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Tumor recurrence of keratinocyte carcinomas judged appropriate for Mohs micrographic surgery using Appropriate Use Criteria.

ABSTRACT: The use of Mohs micrographic surgery (MMS) has increased greatly to treat basal cell and cutaneous squamous cell carcinomas (keratinocyte carcinoma [KC]), and consensus-based Appropriate Use Criteria (AUC) were developed to identify tumors for which MMS is appropriate.We sought to compare recurrence rates after different treatments in tumors judged appropriate for MMS.We used data from an observational prospective cohort study and retrospectively categorized consecutive tumors as appropriate for MMS according to the AUC. Among appropriate tumors, we used survival analyses to compare 5-year recurrence rates after treatments.Among tumors appropriate for MMS (N = 1483), adjusted 5-year recurrence rates were 2.9% (range, 1.4-4.3%) after MMS, 5.5% (range, 3.1-7.9%) after excision, 4.0% (range, 0.6-7.2%) after destruction, and 5.9% (range, 1.5-10.2%) after other treatments. In tumors treated only with MMS or excision (the most similar subgroups), the adjusted hazard ratio of 5-year recurrence after MMS was 0.6 (95% confidence interval, 0.3-1.0; P = .06).This study is limited by its uncertain generalizability, lack of randomization, and unmeasured characteristics.The AUC identified tumors for which recurrence would be less common after MMS than after excision, but the absolute difference in recurrence rates was small.

SUBMITTER: Stuart SE

PROVIDER: S-EPMC5443650 | biostudies-literature | 2017 Jun

REPOSITORIES: biostudies-literature

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Tumor recurrence of keratinocyte carcinomas judged appropriate for Mohs micrographic surgery using Appropriate Use Criteria.

Stuart Sarah E SE Schoen Patrick P Jin Chengshi C Parvataneni Rupa R Arron Sarah S Linos Eleni E Boscardin W John WJ Chren Mary-Margaret MM

Journal of the American Academy of Dermatology 20170329 6

<h4>Background</h4>The use of Mohs micrographic surgery (MMS) has increased greatly to treat basal cell and cutaneous squamous cell carcinomas (keratinocyte carcinoma [KC]), and consensus-based Appropriate Use Criteria (AUC) were developed to identify tumors for which MMS is appropriate.<h4>Objective</h4>We sought to compare recurrence rates after different treatments in tumors judged appropriate for MMS.<h4>Methods</h4>We used data from an observational prospective cohort study and retrospectiv ...[more]

PMID: 28365039

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Project description:ImportanceMohs micrographic surgery (MMS) is a skin cancer treatment that uses staged excisions based on margin status. Wide surgeon-level variation exists in the mean number of staged resections used to treat a tumor, resulting in a cost disparity and question of appropriateness.ObjectiveTo evaluate the effectiveness of a behavioral intervention aimed at reducing extreme overuse in MMS, as defined by the specialty society, by confidentially sharing stages-per-case performance data with individual surgeons benchmarked to their peers nationally.Design, setting, and participantsThis nonrandomized controlled intervention study included 2329 US surgeons who performed MMS procedures from January 1, 2016, to March 31, 2018. Physicians were identified using a 100% capture of Medicare Part B claims. The intervention group included physicians affiliated with the American College of Mohs Surgery, and the control group included physicians not affiliated with the American College of Mohs Surgery.InterventionsIndividualized performance reports were delivered to all outlier surgeons, defined by the specialty society as those with mean stages per case 2 SDs above the mean, and inlier surgeons in the intervention group.Main outcomes and measuresThe primary outcome was surgeon-level change in mean stages per case between the prenotification (January 2016 to January 2017) and postnotification (March 2017 to March 2018) periods. A multivariable linear regression model was used to evaluate the association of notification with this surgeon-level outcome. The surgeon-level metric of mean stages per case was not risk adjusted. The mean Medicare cost savings associated with changes in practice patterns were calculated.ResultsOf the 2329 included surgeons, 1643 (70.5%) were male and 2120 (91.0%) practiced in metropolitan areas. In the intervention group (n = 1045), 53 surgeons (5.1%) were outliers; in the control group (n = 1284), 87 surgeons (6.8%) were outliers. Among the outliers in the intervention group, 44 (83%) demonstrated a reduction in mean stages per case compared with 60 outliers in the control group (69%; difference, 14%; 95% CI of difference, -1 to 27; P = .07). There was a mean stages-per-case reduction of 12.6% among outliers in the intervention group compared with 9.0% among outliers in the control group, and outliers in the intervention group had an adjusted postintervention differential decrease of 0.14 stages per case (95% CI, -0.19 to -0.09; P = .002). The total administrative cost of the intervention program was $150 000, and the estimated reduction in Medicare spending was $11.1 million.Conclusions and relevanceSharing personalized practice pattern data with physicians benchmarked to their peers can reduce overuse of MMS among outlier physicians.

