part of the reason why Nova Scotia hasn't had a clinic is because there are only about 20 Mohs surgeons in the country and only one or two are trained each year, he said.

The technique, which can pinpoint the cancerous cell to within a millimetre, is "universally accepted as the gold standard" for treating basal and squamous cell carcinomas, he said.

The cancers are so common, Stevens said he could perform Mohs surgery five days a week at his clinic in Bedford.

"If we can get this up and running, I'll be ecstatic for my patients," he said. "It's been a long time coming."

He would need equipment, a nurse and a technician in order to get started.

For Briand's recurring cancer, time is of the essence.

When the cancer's return was confirmed in January, she was advised by Stevens not to join New Brunswick's wait list, which he told her stretched for nine months and included about 250 names.

That wait grew by an additional three to five months because of COVID-19, according to Dr. Martin LeBlanc, who works out of a state-of-the-art clinic in Moncton.

While most of the patients are New Brunswickers, about 10 per cent are from Nova Scotia and P.E.I. 

More out-of-province patients would be treated if access was easier, said LeBlanc.

Briand opted for the conventional surgery, but that too was postponed because of the pandemic. It happened earlier this month.

"Nobody likes scars on their face," she said. "The more we can minimize people's face's being cut, the better."

She's frustrated that skin cancer patients in Nova Scotia are going without the best care.

"That kind of thing bothers me a lot, that's an injustice to me," she said.