Breakthrough skin cancer surgery: Interview with Dr Piasecki

Skin cancer is the third most common form of cancer – yet it's still the one that has the most myths. pharmaphorum's Hannah Blake interviews the only person in the world who has the training combination to perform both the skin cancer surgery and then the necessary reconstructive surgery for skin cancer patients, Dr Justin Piasecki from The Skin Cancer Centre.

It's fair to say that everyone loves the sun – no one enjoys spending time outside, whether it's running for the bus, popping to the shops or while working, when it's pouring with rain do they?

However, as the world's ozone levels deplete, the atmosphere continues to lose more of its protective filter function and more solar UV radiation reaches the Earth's surface. This means that over exposure can cause skin cancer – the incidence of both non-melanoma and melanoma skin cancers has been increasing over the past few decades. Currently, one in every three cancers diagnosed is a skin cancer, according to the World Health Organisation.

pharmaphorum's Hannah Blake recently caught up with Dr Justin Piasecki, who founded The Skin Cancer Centre in Washington, US, just over four years ago. Dr Piasecki is the only person in the world to be double certified in plastic surgery and Mohs micrographic surgery – a win / win for patients.

Dr Piasecki dispels some of the common skin cancer myths and shares his thoughts on how pharma can better support patients with skin cancer.

Interview summary

HB: Hello Dr Piasecki, it's really great to speak to you today. Can you start by telling us a bit about your medical background?

JP: Sure, I started my pre-med training at Stanford University, and then went to medical school, and did surgery training at the University of Wisconsin. Then, I did an extra year in micro graphic surgery, and in facial plastic surgery, at the University of British Columbia in Vancouver.

HB: What inspired you to set up The Skin Cancer Centre in 2009?

JP: In my plastic surgery training, I noted that there were a lot of patients coming through who'd had skin cancer treatment, and they were sent to us to have formal reconstruction done. The worldwide standard for skin cancer treatment on the face is a technique called Mohs micrographic surgery, which carries a 99% cure rate. It tends to be more tissue preserving than the other techniques available. The problem with it is that the vast majority of physicians who are trained in micrographic surgery are dermatologists. Dermatology is a medical sub-speciality as opposed to a surgical one, so after removing the cancer, they would be at a loss as to how to reconstruct the patient. So we'd have all these patients sent to us after skin cancer removal, to be put back together, and I had a number of patients for whom noone had looked at the big picture, everyone had done their little bit, noted that there was a lesion, then done a biopsy, and then treated the cancer, but hadn't looked at the whole patient. Several of these patients were too ill to tolerate what we needed to do, reconstruction wise, and as a result, we were very limited in how we could help them. Setting up the Skin Cancer Centre, in my mind, was a way to help these patients, by allowing everything to be done at one centre by the same physicians.

"Setting up the Skin Cancer Centre, in my mind, was a way to help these patients, by allowing everything to be done at one centre by the same physicians."

HB: What are the different types of skin cancer?

JP: The most common types of skin cancer are basal cell carcinoma and squamous cell carcinoma.

Basal cell carcinoma typically appears as a changing or growing sclerotic... it could look like a scar or a red patch of skin, an area that bleeds with minimum trauma. The test I give patients is if you get out of the shower, and a small area bleeds, then that's not normal. Or a wound that's present, and won't heal over the course of several weeks.

Squamous cell carcinoma can look very similar, but it tends to be a fast growing cancer, and it can also grow into a nodule of some kind, like a bump, it kind of looks like a tumour on the skin.

Malignant melanoma, which is actually the one that gets a lot of headlines, is a relatively rare cancer. It makes up only about four per cent of skin cancers, typically looks like a brown or black patch of skin with an irregular border that's changing as well.

HB: Do you think patients are getting wiser about protecting themselves from skin cancer?

JP: I think that they are. I think people have been aware for quite some time that prolonged exposure to the sun is a bad thing. I think that the popularity of sun screen has been on the rise, and that's a very good thing. One of the problems is the false sense of security when people put on sun screen. There's this sense that you can put sun screen on in the morning, and you'll be protected for the whole day, but in truth, there isn't any sun screen that prevents all radiation from getting through, and most of them stop working every two to three hours, so they need to be reapplied. I think people are certainly getting wiser that it's important to protect themselves from the sun, but I do think that there's a bit of a lack of understanding about the best way to do that.

HB: In what ways can physicians better communicate the danger of skin cancer?

JP: I think it's just through continued public service announcements and continued education. I think as physicians, we need to continue to do a good job, by regularly explaining what can happen with skin cancer, and make people aware of the fact that if they don't protect their skin, they will get skin cancer, it's common.

"One of the problems is the false sense of security when people put on sun screen."

Pharma can do a good job by essentially promoting the benefits of the products that are available on the market, and why they work, and why it's a benefit to prevent, rather than waiting until you get a cancer, and then dealing with it.