Project description:ImportanceMelanoma in situ (MIS) is increasing in incidence, and expert consensus opinion recommends surgical excision for therapeutic management. Currently, wide local excision (WLE) is the standard of care. However, Mohs micrographic surgery (MMS) is now used to treat a growing subset of individuals with MIS. During MMS, unlike WLE, the entire cutaneous surgical margin is evaluated intraoperatively for tumor cells.ObjectiveTo assess the outcomes of patients with MIS treated with MMS compared with those treated with WLE.Design, setting, and participantsRetrospective review of a prospective database. The study cohort consisted of 662 patients with MIS treated with MMS or WLE per standard of care in dermatology and surgery (general surgery, otolaryngology, plastics, oculoplastics, surgical oncology) at an academic tertiary care referral center from January 1, 1978, to December 31, 2013, with follow-up through 2015.ExposureMohs micrographic surgery or WLE.Main outcomes and measuresRecurrence, overall survival, and melanoma-specific survival.ResultsThere were 277 patients treated with MMS (mean [SD] age, 64.0 [13.1] years; 62.1% male) and 385 treated with WLE (mean [SD] age, 58.5 [15.6] years; P < .001 for age; 54.8% male). Median follow-up was 8.6 (range, 0.2-37) years. Compared with WLE, MMS was used more frequently on the face (222 [80.2%] vs 141 [36.7%]) and scalp and neck (23 [8.3%] vs 26 [6.8%]; P < .001). The median (range) year of diagnosis was 2008 (1986-2013) for the MMS group vs 2003 (1978-2013) for the WLE group (P < .001). Overall recurrence rates were 5 (1.8%) in the MMS group and 22 (5.7%) in the WLE group (P = .07). Mean (SD) time to recurrence after MMS was 3.91 (4.4) years, and after WLE, 4.45 (2.7) years (P = .73). The 5-year recurrence rate was 1.1% in the MMS group and 4.1% in the WLE group (P = .07). For WLE-treated tumors, the surgical margin taken was greater for tumors that recurred compared with tumors that did not recur (P = .003). Five-year overall survival for MMS was 92% and for WLE was 94% (P = .28). Melanoma-specific mortality for the MMS group was 2 vs 13 patients for the WLE group, with mean (SD) survival of 6.5 (4.8) and 6.1 (0.8) years, respectively (P = .77).Conclusions and relevanceNo significant differences were found in the recurrence rate, overall survival, or melanoma-specific survival of patients with MIS treated with MMS compared with WLE.

Project description:BackgroundCyanoacrylate topical adhesives and fast absorbing gut sutures are increasingly utilized by dermatologic surgeons as they provide satisfactory surgical outcomes while eliminating an additional patient visit for suture removal. To date, no head-to-head studies have compared the wound healing characteristics of these epidermal closure techniques in the repair of facial wounds after Mohs micrographic surgery.ObjectiveTo compare the cosmetic outcome of epidermal closure by cyanoacrylate topical adhesive with fast absorbing gut suture in linear repairs of the face following Mohs micrographic surgery.MethodsFourteen patients with wound length greater than 3cm who underwent Mohs micrographic surgery for nonmelanoma skin cancer of the face were enrolled in this randomized right-left comparative study. Following placement of dermal sutures, half of the wound was randomly selected for closure with cyanoacrylate and the contralateral side with fast absorbing gut suture. Using photographs from the three-month postoperative visit, six blinded individuals rated the overall cosmetic outcome.ResultsThe present study shows no significant difference in cosmetic outcomes between cyanoacrylate and fast absorbing gut suture for closure of linear facial wounds resulting from Mohs micrographic surgery. Cyanoacrylate tissue adhesive may not be as effective in achieving optimal cosmesis for wounds on the forehead or of longer repair lengths. The majority of patients did not have a preference for wound closure techniques, but when a preference was given, cyanoacrylate was significantly favored over sutures.ConclusionCyanoacrylate tissue adhesive and fast absorbing gut suture both result in comparable aesthetic outcomes for epidermal closure of linear facial wounds following Mohs micrographic surgery. Consideration should be given to factors such as need for eversion, hemostasis, and wound tension when selecting an epidermal wound closure method. (ClinicalTrials.gov, Identifier: NCT01298167, http://clinicaltrials.gov/show/NCT01298167).

