Radiation treatment for non-melanoma skin cancer- look before you leap

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I recently saw an 80 year old man. Ten years ago, he had a squamous cell skin cancer on his scalp. His dermatologist recommended radiation therapy. Eight years later, the treated area broke down spontaneously and for two years he has had an ulcer on top of his head that has resisted all efforts to get it healed. On his examination now, he has a 2. 5 cm (1 inch) round ulcer on top of his head. The base of this ulcer is bare bone. The surrounding scalp is fibrous with no elasticity and clearly poor blood circulation. Getting this ulcer healed will require major surgery, if can be done at all.

 

This should never have happened? A squamous cell cancer of the scalp is a simple excision and reconstruction for a plastic surgeon. Until relatively recently radiation has never been the first line of treatment for a non-melanoma skin cancer, e.g. squamous and basal cell cancers. I have referred patients for radiation for skin cancer in the past only when the cancer must be treated (not all such cancers need to be treated) and surgery is not an option. This would include patients who are simply not candidates for surgery because of other medical conditions or other factors. In the past, most radiation oncologists and dermatologists would have agreed that radiation is a secondary choice, not first line treatment. Now, this has changed.

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What has changed is the development over the past ten years or so of new devices that can deliver more focused radiation to small skin cancers in any doctor’s office. These devices have put radiation treatment for skin cancers in the hands of literally any physician who wishes to treat patients this way. They eliminate the need for special office construction with expensive lead shielding and the need to store and work with radioactive materials. Not surprisingly, between 2011 and 2013 the use of this type of radiation, known as high dose rate electronic brachytherapy (HDR-EBT) increased twenty fold in the U.S. This is concerning to me and others.

 

There is a reason surgery has been the gold standard for non-melanoma skin cancers. It is very precise. Only the cancer and a very small margin of normal skin are removed. Surgery provides confirmation that the cancer has been removed completely. Surgery, when performed by a plastic surgeon who can both remove the cancer and reconstruct the defect, is accomplished in a single procedure, usually over the course of an hour or two of office surgery. Once healed, the area will not spontaneously break down later, as it did here. If the cancer recurs, or if a new cancer arises in the vicinity, repeat surgery can be done without any prejudice from the previous treatment.

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Radiation, even supposedly focused radiation, is a blunt instrument which kills cancer cells but also damages the normal skin and soft tissue surrounding the cancer. Radiation ulcers years later are not uncommon because of the damage to the tiny capillaries that nourish the skin and radiation ulcers are among the most difficult to treat. Radiation requires multiple sessions of treatment spread over weeks. With radiation, there is no confirmation that the cancer is gone other than to wait and watch for a recurrence. If the cancer recurs or another cancer occurs within the treated area, radiation cannot be repeated and surgery is then the only option. Surgery is hugely more difficult and less often successful when operating on tissues that have been previously radiated.

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Given those facts, why would any physician recommend radiation first? Cynical me, I believe that there is a very strong monetary incentive to do this. If I remove a skin cancer just over an inch in diameter and cover the area with a skin graft, this takes me typically an hour or so. Medicare pays me between $1100 and $1700 for the entire procedure (the variation is due to geographical differences in Medicare payments). If I do this in my office, Medicare pays me a facility fee of about $600 to cover my out-of-pocket expenses to provide this surgery- supplies, sutures, instruments, disposables, nurses time, utilities, etc. The total payment is therefore between $1700 and $2300. Most skin cancers are smaller than this and do not require skin grafts, so the treatment costs are significantly lower.

 

HDR-EBT for even small skin cancers typically requires eight or more treatment sessions spaced over four weeks. The typical code used for billing to Medicare pays $1750 per session, or $14,000 for the full course of treatment, a nearly seven fold increase over surgery. Total bills of over $20,000 are not uncommon.

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Even some dermatologists have publicly expressed grave misgivings about the inappropriate use of HDR-EBT and the exorbitant billing for these services. Companies marketing these machines to doctors have stressed how lucrative they are over how safe and effective. They push for their use in ever smaller cancers and in younger patients. Cure rates for non-melanoma skin cancers are reportedly good but no better than for surgery. Cosmetic benefits of HDR-EBT have been promoted but cosmesis with surgery is usually good to excellent. Complications, such as radiation ulcers are downplayed and it is next to impossible to find numbers on how often these occur. Because radiation changes to tissue are permanent and often progressive, I expect the incidence of ulcers to rise over time. A recent review of the literature concluded that the safety and efficacy of HDR-EBT have not yet been established.

