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Madison, Wis. — Pat Richter grew up during a time when getting a lot of sun was seen as a good thing.
“Back in those days, you wanted to get a tan, and so you stayed out in the sun and didn’t protect yourself,” he said.
The 78-year-old former football player and UW-Madison athletic director has had his issues with skin cancer. Recently, he was evaluated for a cancerous spot on his cheek. After a thorough evaluation, it was determined that a total of six spots on his face would need to be removed, analyzed and repaired through Mohs surgery, a precise surgical procedure for patients with certain types of skin cancer.
He came to the UW Carbone Cancer Center in February and had the cheek spot treated by Juliet Aylward, MD, a Mohs surgeon with UW Health and professor of dermatology at the UW School of Medicine and Public Health. He made an appointment to see her again in April to take care of two more spots.
Then, COVID-19 threw a wrench into that plan. UW Health made changes across the system to prepare for an expected surge of coronavirus patients. Dermatologic surgeons, who often do several Mohs surgeries a day, were asked to consolidate their operations from three locations down to one clinic, in an effort to conserve personal protective equipment (PPE) and redeploy some staff to the hospital. That left the department needing to reschedule over 600 of these surgeries, including Richter’s next procedure.
“There was a big shift, and everyone had to pivot,” Aylward said.
It all happened during an especially busy time of their year, with many individuals returning to Wisconsin with new cases of skin cancer after spending the winter in a sunny environment.
Facing these limitations, Aylward and colleagues got to work making some changes that would allow patients like Richter to get rescheduled as quickly and as safely as possible. “For us, it was about how to be inventive and innovative in this restricted climate to still help cancer patients,” she said.
It started with administrative changes. With operations down to just one dermatology clinic, the team converted all available clinical space to accommodate this procedure. They developed a system to take patients directly to their room upon arrival, eliminating the need for a waiting room, and keeping that patient in the room for the duration of their stay. They also began scheduling more appointments in a day, prioritizing patients with more aggressive forms of skin cancer. But to make this all work, they also needed some additional help.
There are three elements to Mohs surgery – removal, analysis and repair. A Mohs surgeon begins by cutting out a patient’s visible skin cancer along with a small margin of surrounding skin. After removal, that skin sample is examined under a microscope. If cancer cells are found, the involved areas are then also removed. This process continues until there are no more cancer cells, and the Mohs surgeon repairs the wound by stitching it together as a line or with a skin flap or graft. The whole process is quick, relatively painless and has a high cure rate.
However, Aylward realized that start-to-finish approach wouldn’t work on a tighter-than-normal schedule. While some cancers are gone after the first stage of removal, others take multiple stages. Fortunately, she had some colleagues who were in a unique position to help. She partnered with the chief of UW’s division of plastic surgery, Michael Bentz, MD, to develop an innovative approach. With cosmetic procedures and many surgeries put on hold at UW Health, plastic surgeons, oculoplastic surgeons and ENT surgeons all stepped up. “They were eager to help, but initially had no opportunities,” Aylward said. “We had a lot of need, but a limited, restricted environment.”
With some collaboration, these surgeons were able to take on the repair portion of the procedure, freeing up the Mohs surgeons to focus on removal and analysis, and allowing them to see more patients in a day.
The shift to this model happened quickly. “In 48 hours, we pulled this off, we made all these changes, and we’ve been constantly refining it, taking great care of patients, seeing lots of people safely, and preserving PPE,” Aylward said.
Consider it the temporary evolution of a procedure that has deep Wisconsin roots. Frederic Mohs, a physician and surgeon, developed and refined the procedure at the University of Wisconsin in the 1930s. Over time, dermatologic surgeons would take over the duty of performing the procedure, but the ties to surgery run deep.
“There’s this tradition of working with general surgery because of Dr. Mohs, and in a way, we are revisiting that tradition,” Aylward said. “Our colleagues in surgery feel very proud of their historical connection to him.”
Ultimately, these surgeons will return to their regular duties, and the dermatologic surgeons will resume conducting all three steps of Mohs surgery. That said, Aylward says all departments are ready to pivot back to this model again, should there be a second wave of COVID-19 cases in the future.
As for Richter, Aylward was able to reschedule him for an appointment later in April, where she was able to successfully treat cancerous spots on his lip and nose. “The way they accommodated the surgery, plus the follow up, was terrific,” Richter said. “Everything was spaced far enough apart, and it was just a great set-up.”
Since then, Richter has returned to UW Health to have other spots addressed. He faces more treatment in the future, but hopes his skin is on the road to recovery. Richter says he also appreciates that his care team didn’t lose sight of those personal touches – offering check-ins and updates – even as they were seeing more patients than usual.
“They took the time to personally find out how I was doing,” Richter said. “You couldn’t find any better doctors, as far as I’m concerned.”