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Mohs Is Underutilized for Less Common Cutaneous Malignancies
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
Consensus guidelines have defined select less common skin cancers appropriate for Mohs micrographic surgery (MMS), as these tumors are characterized by asymmetric growth patterns that challenge conventional surgical extirpation of disease.
OBJECTIVE
The authors aimed to define surgical patterns of care and to identify factors affecting treatment selection in the United States.
MATERIALS AND METHODS
Retrospective cohort analysis of nonmetastatic nonmelanoma skin cancers deemed appropriate for MMS by American Academy of Dermatology/American College of Mohs Surgery/American Society for Dermatologic Surgery Association/American Society for Mohs Surgery appropriate use criteria from the National Cancer Data Base from 1998 to 2012.
RESULTS
Of the included 15,121 patients, 8% received MMS, 30% primary excision, 12% narrow re-excision, and 50% wide re-excision. Utilization of MMS was negatively influenced by community cancer programs, Northeast region, lower education, uninsured status, and administration of radiotherapy. High-risk face areas, lower comorbidity score, and microcystic adnexal carcinoma were associated with higher likelihood of receiving MMS. After adjusting for tumor size, tumor location, and histology, MMS remained an independent predictor of achieving negative surgical margins (odds ratio 3.15, 95% CI 2.27-4.36, and p < .0001).
CONCLUSION
There is considerable variation in surgical treatment patterns by both sociodemographic, treatment, and tumor characteristics. Despite low utilization, patients receiving MMS are more likely to achieve negative surgical margins and less likely to receive radiotherapy.
Additional Info
Disclosure statements are available on the authors' profiles:
Underutilization of Mohs Micrographic Surgery for Less Common Cutaneous Malignancies in the United States
Dermatol Surg 2016 May 01;42(5)653-662, ER Ghareeb, BO Dulmage, JA Vargo, GK Balasubramani, S BeriwalFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Under utilization of dermatologic surgery
In this edition of Dermatologic Surgery, Ghareeb et al report that there is a wide variation in the use of Mohs surgery for treatment of nonmetastatic, nonmelanoma skin cancer. They also point out that Mohs surgery achieves higher margin clearance and avoids radiation therapy.
What, you say? Another article touting Mohs surgery? Enough already! No; not enough already, in particular not enough dermatologic surgery.
I heard Marty Makary, MD, speak this weekend. He a surgical oncologist from Johns Hopkins and is the author of Unaccountable: What Hospitals Won’t Tell You. He is a potent advocate for physicians and patients and effective, safe, and efficient medical care. His touchstone story centers around the continued use of open colonic resection of polyps by one of his surgical professors, despite the much safer, better, and less expensive endoscopic removal. It was “just the way he liked to do it.”
This is perfectly analogous to the continued treatment of skin cancer in the hospital operating room. At least 30% of all skin cancers are excised in the hospital setting. This requires hours of operating room (OR) time and the engagement of a pathologist and technician to process frozen sections. This occurs in the face of overwhelming evidence that destruction or excision, with or without micrographic margin control, is safer, yields higher cure rates, and is much less expensive than procedures performed in the hospital operating room. In fact, 99% of all skin cancers should be treatable in the office setting under local anesthesia. Although these procedures are most commonly performed by a dermatologist, the same approach could easily be taken by any surgeon willing to use local anesthesia and make an investment in the equipment and staff. In addition, patients prefer the outpatient setting where parking is often closer, and they avoid a bill from the hospital for use of the OR. Of course, many surgeons continue to operate in the hospital “because that’s the way they do it.” The analogy to the situation that shaped Dr. Makary’s career is obvious!
Mohs surgery is a marvelous technique, and patients with rare tumors, certain subsets of basal cell carcinoma, and squamous cell carcinoma and skin cancers in critical locations should be referred for micrographic surgery (it is particularly underused for cancers of the genitalia). However, all dermatologists can effectively treat skin cancers in a safer manner, and at much lower cost, than anyone in a hospital setting, inpatient or outpatient.
Yes; Mohs surgery is underused, but the bigger picture is that all dermatologic surgery is underutilized. Physicians who are patient advocates should make sure patients receive the safest, most effective treatments.
Our organizations need to focus on explaining the benefits of office-based surgery and take this message to national patient advocacy groups and the public. Perhaps Dr. Makary will read this article and respond! This a great opportunity to improve the healthcare of patients at a reduced cost.