 

What is a patient to do? My advice would that if you are diagnosed with a non-melanoma skin cancer and your doctor recommends radiation using HDR-EBT over surgery, before you forge ahead seek a second opinion from a plastic surgeon. You may save yourself a lot of money now and a good deal of grief later.

 

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Orlando Opinions EP 20 – The Street Food DIstrict

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Orlando Opinions Podcast seeks to offer a new way of looking at how new retail, restaurant and residential projects affect Orlando locals. The 5-minute show is scripted, fast paced and full of sass thanks to host by Mark Baratelli, Editor of Orlando’s longest-running local indie news website, thedailycity.com. The episodes are released every Sunday. Orlando Opinions is a production of PFT Media.

Subscribe here: Spotify | iTunes | Stitcher | Player.FM

Transcript of Episode 20:

For years Tasty Takeover, Orlando’s original weekly food truck event, took place across two separate rear parking lots in The Milk District: a larger lot behind 2428-2434 E. Robinson St and a smaller one behind 2424 E Robinson St. The lots were connected by a pass-through. They regularly hosted 13 trucks.

Starting Tuesday January 9th, Tasty Takeover moves to the smaller lot and go from from 13 to 10 trucks and a new event called “Tuesday Food Trucks” run by Berio Enterprises LLC will take over the larger lot with an as-yet-undisclosed number of trucks. The lots are next door to each other and both events will run every Tuesday 6-10pm.

The addition of “Tuesday Food Trucks” will give The Milk District two food truck nights running on the same day of the week at the same time of day.

Also, just one mile away are two other food truck events at Orlando Fashion Square Mall: The Daily City’s Food Truck Bazaar has 10-15 trucks once a month on 2nd Sundays 6-9pm and Kona Food Truck Luau has 10-15 trucks once a month on 3rd Saturdays 6-9pm.

All 4 food truck events take place within a mile of each other so The Daily City is calling this area the Street Food District.

Honestly, I’ve heard attendance has dwindled lately at Tasty Takeover as it also has at Food Truck Bazaar. Maybe the days of food truck events are numbered. We are sure to find out in 2018. Perhaps the area is over-saturated. We’ll find out in 2018…

According to Wall Street Journal, NPD Group says tacos are one of the top five foods ordered at restaurants in the US. The owners of KASA must have been paying attendtion because they’re kicking their KASA concept out and replacing with… a taco restaurant! The name is Chela Tequila and Tacos and will launch the newall-Mexican menu January 23rd.

KASA isn’t the only restaurant heeding the call of the taco. The over abundance of taco restaurants made Orlando Weekly’s “Top 10 Orlando Food Trends We Hope Stay Behind” for 2018. The writer of that piece said,”Restaurateurs responded to Orlandoans’ cries for “better Mexican food!” with approximately 15,000 new Mexican restaurants…” Here’s one more!

Crate and Barrel is closing inside Mall at Millenia. I didn’t care either right? Cuz I’m a man and the only reason I’d ever need a $350 Le Crousset sauce pan is to slap my dick on because thats what men do, you pussy fucks! Well apparently people do care about the closing of Crate and Barrel because we taped a tongue in cheek sad video walk thru of the 99% empty store and people’s comments were… sad!. Some locals really like this store and are sad to see it leave. Also, a couple employees said the closing was announced to them a week before Christmas. Now that is some sad shit right there we never thought about. We were too busy dick slappin’ water goblets in the tableware section to care. Watch the video on our Facebook page at facebook slash the daily city.

The U.S. Department of Justice awarded Orange County $3,125,000 to hire 25 full-time, sworn, career law enforcement officers over the three-year grant period ending October 31, 2020. The county must match that award with $3,409,749 comign from the Orange County Sheriffs Office.

The 25 officers will be assigned to three departments:

  1. Problem Oriented Policing Squad (“a proactive enforcement plan promoting change in the community’s view of police response”) 
  2. SWAT 
  3. And Homeland Security. 

This grant can be used for the following: (1) hire new officers, (2) rehire officers who have been laid off, or (3) are scheduled to be laid off on a specific future date, as a result of local budget reductions.

