Underutilization of Mohs Micrographic Surgery for Less Common Cutaneous Malignancies in the United States

Abstract

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. The authors aimed to define surgical patterns of care and to identify factors affecting treatment selection in the United States. 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. 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). 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.