DS06 Does the content of patient information leaflets reflect real-life practice? A comparison of four patient information leaflets in Mohs micrographic surgery

Abstract

Abstract In our experience, patients referred for Mohs micrographic surgery (MMS) often have unrealistic expectations, anticipating defects that are small in size and depth, and incorrectly describe the procedure as removal of skin cancer by ‘taking away thin slices’ or ‘skimming the skin layer by layer’. This observation prompted us to critically appraise four widely accessed online patient information leaflets (PILs) on MMS produced by the British Association of Dermatologists, the American Academy of Dermatology, Dermnetnz.org and the European Society of Micrographic Surgery. Our aim was to evaluate the wording used and propose evidence-based changes to help manage patients’ expectations. We focused on two core themes: (i) excision of tumour by MMS, including the number of stages, and (ii) cosmetic benefit of MMS over standard excision (SE). All of these PILs state the need for ‘stages’ to achieve margin clearance, with an initial margin of excision as low as 1 mm per stage mentioned in one PIL. The leaflets suggest cosmetic benefit and tissue preservation of MMS over SE, and one leaflet ranked this higher than other advantages offered by MMS. We feel that these points are overstated and better addressed with evidence-based facts. Studies have shown that 60% of cases of MMS are cleared in one stage; > 90% of tumours are cleared within two stages, and the number of patients needing three or more stages is only 6% (Macfarlane L, Waters A, Evans A et al. Seven years’ experience of Mohs micrographic surgery in a UK centre, and development of a UK minimum dataset and audit standards. Clin Exp Derm 2013; 38:262–9). In our experience, a surgical margin of 1 mm is not feasible in MMS. There is no direct evidence that MMS improves cosmesis compared with SE (Brown AC, Brindley L, Hunt WTN et al. A review of the evidence for Mohs micrographic surgery. Part 2: basal cell carcinoma. Clin Exp Dermatol 2022; 47:1794–804). Cosmetic and functional outcomes are usually only relevant in high-risk sites (e.g. the central face H zone) and in certain high-risk tumours where wide local excision would be the alternative treatment. In conclusion, we propose that PILs in MMS should avoid using misleading language like ‘thin’ and ‘small’ when describing the procedure. Patient information leaflets should clarify that the vast majority of tumours are cleared after two stages rather than requiring multiple stages. Tissue sparing should not be highlighted as the main advantage of MMS, and patients should not be pledged small wounds and better cosmetic outcomes.