The maximum reimbursement for each officer’s salary and fringe benefits is $125,000.

And finally, get your hankies ready. On the blog I shared the top 10 clicked-on stories of 2017 and also shared my thoughts on the year and the history of The Daily City. I am going to read that now.

I am grateful for every click readers choose to give me. Bringing back this blog from the dead was a slow and steady, be happy with every click you get, write about what you want, write when you want… effort. Getting back into the routine of being 100% responsible for 100% of the content took a year. 2017 was a year of getting back on the horse.

The Daily City grew slowly in popularity 2007-2012. It won all the blog awards, I was invited to City of Orlando brainstorms and I was putting on special events like Orland’s first pop up shop, pop up dinner, recurring U-Haul art show, Cardboard Art Festival, Taco Truck Taste Test and eventually the gigantically successful Food Truck Bazaar. I loved what I and many many others had created: this little brand that could do a blog and events.

And then I caused its downfall (1) I turned my attention to Food Truck Bazaar which by 2012 had turned into a legit real business and (2) I fired my writer. Bazaar started as a one-night event but I turned it into a 8-15 night a MONTH event. While the decision to focus on Bazaar was the adult thing to do (I was a poor and old-ish), it took my attention away from the blog which was my passion and how everything got started. My passion was the blog… and yet I screwed that up by firing the one person who was creating content for it.

Bazaar flourished and The Daily City died.

In February 2016 I announced I was closing the blog after 9 years in business. Orlando Sentinel wrote about the closing which shocked me because I felt it’d been dead a long time. At that point in 2016, The Daily City had just no relevance anymore. It was gone.

Then in 2017 I told myself to screw my 5-posts-a-day requirement and (1) write when I felt like it and (2) write about what I personally was interested in and (3) celebrate any clicks I got ever. If I got 50 clicks I would make myself say “Awesome!” These three things brought me back to life slowly over 2017.

I am so proud of myself for completing 714 posts on my own this year and I want to thank you for reading the site in 2017. I appreciate your readership.

VIP Tent Will Have Glam Bar, Booze Bar and Air Conditioning at the Orlando Pride Parade

Get smacked in the face with mardi gras beads and relators’ logo’d stress balls during this year’sCome Out With PrideParade in style and high fashion and tented luxury. For those wealthy enough to afford it, the VIP Experience: $85 ($95 day of because rich) gives the cultural elite an air-conditioned tent with open bar (2:00pm – 9:00pm), light bites (1:00pm – 7:00pm), and a Glam Bar so that guests can get glittered up before enjoying the photo booth. We’re still doing photo booths?

If the East Coast Ivey League amongst us want a clear view of the sweaty drunk drag queens and gay Republicans and whatnot, they’ll want theVIP Experience + Guaranteed Parade Grandstand Seating for $105 ($115 day of because rich). The grandstand is in the “prime seating location.”

The tent will be located atLake Eola Park,512 E Washington St, Orlando, FL 32801.

Rich people click here

The Daily City will be sitting on the dirty curb adjacent to the History Center.

Open Language Lab

When: Thursday, August 10, 2017 – 2:00 PM – 4:00 PM

Where: Windermere Branch at Windermere – Computer Area

Explore and learn English (ESOL) or the language of your choice in an open lab environment. Learn and practice using one of the available programs.

Life in Wine with the Dauntless @JeanKReilly, a Master of Wine!

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The Mount Everest encompassing all things wine is Master of Wine or Master Sommelier, a distinction earned only by the most tenacious and fearless women and men with an insatiable quest for knowledge. Personally, I consider them the modern age explorers, think perseverance of an Iron Man winner such as Mark Allen and Natascha Badman, and stealth like Chanakya and Vishwanathan Anand. MW or MS is a novel blend of doctorates such as PhDs in Law, MBA, Language, & Journalism all entwined together with an unparalleled combination of fearlessness and faith.

354 MWs across 28 countries in the world, out of which 41 MWs reside in the US, 15 of which are women, and only 1 lady MW in Florida, to be precise Orlando. Needless, to say we are honored and humbled to introduce Master of Wine Jean Reilly to our fellow oenophiles and WSET Diploma students (including yours truly), aiming to follow the foot steps of these high achievers.

RP: Master of Wine, eh? What precisely does it mean and tell us about your arduous journey into becoming one of the 15 women MWs in the United States.

