The number of Medicare beneficiaries undergoing Mohs microsurgery for nonmelanoma skin cancers doubled between 2001 and 2006, while the rate of surgical excision remained relatively stable, according to new research presented here at the American Academy of Dermatology (AAD) 69th Annual Meeting.
“In 2001, 0.75 of every 100 Medicare beneficiaries received Mohs micrographic surgery for the treatment of nonmelanoma skin cancer; in 2006, 1.5 of every 100 Medicare beneficiaries received Mohs micrographic surgery. This is quite an amazing number,” Kate V. Viola, MD, MHS, currently a dermatopharmacology fellow at Albert Einstein College of Medicine in New York City, told Medscape Medical News.
More than 1 million basal cell carcinomas and 250,000 squamous cell carcinomas are diagnosed annually in the United States, and 1 in 5 Americans will develop skin cancer in their lifetime, Dr. Viola stated.
In 1995, the American Academy of Dermatology released guidelines for the use of Mohs micrographic surgery in patients with skin cancer in whom adequate excision and negative margins are essential, particularly in lesions with a high risk for local recurrence or metastasis or located in anatomical areas that require tissue preservation, such as the face.
“In those cases, Mohs is the gold standard,” Dr. Viola said.
The National Comprehensive Cancer Network also supports the removal of nonmelanoma skin cancers using Mohs micrographic surgery, she noted.
In this study, which was done while Dr. Viola was part of the Robert Wood Johnson Clinical Scholarship Program at Yale College of Medicine in New Haven, Connecticut, she and her team performed a retrospective review of Medicare beneficiaries receiving surgical intervention for nonmelanoma skin cancer, using a 5% random sample of Medicare claims from the Surveillance, Epidemiology and End Results (SEER) database, representing 26% of the American population.
They found that of the 26,931 people surgically treated during that time period, 36% received Mohs.
In addition to discovering that the use of Mohs doubled between 2001 and 2006, the researchers found that a higher proportion of Mohs micrographic surgery was performed in younger individuals and on the head and neck.
“We found that 50% to 70% of all Mohs surgeries were performed on the face,” Dr. Viola said. “That goes back to what the American Academy of Dermatology‘s guidelines are promoting for optimal preservation of tissue.”
The finding that the number of Mohs surgeries decreased as patients increased with age is not surprising, she added. “I think the older one gets, the more comorbidities one may have, and this may prevent Mohs micrographic surgery. It may be easier just to remove the lesion very quickly with surgery.”
The researchers also found that the use of Mohs micrographic surgery was not equal throughout the United States.
Atlanta, Georgia had the highest proportion of patients treated with Mohs (45%), and Louisiana had the lowest (11%). The density of Mohs surgeons was highest in the San Jose–Monterey region of California (0.142 surgeons per 1000 Medicare beneficiaries) and in rural Georgia (0.103 surgeons per 1000 Medicare beneficiaries); whereas Detroit, Michigan and Los Angeles County, California had the lowest density of Mohs surgeons (0.003 and 0.007, respectively).
“This is the first study to examine national patterns of Mohs utilization. We really hope that this research will promote analysis of treatment outcomes for nonmelanoma skin cancer while highlighting potential disparities among populations with nonmelanoma skin cancer in the future,” Dr. Viola said.
Vincenzo Bettoli, MD, from the University of Ferrara in Italy, told Medscape Medical News that the increase in the use of Mohs micrographic surgery revealed in this analysis is impressive.
“It is not easy to convince doctors to change their habits of practice, even when there are guidelines that are established by the main scientific organization,” he said. “Going from 0.75 to 1.5 [per 100 Medicare beneficiaries receiving] Mohs surgery is a great step ahead.”
Dr. Bettoli added that the use of Mohs is not as widespread in Italy, but he hopes that it will start to become more common.
“It is already established that the possibility of having a recurrence [of skin cancer] is lower with Mohs micrographic surgery. Also, technically, the skill of dermatologists is growing. I think that Mohs will be the therapy of the future,” he said.
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