The Value of Radiation as an Option for BCC and SCC

The Skin Cancer Foundation calls Mohs micrographic surgery the gold standard for treating basal cell carcinomas and squamous cell carcinomas.¹ However, another option may be preferable for patients for whom cosmetics or minimizing pain is a priority: radiation. The Skin and Cancer Institute notes that image-guided superficial radiation therapy (SRT)-brachytherapy, a form of radiation treatment, offers a noninvasive alternative with “unparalleled benefits” including precision and accuracy, minimized discomfort and downtime, cosmetic excellence, and advanced technology for personalized treatment.

Bryan Gray, DO, performs both treatments at Gray Dermatology & Cosmetic Surgery in Ohio. For Skin Cancer Awareness Month, Practical Dermatology spoke with Dr. Gray about why radiation should not be dismissed as an option.

Why is radiation therapy an important option to offer nonmelanoma skin cancer patients?

For patients who definitely need surgery, I perform surgery. With radiation, however, the scarring tends to be significantly better in certain locations—especially in cosmetically sensitive areas—so it is a good fit for many patients. For painful sites for local anesthesia (eg, the nose, ear, and scalp), it has been a valuable treatment.

There is emerging research regarding combination therapies as well. We have discussed conducting trials involving topical therapy, and some clinics are incorporating hyperthermia—heating the tumor before radiation. There is also growing interest in combining radiation with oral hedgehog inhibitors. In the next 5 to 10 years, new protocols are likely to emerge.

A major issue with radiation is that, depending on the site, patients may require up to 20 fractions, which can be time-intensive. With combination therapy, using several modalities might reduce the number of visits and fractions, which would be ideal for patients.

What are some misconceptions about radiation therapy?

A prevailing belief among dermatologists who do not offer radiation therapy is that it is primarily a revenue-generating procedure because it bills more than Mohs surgery. While it does reimburse at a higher rate, it is still cost-effective. The higher expense reflects the significant capital investment needed for an advanced machine and a radiation technician.

Consider this: We often prescribe biologic therapies that cost upward of $60,000 annually, yet a one-time capital-intensive procedure is labeled a “money grab.” Of course, I am speaking from the perspective of running my own practice: Performing the Mohs procedure vs. utilizing radiation does not really affect me. For contracted Mohs surgeons working on a production model, I can understand the perceived threat. That said, radiation remains an effective treatment, and patients are generally satisfied with the results.

What should the conversation be with the patient when considering this?

The bottom line is simply to have the conversation. It’s important to help patients understand when radiation therapy is appropriate—when it is less painful, when it enables faster recovery, and when it may be unnecessary.

For example, if a lesion is in a surgically accessible area, why bring someone back for 12 to 15 treatments when I can just treat them once? Educating patients and breaking down stereotypes about it is essential for patient-centered care. 

Reference

1. Skin Cancer Foundation. Mohs surgery: the most effective technique for treating common skin cancers. Accessed April 7, 2025. https://www.skincancer.org/treatment-resources/mohs-surgery/