MW Jean Reilly: Becoming a Master of Wine took me 7 years, $100,000 and an incalculable amount of blood, sweat and tears. There are no courses to take when studying for the Master of Wine title, it’s more of a DIY venture. The exam is a 4-day long intellectual marathon. Half of the day is spent on essay questions, such as ‘Assess the role of oxygen in the maturation of fortified wine,’ or ‘Discuss the impact of climate change on the global wine business.’ There is also a blind tasting of 36 wines. Students are expected to divine the grape variety, the country, the region in that country the wine comes from and possibly the town or vineyard if they’re important. And more detailed questions as well, such as the weather during the year the grapes were growing, the temperature the wine was fermented at, the type of vessel it was matured in, etc. When I started, no American had passed in 4 years, so it was a daunting prospect. But also fun; while cramming for the exam was difficult, I had a great time running around vineyards on five different continents, interviewing winemakers and viticulturalists. By the time I passed the exam, I had visited over a thousand wineries and also worked in Burgundy and New Zealand during the harvest.

RP: Why wine? What drew you to wine and how did your career unfold?

MW Jean Reilly: I was always interested in wine. My parents drank French wine with dinner when I was growing up and I can remember sneaking sips out of their glasses when they weren’t looking. Then I lived in Paris for a year when I was 19; wine is just part of the lifestyle there so that’s when it really got into my blood. In my early twenties, I picked up a book on wine (partly to keep my then boyfriend from lording his superior knowledge over me) and I was hooked. I read as many books as I could find and tasted everything I could get my hands on. I was in banking at the time and continued in that path until 9/11 when I decided I wanted to do something different. I had been writing a column about wine while I was in finance so I expanded that to a full-time job, which gave me an opportunity to further my education by asking really geeky questions at the wineries I visited.

RP: Does being a woman pose a challenge in the wine industry?

MW Jean Reilly: The stereotype of a wine expert is a white man, with white hair, wearing a tuxedo. However, I have found people in the wine business to be very open and helpful. There is also research that suggests that women are more sensitive tasters than men; perhaps this is why a dramatically increasing percentage of the new Masters of Wine are women.

RP: Tastings: Be it blind or open, what criteria does one utilize to assess a wine? And does price matter?

MW Jean Reilly: There are many things we look at when assessing the quality of a wine. The concentration is one of the first things any wine drinker notices. The amount of time the taste of a wine stays in the mouth (the ‘finish’) is also very important; a wine that has a 10 second finish gives you 10 times the pleasure of a wine with a 1 second finish. And then there’s what we call ‘complexity’, which is just a function of the number of different aromas and tastes.

In wine, there certainly is a correlation between price and quality, particularly at the moderately-priced end of the spectrum. However, when you spend over $100, you are usually paying for scarcity and prestige. I think the $15-$25 bracket is one of the most exciting right now, with many wines delivering enormous value.

RP: Wine Pairings: is there a trick behind a successful dining experience?

MW Jean Reilly: My best advice for anyone who wants to understand food and wine pairing is to try at least two different wines with every dinner. You don’t have to be part of the Walton family to do this without extra expense; there are loads of wine preservation devices on the market now, including Coravin and VacuVin, that make this more practical. The single most important aspect of food and wine pairing after having fun with it is to be willing to experiment. I often do employee or client appreciation events around food and wine pairing and one of the biggest ‘ah-ha’ moments is always when someone tries a red wine with a dish normally paired with white wine. Don’t be afraid to try a Beaujolais with halibut and a Chardonnay with a steak. Be bold and listen to your palate.

RP: Are wines considered fashionable? What are the latest trends in the wine business?

MW Jean Reilly: Wines continue to grow in popularity in the US. Recently, it is the ever-curious Millennial generation that has been driving the growth. They are more open to trying new things, which has led a much broader range of wines appearing on the market. We have yet to see what the iGen thinks about wine the first of them are just turning 21 but I think this trend will continue for quite some time.

Ros is one of the trendiest wines right now. The Millennials missed the White Zinfandel craze and so were quick to appreciate that there is a world of high quality ross out there that are dry, food-friendly and just plain exciting. There is also a trend to making white wine in the way it was made several thousand years ago (and still is in some parts of Georgia and Armenia). These wines are fermented with their skins, in the same way as red wine. The result is a gold colored wine called an ‘orange wine.’ Often they have less sulfur added. Sometimes these hollaback wines are enticing; other times, well, let’s say that a little modern know-how is not always a bad thing.

