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Underutilization of Mohs Micrographic Surgery for Less Common Cutaneous Malignancies in the United States
Erica R Ghareeb1, Brittany O Dulmage, John A Vargo
1*Department of Medicine, Section of Dermatology, West Virginia University, Morgantown, West Virginia; †University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; ‡Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania; §Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania.
Background:
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.
Insights
Mohs micrographic surgery (MMS) is underutilized for specific skin cancers, yet it significantly improves the chances of achieving negative surgical margins. Factors like location and patient characteristics influence treatment choices, with MMS offering better outcomes.
Area of Science:
- Dermatology and Surgical Oncology
- Skin Cancer Treatment Modalities
- Health Services Research
Background:
- Consensus guidelines recommend Mohs micrographic surgery (MMS) for less common skin cancers with complex growth patterns.
- Conventional surgical methods may be challenging for these specific tumor types, necessitating specialized techniques.
Purpose of the Study:
- To analyze surgical treatment patterns for nonmelanoma skin cancers in the United States.
- To identify demographic, clinical, and facility-related factors influencing the selection of MMS versus other surgical options.
Main Methods:
- Retrospective cohort analysis of 15,121 patients with nonmetastatic nonmelanoma skin cancers.
- Data sourced from the National Cancer Data Base (1998-2012), applying American Academy of Dermatology/American College of Mohs Surgery appropriate use criteria.
- Statistical analysis to determine factors associated with MMS utilization and treatment outcomes.
Main Results:
- Mohs micrographic surgery (MMS) was utilized in 8% of cases; primary excision (30%), narrow re-excision (12%), and wide re-excision (50%) were more common.
- MMS utilization was lower in community cancer programs, the Northeast region, for patients with lower education or uninsured status, and when radiotherapy was administered.
- High-risk facial areas, lower comorbidity scores, and microcystic adnexal carcinoma were linked to higher MMS likelihood. MMS independently predicted negative surgical margins (OR 3.15).
Conclusions:
- Significant variability exists in surgical treatment patterns for skin cancers, influenced by patient demographics, tumor characteristics, and treatment setting.
- Despite lower utilization rates, MMS is associated with a higher likelihood of achieving negative surgical margins and reduced need for radiotherapy.
