Commentary: Mohs overkill: 'Aggressive' procedure often performed unnecessarily

January 1, 2009

My friend and colleague, Ted Miller, recently related a story about one of his patients, who was 92 years old and had consulted with another dermatologist about several growths on his face.

Key Points

Five biopsies of small lesions were all interpreted as basal cell carcinoma.

The dermatologist proceeded to treat all of these primary tumors with Mohs micrographic surgery. Incensed that his elderly patient was subjected to this apparent overkill, Dr. Miller contacted the treating physician, who justified this approach by stating that the Mohs technique is the most effective means of eradicating the tumors, and anything less would amount to substandard care.

This attitude has become widespread over the past few years. Another friend, who is a medical dermatologist now, sends all skin cancers of the face for Mohs surgery, partially for medical-legal reasons.

This is reflected in Medicare statistics, which have shown a 300 percent increase in charges for the Mohs procedure over the past few years.

Patient selection

Before I reflect on these developments, let me state at the outset that I love Mohs micrographic surgery for patients with certain types of skin cancers, and I refer many patients each month to one of several extremely capable Mohs surgeons in my community.

However, it is my strongly held opinion that one must carefully select appropriate patients to undergo this procedure.

My understanding is that the indications include recurrent non-melanoma skin cancers, particularly in the head and neck area, selected large primary tumors and primary neoplasms in anatomically sensitive sites such as the nasolabial fold, inner canthus of the eye, nasal tip and the ears.

Choosing other modalities

That leaves us with hundreds of thousands of tumors every year that are small and easily treated with other modalities, such as destruction by electrodesiccation and curettage, cryosurgery or by elliptical excision.

In my view, the argument made by the Mohs surgeon to justify the wholesale removal of primary skin cancers in a 92-year-old is completely bogus. Cure rates of at least 90 percent can be achieved in small, uncomplicated skin cancers without using Mohs surgery.

While the cure rates are not as good as with the Mohs technique, they are still quite good.

'Unjustified' surgeries

Most patients are happy to "gamble" on a slightly lower rate of cure to avoid the wear and tear - and the expense - associated with the more aggressive approach. In many of these small tumors, the worst-case scenario is a recurrence that can then be treated in a different way.

Let us take this one step further. There are recent reports of excellent cure rates in patients with Bowen's disease treated with Mohs surgery. So what? Bowen's disease has minimal potential to be an aggressive, serious problem, and it is very easily and effectively treated by destructive procedures or medical means, such as topical fluorouracil or imiquimod. It makes almost no sense to subject patients to extensive surgery for this pre-invasive disease.

To carry this to the ultimate illogical extreme, I have seen a few patients who had Mohs surgery for hypertrophic actinic keratoses. I am sure that the lesions were successfully eradicated, but the use of this technique was totally unjustified.

Effecting change

How do we effect any change in this situation after the proverbial train has left the station? I have a few impractical, untenable, but provocative suggestions.

I would propose that Mohs surgeons only perform the procedure on patients referred to them from others. In that way, there will be no taint of conflict of interest. The cliché of the hammer and nail immediately comes to mind - if you have a hammer, everything looks like a nail.

I would suggest that all third-party payers agree to pay a fixed amount for the treatment of all primary tumors less than 1 cm in diameter - perhaps $400 - regardless of the procedure used to treat the lesion. This would represent a bonus payment for the use of destructive modalities, be about what an elliptical excision would yield now, and would represent a significant discount for the Mohs procedure over today's prices.

I may be wrong about this, but I would predict that there would be at least a 50 percent drop in the use of the Mohs technique if this new reimbursement schedule were adopted. I would further predict that the general health of our patients would not suffer in any substantial way.

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