Project description:ImportanceAlthough previous database studies suggest that Mohs micrographic surgery (MMS) treatment is associated with improved overall survival (OS) for head and neck melanomas, outcomes for trunk and extremity (T&E) tumors have not been adequately evaluated.ObjectiveTo assess survival outcomes for patients with melanomas of the T&E treated with MMS vs wide local excision (WLE).Design, setting, and participantsThis retrospective cohort study examined deidentified data from the National Cancer Database between 2004 and 2015. Inclusion criteria for the analysis included diagnosis of trunk, upper extremity, or lower extremity melanoma; known Breslow depth; removal by MMS or WLE; and known last date of survival status.Main outcomes and measuresFive-year all-cause mortality (ACM) rates.ResultsA total of 188 862 in situ and invasive melanomas were included in the analysis (MMS, 2.3%; WLE, 97.7%); the mean (SD) age of patients included was 58.8 (16.0) years, and 52.7% were male. Multivariate analysis demonstrated no OS difference among trunk (WLE hazard ratio [HR], 1.097; 95% CI, 0.950-1.267; P = .21), upper extremity (WLE HR, 1.013; 95% CI, 0.872-1.176; P = .87), lower extremity (WLE HR, 0.934; 95% CI, 0.770-1.134; P = .49), or combined T&E (WLE HR, 1.031; 95% CI, 0.941-1.130; P = .51) tumors. Factors associated with increased risk of ACM on multivariate analysis of all tumors included increasing age (HR, 1.043; 95% CI, 1.042-1.044; P < .001), no insurance or nonprivate insurance (none: HR, 1.921 [95% CI, 1.782-2.071]; Medicaid: HR, 2.410 [95% CI, 2.242-2.591]; Medicare: HR, 1.237 [95% CI, 1.194-1.281]; other government insurance: HR, 1.279 [95% CI, 1.117-1.465]; P < .001 for all), positive surgical margins (HR, 1.609; 95% CI, 1.512-1.712; P < .001), a Charlson-Deyo comorbidity score greater than 0 (Charlson-Deyo score of 1: HR, 1.340; 95% CI, 1.295-1.385; P < .001; Charlson-Deyo score of ≥2: HR, 2.044; 95% CI, 1.934-2.159; P < .001), tumor ulceration (HR, 2.175; 95% CI, 2.114-2.238; P < .001), and increasing Breslow depth (HR, 1.002 [per 0.1 mm]; P < .001). Female sex (HR, 0.698; 95% CI, 0.680-0.716; P < .001) and nonnodular subtype (lentigo maligna/lentigo maligna melanoma: HR, 0.743; 95% CI, 0.686-0.805; P < .001; superficial spreading: HR, 0.739; 95% CI, 0.710-0.769; P < .001; other subtype: HR, 0.817; 95% CI, 0.790-0.845; P < .001; nodular: HR, 1 [reference]) were associated with improved OS.Conclusions and relevanceThis cohort study of patients surgically treated for melanomas of the trunk and/or extremities found that, compared with WLE, MMS was not associated with significantly different OS for T&E melanomas.

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Tumor recurrence of keratinocyte carcinomas judged appropriate for Mohs micrographic surgery using Appropriate Use Criteria.

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Tumor recurrence of keratinocyte carcinomas judged appropriate for Mohs micrographic surgery using Appropriate Use Criteria.

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