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Distinct from other cancers, most skin cancers are managed in a doctor’s office or ambulatory clinic in the community rather than in a referral hospital. For this reason, skin cancer patients can navigate the health system without the input of the integrated team approach which may otherwise be needed. As is the case with practically all aspects of medicine, both communication between specialists and integration of care are key components in reaching the best patient outcomes.
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INTRAOPERATIVE MCS OUTSIDE OF THE MMS SETTING
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To assess surgical margins intraoperatively, the broad range of medical specialists involved in skin cancer surgery typically rely on their local pathologists who are also involved in the processing of the specialists’ regular specimens. The laboratory may be within an operating room suite or at a separate location, in which case communication between the laboratory and the surgeon is important while the tumor is being removed, orientated, labeled, and transported.
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To facilitate communication, photographs of the tumor before excision and of the specimen with orientation can easily be sent to the pathologist. Teleconference programs can also be used so that the pathologist is able to see the tumor before it is excised and discuss orientation and clinical details with the surgeon intraoperatively. A workflow of the process is summarized in Table 2.1.
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Many surgeons are unaware of the method pathologists use to assess margins. And if the services within a laboratory are delegated by the pathologist to another staff member such as a technician, the pathologist may also be unaware of exactly what takes place in the examination of a specimen. It is important that the surgeon has a good understanding of the procedures involved in order to provide the most appropriate specimen and information required for accurate margin assessment. For example, sending piecemeal biopsies of the peripheral margins may seem like an attractive idea to the surgeon but these can make a subsequent complete assessment of the margin impossible for the pathologist. Thick, wide excisions for small tumors can cause processing difficulty and delays. It is essential that the surgeon appreciate that precise technical expertise and time are required to complete a full-margin assessment.
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