By Lorie Chater

Mohs surgery was developed in the 1930s by American surgeon Dr. Frederic Mohs, primarily for skin cancers on the head and neck. This procedure offers the highest cure rates, while also sparing as much normal tissue as possible. Mohs surgery is proven to be more cost-effective than electrosurgery, radiation and other excisional procedures.

Dr. Jillian MacDonald (BSc’01, MD’05), associate professor of the Department of Medicine at the Ottawa Hospital, is one of only 16 accredited Mohs surgeons in Canada, along with fellow alumni, Dr. Robert Hayes (MD’00), the only Mohs surgeon to service the Maritime Provinces and Dr. Christian Murray (MD’98), the director of the Mohs surgery fellowship at the University of Toronto.

High demand, long waitlists

“Mohs surgery is a very unique specialty with a growing demand and increasing waitlist,” says Dr. MacDonald. “Unfortunately, Canada is extremely under-serviced in this field, and Mohs is still not particularly well-known among our medical colleagues, or even the general population.”

Each year, Dr. Hayes’s clinic in Saint John, New Brunswick treats approximately 500 patients from across Atlantic Canada with challenging basal and squamous cell carcinoma.

“Every year we see more and more skin cancers in Atlantic Canadians, and the current demand for Mohs surgery is outpacing the supply,” says Dr. Hayes. “Whenever possible, I favour a team approach with the patient’s referring dermatologist, plastic surgeon, radiation oncologist, or otolaryngologist.”

Dr. Murray agrees with his colleagues that Mohs surgeons are expanding their ability to treat patients, but the wait list continues to grow.

“Mohs saves money for the health system because it reduces costs associated with treating recurrences and does not require radiation, hospital operating rooms, or inpatient stays,” says Dr. Murray. “Cost-effectiveness is critical to our health system and certainly any method that combines safety, effectiveness, and improved quality of life measures will be popular with patients and health care providers alike.”

A day in the life of a Mohs surgeon

“I really love what I do, and I think in large part it’s because of the relationships I’m able to form with my patients,” Dr. MacDonald says. “Patients are often anxious and worried about having surgery, but I’ve got a great team that is very invested in Mohs and we do everything we can to put patients at ease.”

Throughout the day, Dr. MacDonald is face-to-face with her patients, as they come in for all-day surgery. Because the patients are awake throughout the procedure, Dr. MacDonald is able to speak directly with each patient, learning more about their everyday lives to develop a sincere and trusting bond.

“It’s rewarding because these patients are very grateful for the care that we provide,” she says. “I feel privileged to have the opportunity to do this kind of work and have patients leaving relieved.”

Surprisingly, Dr. MacDonald has not always known that she’d be doing this kind of work. Coming from an athletic background, Dr. MacDonald originally considered orthopedic surgery. As medical school progressed, she found herself enjoying her plastic surgery electives and core dermatology lectures while developing a particular interest in skin cancer. Dr. MacDonald discovered Mohs surgery in her third year of residency and found it to be a natural fit, as the subspecialty virtually marries dermatology and plastic surgery.

Awareness and expertise

Dr. MacDonald stresses that awareness is still a big challenge but notices that more colleagues, such as ENT specialists, general practitioners, and dermatologists, are beginning to refer patients to Mohs surgeons. With a catchment area including a population of approximately two million people, Dr. MacDonald also sees the increasing demand of Mohs surgeons as a major challenge.

“I recommend that students look into Mohs surgery as an option if they enjoy the core elements of dermatology and really want to incorporate technical skills and surgery into their practice,” he says. “It’s a holistic and all-encompassing approach to skin cancer that allows you to see the full clinical picture, as well as the pathological or histological picture, and then administer the treatment.”

Dr. Murray adds that expertise in Mohs surgery requires exposure to high volumes of complex skin cancer patients, meaning that the appropriate education is crucial.

“I think at this point in time, you really need to complete an accredited fellowship after a dermatology residency to become proficient,” says Dr. Murray. “Our centre sees over 3,000 Mohs patients per year, the most in Canada, and that experience provides comfort for the Mohs team and also the patient, who knows Mohs is unpredictable by nature.”

Dr. Murray also considers his colleagues a source of enjoyment in practice.

“We have a great relationship with so many exemplary surgeons, radiation oncologists and dermatologists. This respect translates to happier patients and better outcomes because we refer appropriate cases back and forth and each of our strengths work together for the best interests of the patient.”

This article originally appeared in the Spring 2014 issue of  VoxMeDal.