RP: As an MW, you also assess spirits? Gin, vodka, whiskey etc

MW Jean Reilly: I love both spirits and beer almost half of the events I do for corporate groups at Masterful Wine Events revolve around spirits or beer. If there were a ‘Master of Spirits’ title, I would be studying for it. I just started offering spirits classes at Slate Wine Academy and I am really looking forward to engaging with the spirit-loving population.

RP: For people considering a career in the wine industry, especially through the WSET program, what piece of advice would you offer them?

MW Jean Reilly: The wine industry is full of career-changers Americans just don’t turn 21 and say ‘what I want to do is work with wine!’ But before launching into a career in wine, you have to do 2 things. First, you need to understand the structure of the wine industry. Due to regulations dating to the repeal of prohibition, it is quite convoluted and it takes some study to figure out where you might find a good fit.

Then, you need to learn about wine. I teach classes that lead to professional certifications through the WSET, which are the most academically rigorous and the most recognized in the industry. One thing I would caution people is to start at the right level. If you have been in the industry, you’ll want to skip Level 1. If the school you contact tells you that everyone has to start at the lowest level, run the other way; that’s just not how education works. There are also numerous other certifications out there. Having one of these certifications really gives you a leg up when you’re looking for a job.

RP: Wine Education: Tell us how it can be helpful especially to the emerging market of millennials.

MW Jean Reilly: People who like wine always end up getting more pleasure out of it when they learn more about it. Starting with a good book is a great first step. But if you want to learn about tasting wine and understanding the terms people use to talk about wine, you really need to take a class you can’t learn to taste from a book. There are loads of options out there from the $25 2-hour wine classes at Tim’s Wine Market which are an incredible deal- to more challenging certification classes like the ones I offer at Slate Wine Academy. The millennial generation is much more knowledgeable about wine than earlier generations so those who don’t know much may feel left out. And of course wine knowledge is very important in business entertaining. As a junior employee, being wine savvy can bring you to the attention of senior management. Before I left the world of finance, I can remember being invited to several dinners with the president of my company just so I could pick the wine and talk about it with the customers he was entertaining.

RP: We heard through the grape vine you are also a certified sky driver? Tell us about it?

MW Jean Reilly: I did my first skydive in 2005 after working at a winery in New Zealand during the harvest. I learned an amazing amount but it was absolutely grueling. I was working 13-hour days and I didn’t have a day off until I’d been there three weeks. So I guess you could say I needed something extra to help me unwind. When I finally became a Master of Wine in 2010, I had some spare time for the first time in 7 years and decided to get certified. Now I have several professional licenses that allow me to teach skydiving and also put on skydiving shows at unorthodox places like resorts or golf courses. Sometimes, I even get to arrive at a wine tasting by parachute. I think in addition to the adrenaline rush, what appeals to me is that it is a great stress-reliever. You’re never thinking about what’s going on in the office when you’re in freefall!

RP: We have to ask what is your favorite wine?

MW Jean Reilly: I have thousands of favorite wines and I get asked that question frequently. Over the years, I have learned that my answer should depend on what I think the best bottle in the cellar of the person asking the question might be; they’ll usually take it out and share it with me if I can name it. So, Rashmi, I think my favorite wine is . . . the Rangen de Thann Riesling from Zind Humbrecht?

Here’s how you can enroll in MW Jean Reilly’s classes Slate Wine Academy.

For Wine Tastings and additional seminars check out Tim’s Wine Market with5 locations including Orlando -1223 North Orange Ave Orlando, FL 32804. location phone407-895-9463.

Florida residents employed in an industry related to the production, sale or service of alcoholic beverages, wishing to advance their knowledge of fine wine, craft beer and/or distilled spirits or obtain recognized certification of professional expertise can apply to The Merendino Foundation for scholarship assistance.

D is for Dinosaur

When: Thursday, June 01, 2017 – 2:00 PM – 3:00 PM

Where: West Oaks Branch at West Oaks – Meeting Room 1

Dino time is near, let’s give a roaring cheer! We are off on a dinosaur adventure using stories and activities and having a great time together! Ages 3-5.