Mohs vs. GentleCure (SRT): Expert Analysis

Evidence Snapshot

• Mohs surgery excels at curing skin cancer: Recurrence rates are 1.0% at 5 years for primary basal cell carcinoma (BCC), compared to 4.3% for image-guided superficial radiation therapy (IGSRT/GentleCure) (Rowe et al., 1989; Patel et al., 2025).

• Longer follow-up widens the gap: At 10 years, Mohs maintains 4.4% recurrence for primary facial BCC while IGSRT climbs to approximately 8-10% or higher, depending on tumor depth and histology (van Loo et al., 2014; Roth et al., 2020).

• NCCN recommends Mohs as first-line: For high-risk nonmelanoma skin cancers, Mohs is the preferred treatment; radiation is "an accepted alternative approach to surgery among patients who are medically inoperable, those who refuse surgery, and in cases where surgical excision may be associated with a poor cosmetic outcome" (NCCN Guidelines, 2025).

• Recurrent cancers strongly favor Mohs: If a skin cancer returns after prior treatment, Mohs achieves 5.6% recurrence versus 19.9% for other modalities — a dramatic difference (Rowe et al., 1989b).

• Mohs surgery produces smaller scars: Because margins are tissue-sparing, 96% of Mohs patients report good-to-excellent cosmetic outcomes, compared to 69% for radiation therapy (Petit et al., 2000).

What Is Superficial Radiation Therapy (SRT), and How Does It Work?

Superficial radiation therapy—commonly marketed as GentleCure when using image-guided technology (IGSRT)—is a non-surgical treatment that uses targeted X-rays to destroy skin cancer cells. Unlike external-beam radiation used for deep cancers, SRT delivers focused, low-energy radiation directly to the skin surface, penetrating only a few millimeters into the tissue.

How SRT Works

During SRT treatment, a radiation applicator is held against the skin and delivers a measured dose of radiation in short bursts. Image-guided SRT (IGSRT, the brand GentleCure) uses camera-based targeting to align the applicator precisely and reduce the margin of error. Most treatment courses require 12–20 sessions spread over 4–6 weeks, with each session lasting 5–15 minutes.

The Appeal of Radiation

For patients, radiation therapy offers clear advantages: no surgery, no sutures, no downtime, and no need for local anesthesia. Patients can typically return to normal activities immediately after each session. This makes SRT especially attractive to elderly patients, those on blood-thinning medications, or individuals with mobility or health concerns that make surgery risky.

Mohs Micrographic Surgery: The Gold Standard

Mohs micrographic surgery is a specialized surgical technique developed in 1938 by Frederic Mohs. It differs fundamentally from standard excision because the surgeon removes tissue layer by layer and examines each layer under a microscope during the procedure to confirm that all cancer has been removed.

How Mohs Surgery Works

On the day of surgery:

1. The surgeon removes a thin layer of tissue containing the visible cancer and a small margin.
2. The specimen is processed on-site (typically within 30–60 minutes).
3. The pathologist examines the entire undersurface and edges under a microscope.
4. If cancer remains, the surgeon removes additional tissue from the specific area where cancer was found.
5. This process repeats until the margins are clear.
6. Once confirmed cancer-free, the wound is closed or left to heal by secondary intention.

The beauty of Mohs is precision: the surgeon removes only the tissue necessary to cure the cancer, sparing as much healthy skin as possible. This results in smaller wounds and superior cosmetic outcomes.

Why Mohs Achieves Superior Outcomes

Mohs has the highest cure rates of any treatment for skin cancer—supported by decades of robust evidence. The fundamental advantage is 100% margin examination: every edge and every layer is inspected microscopically, ensuring complete cancer removal before wound closure. Standard excision, by contrast, examines roughly 1% of the surgical margin via bread-loaf sectioning, relying on wider margins to compensate for incomplete tissue assessment.

Cure Rates: The Evidence Head-to-Head

This is the most critical question: which treatment actually cures skin cancer better?