HB: There are many different treatments for patients with skin cancer, so how does Mohs surgery compare with chemotherapy or biologic therapy?

JP: That's a great question. The only way we can treat any cancer, not just skin cancer, is to destroy or remove all the cancer cells, we don't have any other ways of doing this. With skin cancer, the cells are typically accessible because they begin on the surface of the skin, so they can be frozen, they can be burned off, they can be radiated, there are some topical creams, or they can be excised. All of the techniques have an 80 to 85% cure rate, so it's okay, but it's not great. Micrographic surgery has a much higher cure rate, it's about 99.2%, and the reason for this is that we're essentially eliminating human error from the equation. We are mapping the cancer out, and going along the margins with microscopic control, rather than just guessing how much extra to freeze or cut, and that's very important with skin cancers because they tend to grow with roots, and the roots tend not to be visible to the naked eye. Mohs surgery carries a much higher cure rate, because you're eliminating the guess work, eliminating human error, and it's much more tissue preserving.

As I mentioned before, the big problem with Mohs surgery is that once we've eliminated the cancer, we've replace one problem with another, there's no more cancer, but there's a hole. This was why I was motivated to pioneer this new field where I could do everything for one person, and it turns out I'm the only physician on the planet who's double boarded in plastic surgery and facial plastics, and also certified in Mohs surgery, so it's a win/win for patients.

"Mohs surgery carries a much higher cure rate, because you're eliminating the guess work..."

HB: There's recently been a boost in the number of FDA approved melanoma drugs, so what does this mean for patients?

JP: Melanoma, as opposed to basal and squamous cell carcinoma, is much more aggressive, and if left untreated, it will almost always kill patients, which is a very scary thing. When we catch melanoma early, we are very good at curing it, and surgery is the main treatment for that. The problem with melanoma is that once it spreads to lymphnodes or other parts of the body, our ability as physicians to treat and cure patients is very low. So the boost in the number of FDA approved drugs is of particular significance to patients for whom their cancer is more advanced, and their cancer has spread from the skin to the lymphnodes, or to other parts of the body. This is important because we weren't very good at treating that before, and these new drugs offer us hope that we can treat people who have advanced melanoma.

HB: One of the hot topics at ASCO 2013 was the PD1 and PDL1 immunotherapies for metastatic melanoma. What excites you the most about the research and development into skin cancer?

JP: What excites me the most is that there's interest in this, and there's an understanding by pharma that skin cancer's important, it's very common, and as a result it's worth investing research dollars into new products to help patients with these diseases. I love treating patients surgically, but it would be one of the happiest days of my career if I was out of a job, and there were medications that could cure patients better than I can. We do a great job with surgery, but if patients can take a medication that can take care of their cancer, then that's a win/win for everyone. What excites me the most is simply that there's interest, and there's a tremendous amount of thought going into how to treat these patients. The patients with metastatic disease, as I mentioned before, we're not very good surgically at treating these patients, we can't get all the cancer cells out with a scalpel, so we need medications to assist us in treating these cancer cells and getting rid of them, so it's a very exciting time for skin cancer.

HB: Finally, what are your plans for the future, regarding your role as an advocate for skin cancer awareness?

JP: I have been, for the last year, trying to get the message out there not only about what we do, but skin cancer awareness as well. We're launching a skin care line, not only here in the US, but internationally as well, with the proceeds to go to charity, and towards a foundation that supports increasing advocacy for skin cancer awareness. So we've got a bunch of plans on the horizon for helping patients with these diseases.

HB: It was great to speak with you Dr Piasecki. Good luck with your plans to raise further awareness!

About the interviewee:

A graduate of Stanford University with a degree in biology, Dr Justin Piasecki went on to Vanderbilt Medical School, where he was elected to the Alpha Omega Alpha honor society. While in medical school he took a two-year leave of absence to compete on the US National sprint kayaking team and was ranked #4 in the world, winning gold medals at the Pan Am Games, World Cup and at the U.S. National Championships.

After graduation from Vanderbilt, Dr Piasecki did a five-year plastic and reconstructive surgery residency at the University of Wisconsin, where he won several awards for his research and teaching. He then completed a Mohs surgery fellowship at the University of British Columbia, training under some of the most respected dermatopathologists in North America.

Dr Piasecki is one of seven physicians worldwide who are board certified by the American Board of Plastic Surgeons, which indicates that he has met the highest level of requirements for practicing plastic and reconstructive surgery and a Member of the American College of Mohs Surgery.

Dr Piasecki lives in Gig Harbor with his wife and three young daughters. He continues to kayak recreationally and enjoys spending time outdoors with his family.

NB: Photo credit of Dr Piasecki: Bobby Quillard (www.quillardinc.com)

How can pharma and physicians better work together to support skin cancer patients?