No - Mohs Surgery Is Being Properly Utilized.

By Gary Monheit, M.D.

Mohs micrographic surgery is not overutilized, it's increasingly utilized.

A recent study reported a twofold increase in the proportion of Mohs surgery being done in Medicare patients from 2001 to 2006, while the rate of excisions has remained stable. So what's driving this increased utilization of Mohs surgery?

Is it greedy surgeons applying Mohs micrographic surgery to actinic keratoses on the arms and trunk? The few surgeons who are utilizing it inappropriately need to be controlled, but I don't believe this is the main reason for the increased utilization.

In most cases, increased Mohs utilization is appropriate. Mohs is a superior and much more cost-effective modality than excision and it has a greater cure rate, which is now being recognized.

The vision of Dr. Frederic E. Mohs was a change in the treatment of skin cancer. He was tired of seeing recurrences with excision. He realized that if things were accurately mapped out, physicians would have a better understanding of how to treat tumors, spare tissue, and reduce costs.

Brilliantly, it was a merger of surgery and histopathology controlled by one practitioner, the Mohs surgeon. Results of surgical treatment approach 100% the first time.

Should this be done for all nonmelanoma skin cancers at all locations? Should patients be cured the first time rather than risk recurrences? Is this cost effective for most tumors?

Twenty years ago, 50% or more of the Mohs surgeries that I did were on patients with tumors that had undergone two surgical excisions with recurrences that were covered up with flaps. I'm very happy to say that now I'm curing patients with a primary basal cell carcinoma the first time I operate.

We are having a cancer epidemic. The annual incidence of nonmelanoma skin cancer is a staggering 3.5 million, according to a recent study involving epidemiologic databases and the National Cancer Institute (Arch. Dermatol. 2010;146:283-7). And, I think the incidence is much higher.

The same study reported a 4.2% annual growth rate. That would predict a 23% growth rate in Mohs micrographic surgery from 2001 to 2006. Instead, we had a 70% growth rate.

What accounts for this? I believe the high growth rate is driven by what I call the "miracle of Mohs surgery." Five-year recurrence rates after Mohs are 1% for primary basal cell carcinomas, compared with 10% for surgical excision in well-controlled studies, and 4% after Mohs surgery for recurrent basal cell carcinomas, as opposed to 17% for excision.

Studies have found that 18%-32% of facial basal cell carcinomas are incompletely excised and require a second procedure. Repeat excisions create larger defects and worse cosmetic outcomes. Complete re-excisions are challenging after flap repairs. But with Mohs, one procedure does it all.
Studies have shown that Mohs surgery is superior financially because it is more cost effective than traditional excision if you include the costs of re-excision and pathology, and re-repair and treatment of recurrences after excisions.

Patients also are twice as satisfied with Mohs surgery, another study found (Dermatol. Surg. 2009;35:1041-9).

We've got an epidemic of cancer, and we have recognition that Mohs is the best technique for treatment. Patients with tumors that would have been excised and recurred are being referred initially for Mohs surgery. Simple primary lesions that are in the right areas should be treated with Mohs.

Does increased utilization of Mohs surgery translate to greater expense in treating skin cancer? The data show that for primary lesions and recurrences, the cost savings is greater with Mohs surgery. Insurance companies are starting to recognize that, but we can't let insurance companies govern simply by cost.

We really don't know for sure what's driving the increase in Mohs micrographic surgery utilization. However, I do believe that the superiority of the technique, which is becoming more recognized and established, and the epidemic of skin cancer have produced this high rate of utilization.

The growth rate reflects recognition of the unparalleled value of Mohs micrographic surgery as we confront the skin cancer epidemic.

Dr. Monheit is a Mohs surgeon in private practice in Birmingham, Ala., and has directed Mohs fellowship programs for 25 years. He said he has no other relevant conflicts of interest. These remarks were presented at the American College of Mohs Surgery meeting.