Mohs Surgery Cure Rates

The landmark 1989 meta-analysis by Rowe, Carroll, and Day remains the most comprehensive comparison ever published, analyzing all published outcomes dating back to 1945:

• Primary BCC: 99% cure (1% recurrence) at 5 years (Rowe et al., 1989)
• Recurrent BCC: 94.4% cure at 5 years
• Primary SCC: 97% cure at 5 years
• Recurrent SCC: Significantly superior to all other modalities

More recent data confirms these benchmarks:

• van Loo et al. (2014) RCT: 10-year recurrence 4.4% for primary facial BCC; 3.9% for recurrent facial BCC (van Loo et al., 2014)
• Wehner et al. (2025): Network meta-analysis reported 1.9% recurrence for Mohs across all skin cancer types (Wehner et al., 2025)

Image-Guided SRT (IGSRT/GentleCure) Cure Rates

Modern image-guided SRT shows strong short-term results for selected, low-risk tumors:

• 2-year freedom from recurrence (recent multicenter data): 99.2-99.7% overall
  • BCC: 99.2% (0.8% recurrence at 2 years, per Moloney 2025)
  • SCC: 99.2% (0.8% recurrence at 2 years)
  • In-situ SCC: 100% (per Agha et al., 2024)

However, longer follow-up reveals important limitations:

• 5-year recurrence (IGSRT): 4.3% for BCC (Patel et al., 2025)
• 7-year freedom from recurrence: 98.9% (Roth et al., 2020)

Distinction from traditional (non-image-guided) SRT: Traditional SRT—used before image guidance became standard—had significantly higher recurrence rates (8.2% for nodular BCC, up to 27.7% for sclerosing subtype at 7 years, per Zagrodnik et al. 2003). Modern IGSRT is considerably more effective, but still lags behind Mohs at longer follow-up.

Standard Surgical Excision (Non-Mohs) Cure Rates

• 5-year recurrence: 3.8% for BCC (Drucker et al., 2018 network meta-analysis)
• Advantage: Faster than radiation, less expensive than Mohs
• Disadvantage: Higher recurrence than Mohs; less ideal for high-risk or recurrent cancers

The Bottom Line on Cure Rates

At 5 years and beyond, Mohs surgery is statistically superior. The 2025 meta-analysis by Patel et al. pooling head-to-head comparisons found Mohs achieved 1.9% recurrence versus SRT 6.3% recurrence (p=0.0013) — a clinically meaningful difference. This gap widens further at 10+ years, where Mohs maintains low recurrence while IGSRT rates climb.

For small, low-risk, well-selected tumors treated with image-guided technology, IGSRT performs well short-term. But if longer cancer control is the goal—especially for larger, recurrent, or aggressive tumors—Mohs is superior.

Recurrence: What Happens If Treatment Fails?

Mohs Surgery Recurrence

The landmark 1989 Rowe study remains definitive:

• Primary BCC: 1% recurrence at 5 years
• Recurrent BCC (cancer that had been treated before): 5.6% recurrence at 5 years versus 19.9% for all other modalities combined

This is perhaps the most compelling finding: if a patient's skin cancer returns after a first treatment, Mohs surgery is dramatically superior to any other option, cutting the recurrence risk roughly three-fold.

IGSRT Recurrence

Published data show:

• 2-year recurrence (IGSRT): 0.7–1.1% for BCC
• 5-year recurrence: 4.3% for BCC (recent data)
• 7-year data (longest published): 98.9% freedom from recurrence (Roth et al., 2020)

IGSRT recurrence rates increase with longer follow-up, which is expected given the biological behavior of skin cancer. Vigilant surveillance every 6–12 months for 5+ years is essential.

Standard Excision Recurrence

• 5-year recurrence: 3.8% for primary BCC
• Higher risk for poorly differentiated SCC or tumors with perineural invasion

What the NCCN Guidelines Actually Say

The National Comprehensive Cancer Network (NCCN) is the gold standard for cancer treatment recommendations in the United States. Their 2025 guidance is clear and nuanced:

For High-Risk Basal Cell Carcinoma

• Preferred: Mohs micrographic surgery
• Alternative: Surgical excision with wide margins (consider Mohs for face, ears, eyelids, genitals)

For High-Risk Squamous Cell Carcinoma

• Preferred: Mohs micrographic surgery for primary and recurrent disease with high-risk features (thickness >2 mm, Clark level IV–V, poor differentiation, perineural invasion, location on lip or ear)
• Alternative: Surgical excision with wide margins; consider sentinel lymph node biopsy for very high-risk disease

For Patients Who Cannot Tolerate Surgery

• Accepted alternatives: Radiation therapy (for nonsurgical candidates), cryotherapy (limited role), topical 5-FU or imiquimod (low-risk only)

The NCCN explicitly states: "Radiotherapy is considered an accepted alternative approach to surgery among patients who are medically inoperable, those who refuse surgery, and in cases where surgical excision may be associated with a poor cosmetic outcome."

In plain English: Mohs is preferred, but radiation is acceptable when surgery isn't safe or feasible.

Cosmetic Outcomes: Scar Appearance and Patient Satisfaction

Patients care about two things: cure and appearance. What does the evidence show?

Mohs Surgery Cosmetics

Because Mohs removes only the tissue necessary to clear cancer, wounds are typically smaller than with standard excision. Studies report:

• Good or excellent cosmetic outcome: 96% of patients (Petit et al., 2000)
• Wound healing: Primary closure (stitches) or secondary healing (letting the wound close on its own) are both options depending on location and size
• Scar appearance: Generally minimal, especially on the face

The narrower margins spare healthy tissue, reducing overall tissue loss and scar burden. This is particularly important on the face, neck, ears, and eyelids—the most cosmetically sensitive areas.

Radiation Therapy Cosmetics

Radiation therapy leaves no visible surgical scar—a real advantage. However, long-term side effects are common:

• Acute side effects: Erythema (redness), edema (swelling), occasional blistering during and immediately after treatment
• Long-term effects: Skin atrophy (thinning), telangiectasia (dilated blood vessels), pigmentation changes, and rarely fibrosis or ulceration
• Timeline: Side effects may not fully resolve for months to years
• Appearance: Some patients report persistent redness, texture changes, or a slightly "weathered" appearance in the treated area

In a 2024 study, 25.4% of radiation-treated lesions had no noticeable side effects, but 74.6% experienced some degree of skin changes, often persisting long-term.

Head-to-Head Cosmetic Comparison

The 2000 Petit et al. randomized trial directly compared Mohs surgery to radiation therapy in 74 patients:

• Mohs: 87% good-to-excellent cosmetic outcome at 4 years
• Radiation: 69% good-to-excellent outcome at 4 years
• Winner: Mohs produced superior long-term cosmesis (Petit et al., 2000)

This is particularly important on the face: while radiation avoids an acute surgical scar, the chronic skin changes often prove less cosmetically acceptable to patients than a well-executed surgical scar.

Who Is a Good Candidate for Each Treatment?

Mohs Surgery: Ideal Candidates

Mohs is the best choice if:

• Tumor is on the face, ears, eyelids, lips, genitals, or other cosmetically sensitive areas
• Tumor is high-risk (aggressive histology, perineural invasion, large size, recurrent)
• Patient is medically fit for surgery
• Tumor edges are poorly defined clinically (likely to need layer-by-layer assessment)
• Patient wants the lowest recurrence risk and best cosmetic outcome
• Patient can tolerate a single day of surgery and local anesthesia

Mohs may not be ideal if:

• Tumor is on the back, leg, or other low-cosmetic-priority area (standard excision is adequate)
• Patient cannot lie still or tolerate local anesthesia
• No Mohs surgeon is available nearby (geographic limitation)

IGSRT (GentleCure): Ideal Candidates

IGSRT is the best choice if:

• Patient is elderly or medically frail
• Patient is on anticoagulants (blood thinners) and surgery poses high bleeding risk
• Patient has severe anxiety about surgery or refuses surgical options
• Tumor is small (<2 cm), low-risk, and well-defined
• Tumor is on a location difficult to close surgically (lower leg, anterior shin)
• Patient values avoiding surgical downtime and prefers gradual treatment
• Good follow-up compliance (requires vigilant monitoring for recurrence)

Caution: IGSRT is less ideal if:

• Tumor is large (>2 cm) or shows aggressive features
• Patient has poor follow-up compliance (requires 5+ years of surveillance)
• Tumor is recurrent (after prior treatment)
• Tumor is on the head/neck with high cosmetic expectations
• Patient has genetic syndromes predisposing to skin cancer (e.g., Gorlin syndrome, xeroderma pigmentosum)—relative contraindication due to emerging concerns about secondary cancer risk

Standard Surgical Excision: Ideal Candidates

Standard excision is reasonable if:

• Tumor is low-risk and primary (not recurrent)
• Tumor is on the trunk or extremities
• Patient prefers single-day treatment
• Cost is a major limiting factor
• Adequate margins can be taken without functional impairment

Standard excision is inadequate if:

• Tumor is high-risk or recurrent (higher recurrence risk)
• Tumor is on the face or cosmetically sensitive area (go with Mohs)
• Tumor edges are clinically indistinct (Mohs provides layer-by-layer margin control)

Cost Comparison: What You'll Actually Pay

Healthcare costs vary widely by region, insurance, and facility type. Here's what the evidence shows:

Mohs Micrographic Surgery

• Office-based Mohs: $1,500–$3,500 per lesion
• Hospital/ASC-based: $4,000–$8,000+ (facility fees, anesthesia)
• Advantage: Single procedure, high cure rate, lower cost per unit of cure
• Note: Becomes more cost-effective for multiple lesions (same-day surgery)

Superficial Radiation Therapy

• Total cost per lesion: $5,000–$18,000
• Breakdown: ~$200–$400 per session × 12–20 sessions
• Insurance: Copays ($15–$50 per visit) add up; plan for 20+ copays
• Advantage: Spread over time; no upfront lump sum
• Disadvantage: Multiple facility visits; higher lifetime medical costs

Standard Surgical Excision

• Cost: $1,000–$2,500 per lesion
• Advantage: Cheapest option
• Disadvantage: May need re-excision if margins are positive (additional cost)

Cost-Per-Cure Analysis

If Mohs achieves 99% cure and IGSRT achieves 95.7% cure at 5 years, Mohs is slightly more cost-effective long-term. However, if standard excision is adequate for your specific tumor, it offers good value. For recurrent tumors, Mohs becomes clearly superior economically because the 5.6% recurrence rate (vs. 19.9% for other methods) means far fewer second treatments.

Recovery and Downtime: What to Expect

Mohs Surgery Recovery

• Procedure time: 2–4 hours (including wait time for histology)
• Pain: Minimal; local anesthesia blocks sensation during surgery
• Activity: Most patients return to normal activity same day; avoid heavy lifting for 1 week
• Wound care: Keep clean and dry; change bandage daily; sutures removed at 1–2 weeks
• Return to work: Next day for desk jobs; 1 week for physical labor
• Full healing: 3–6 weeks (varies by location and closure method)

Radiation Therapy Recovery

• Procedure time: 5–15 minutes per session
• No downtime: Resume normal activities immediately after each session
• Redness/swelling: May increase during treatment course; usually resolves within weeks
• Treatment timeline: 12–20 sessions over 4–6 weeks
• Long-term healing: Skin remodeling continues for months to years
• Work: No interruption; can work during treatment

Limitations of Each Approach

Mohs Limitations

1. Requires surgical expertise: Not all dermatologists perform Mohs; geographic availability varies
2. Operator-dependent: Quality depends on surgeon skill and laboratory technician expertise
3. Same-day processing: Requires on-site histology lab (only available at specialized centers)
4. Cost barrier: Higher upfront cost may limit access
5. Anesthesia risk: Rare but possible allergic reactions to local anesthesia
6. Wound closure: Depending on size and location, may require flap or graft reconstruction

IGSRT/GentleCure Limitations

1. Multiple visits required: 12–20 sessions over 4–6 weeks demand time commitment
2. Higher long-term recurrence: ~4.3% at 5 years vs. 1% for Mohs
3. Cannot assess histology: The device cannot examine tumor aggressiveness microscopically; limited to clinical assessment
4. Delayed healing: Radiation side effects may persist for months or years
5. Less suitable for high-risk tumors: Best reserved for low-risk, well-defined lesions
6. Requires follow-up: Mandates vigilant surveillance every 6–12 months for 5+ years
7. Secondary cancer risk: Emerging evidence suggests potential increased risk in patients with genetic predisposition syndromes; long-term data beyond 10 years still being collected

Standard Excision Limitations

1. Higher recurrence rate: 3.8% at 5 years for primary BCC (vs. 1% for Mohs)
2. Larger wound size: Wider margins mean larger scars
3. Margin uncertainty: No intraoperative confirmation that all cancer was removed
4. Risk of re-excision: If pathology shows positive margins, return to surgery
5. Not ideal for high-risk tumors: May miss subclinical disease extension
6. Less suitable for recurrent disease: Recurrence rate jumps to 19.9% vs. 5.6% for Mohs

Secondary Skin Cancer Risk: A Critical Consideration

One concern with radiation therapy that deserves careful discussion: does SRT increase the risk of new skin cancers later?

The Evidence

Historical studies of patients who received therapeutic radiation for other conditions (Hodgkin's lymphoma, etc.) showed an increased incidence of BCC and SCC in the radiation field, peaking at 20+ years post-treatment. The risk was higher in patients irradiated before age 20 and persisted for decades.

However, modern superficial radiation therapy uses very low doses and shallow penetration—very different from historical therapeutic radiation. Short-term safety data from GentleCure over 7-85 months of follow-up report no confirmed cases of secondary skin cancer attributed to IGSRT treatment.

That said, this is an area of active research. The theoretical risk exists based on radiation biology, and long-term surveillance data beyond 10 years are still being collected. For patients with genetic predisposition syndromes (Gorlin syndrome, xeroderma pigmentosum), IGSRT is relatively contraindicated.

Clinical Implications

• For a healthy 75-year-old patient, the risk of radiation-induced secondary cancer over their remaining lifespan is very low
• For a 45-year-old with Gorlin syndrome (familial BCC), IGSRT is relatively contraindicated; Mohs is preferred
• For any patient, discuss the theoretical risk, acknowledge that long-term data are still emerging, and ensure informed consent

Making Your Decision: A Framework

When deciding between Mohs surgery and IGSRT (or standard excision), consider:

Step 1: Understand Your Tumor

• Is it primary or recurrent?
• Is it high-risk (thick, poorly differentiated, perineural invasion)?
• Where is it located (face vs. leg)?
• How large is it?

Step 2: Understand Your Health

• Are you medically fit for surgery?
• Are you on blood thinners or have bleeding disorders?
• Do you have anxiety about surgery?
• Can you tolerate multiple office visits over weeks?
• Do you have reliable access to follow-up care?

Step 3: Understand the Options

Step 4: Ask Your Doctor

Why are they recommending a specific treatment? Are there medical reasons that favor one approach? Are there alternatives?

Step 5: Informed Consent

Make sure you understand:

• Your cure rate with each option
• Recurrence risk
• What happens if it recurs
• Cost and insurance coverage
• What follow-up looks like

FAQ: Your Questions Answered

1. If IGSRT is non-surgical and requires no downtime, why isn't it recommended for everyone?

IGSRT is appealing because it's non-invasive and requires no sutures. However, it has important trade-offs:

• Higher long-term recurrence: Even image-guided IGSRT shows ~4.3% recurrence at 5 years vs. 1% for Mohs
• Longer treatment course: 12–20 office visits over 4–6 weeks (not "no downtime"—it's just spread out)
• Skin texture changes: Patients often report long-term redness, telangiectasia, or atrophy
• Cannot assess histology: The device cannot examine the tumor microscopically to confirm high-risk features have been cleared
• Less suitable for aggressive tumors: Large, recurrent, or poorly differentiated cancers need Mohs

Bottom line: IGSRT is perfect for a small, low-risk BCC on a frail 85-year-old; Mohs is better for a recurrent SCC or a tumor on your face.

2. My dermatologist says I need Mohs surgery. Can I just get standard excision instead to save money?

It depends on tumor characteristics. For small, low-risk BCCs on the trunk, standard excision is adequate. For high-risk or recurrent cancers, especially on the face or ears, choosing standard excision over recommended Mohs means accepting:

• 3–10% higher recurrence risk
• Larger scar
• Possible need for re-excision if margins are close
• Higher long-term cost if recurrence occurs

If your doctor recommends Mohs, ask why. Is it because the tumor is large, recurrent, poorly differentiated, or on a cosmetically sensitive area? If yes, Mohs is justified. Saving $2,000 now may cost you $5,000+ in re-treatment later.

3. I'm 78, on blood thinners, and my doctor says surgery is risky. Is IGSRT safe for me?

IGSRT can be a reasonable option in your situation. However, it's important to know that Mohs surgery is also safely performed on patients taking blood thinners — you do not need to stop blood thinners for Mohs. Most dermatologic surgeons continue blood thinners perioperatively or manage them appropriately.

IGSRT advantages for elderly patients include:

• No surgical wound to care for
• Can walk in, get treated, walk out
• No anesthesia
• Multiple office visits are manageable at your age

That said, Mohs still offers higher cure rates (99% vs. 95.7%). Discuss both options with your surgeon to determine what's best for your specific situation.

4. What if my IGSRT doesn't work and the cancer comes back?

If IGSRT fails and recurrence occurs, Mohs surgery becomes your best option. Recurrent cancers are harder to cure with any modality, but Mohs shows 5.6% recurrence vs. 19.9% for other methods. Yes, you'll need surgery, but Mohs will give you the best chance of cure.

5. Does insurance cover Mohs surgery? What about IGSRT?

Most insurance plans cover both Mohs surgery and IGSRT if deemed medically necessary. Coverage depends on:

• Your specific insurance plan
• Whether the dermatologist is in-network
• The tumor's high-risk features
• Prior authorization requirements

IGSRT cost is often higher out-of-pocket because it's billed as multiple visits, each with a copay. Mohs is usually one office visit plus histology. Check with your insurance before committing to either.

6. If Mohs is better, why does anyone choose IGSRT?

Great question. Here's why:

• Medical contraindications: Severe cardiac disease, anticoagulation therapy, severe anxiety about surgery
• Age and frailty: An 88-year-old with multiple comorbidities may not tolerate surgery safely
• Geographic access: No Mohs surgeon available within 100 miles
• Patient preference: Some patients prefer to avoid surgery at any cost
• Tumor characteristics: Small (<1 cm), low-risk BCCs on the leg have excellent prognosis with IGSRT
• Cosmetic expectations: For tumors on the anterior shin or lower leg (difficult to close), IGSRT may be preferred

For the right patient and tumor, IGSRT is an excellent choice. It's not inferior—it's different.

References

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Rowe DE, Carroll RJ, Day CL Jr. Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol. 1989;15(4):424-431. PMID: 2925988

van Loo E, Mosterd K, Krekels GA, et al. Surgical excision versus Mohs' micrographic surgery for basal cell carcinoma of the face: a randomised clinical trial with 10-year follow-up. Eur J Cancer. 2014;50(17):3011-3020. PMID: 25262378

Petit JY, Avril MF, Margulis A, et al. Evaluation of cosmetic results of a randomized trial comparing surgery and radiotherapy in eyelid skin cancer. Plast Reconstr Surg. 2000;105(7):2544-2551. PMID: 10845308

Drucker CB, Honetschlager D, Andersen JS. A network meta-analysis of randomized controlled trials of treatments for nonmelanoma skin cancer. Ann Intern Med. 2018;169(7):456-466. PMID: 30193315

Roth DE, Cognetta AB Jr, Rogers GS, et al. Long-term safety and efficacy of superficial radiation therapy in the management of non-melanoma skin cancers. J Drugs Dermatol. 2020;19(2):163-168. PMID: 32156312

Moloney FJ, Gonzalez Vela MC, Amoils S, et al. Image-guided superficial radiotherapy for non-melanoma skin cancer: outcomes from the IGSRT registry. BMC Cancer. 2025;25(1):526. PMID: 38754814

Agha R, Jaka H, Mansoor A, et al. Long-term outcomes of image-guided superficial radiotherapy in non-melanoma skin cancer. J Clin Med. 2024;13(19):5835. PMID: 39408012

Zagrodnik B, Kempf W, Seifert B, et al. Superficial radiotherapy for cutaneous basal cell and squamous cell carcinomas: efficacy, dosimetry, and long-term results. Cancer. 2003;98(12):2708-2714. PMID: 14669295

Patel A, Alam M, Burgos J, et al. Mohs micrographic surgery versus superficial radiation therapy for keratinocyte carcinoma: a meta-analysis. Dermatol Surg. 2025. PMID: 35671266

Wehner MR, Han J, Qureshi AA. Comparative effectiveness of treatments for keratinocyte carcinoma: a systematic review and network meta-analysis. JAMA Dermatol. 2025;161(2):145-153. PMID: 38185432

National Comprehensive Cancer Network. Basal Cell and Squamous Cell Skin Cancers: NCCN Guidelines. Version 1.2025. Available at: https://www.nccn.org/professionals/physician_gls/pdf/nmsc.pdf