Dermatology Weekly

Mohs micrographic surgery (MMS) entails many controversies – from specialty certification to the types of tumors treated. Three dermatology residents – Dr. Julie Croley, Dr. Elisabeth Tracey, and Dr. Daniel Mazori – discuss MMS for melanoma and other tumors as well as reimbursement for and the cost-effectiveness of the procedure. They also highlight controversies surrounding the Mohs Appropriate Use Criteria (AUC). “It appears further investigation is needed to elucidate and optimize solutions to many of the current controversies associated with Mohs micrographic surgery,” Dr. Croley says. 

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We bring you the latest in dermatology news and research:

1. Apremilast for Behçet’s oral ulcers: Benefits maintained at 64 weeks
   Reassuring results of a long-term extension of the phase 3 RELIEF trial.
2. Melanoma incidence drops in younger age groups
   Fewer teens and young adults developed melanoma between 2006 and 2015, while incidence increased in older adults.
3. In Oregon, ‘war on melanoma’ takes flight
   A research project hopes to shrink melanoma mortality by emphasizing education, screening.

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Things you will learn in this episode:

• The 5-year survival in metastatic rates for melanomas treated with Mohs micrographic surgery (MMS) with frozen sections were the same or better when compared with historical controls treated with conventional wide local excision.
• Immunostaining in melanoma may improve accuracy but includes many challenges: It is time-consuming, reagents can be costly and could expire, some cases are equivocal, clinicians’ exposure to immunostaining education is limited, and training is required to interpret margins. “So there are a lot of barriers to using immunostaining,” Dr. Croley says, “but I think it has a lot of potential in the future.”
• Utilization of MMS has increased in recent years, possibly due to superior efficacy for appropriately chosen cases and it is being expanded to treat other tumors such a melanoma and Merkel cell carcinoma.
• There is wide variation in mean number of Mohs stages among dermatologic surgeons. Mailing out individual reports of practice patterns to high-outlier physicians resulted in a reduction in mean stages per tumor as well as an associated cost savings when compared with outlier physicians who did not receive these reports.
• Codes for MMS are frequently reviewed by a Relative Value Scale Update Committee, and the procedure is listed as a potentially misvalued service according to the Centers for Medicare & Medicaid Services. “Reimbursements for Mohs surgery and reconstructive surgery have gone down by more than 20% in the last 15 years – at least, in part, as a result of this scrutiny,” Dr. Tracey states.
• Mohs AUC has been criticized for classifying most primary superficial basal cell carcinomas as appropriate for MMS and for not considering variables such as operating on multiple tumors on the same day and operating on a tumor that is incorporating into an adjacent wound.
• Specialty certification in MMS has been a split issue. “Proponents have argued that certification could bring more consistency and decrease divisiveness among dermatologists,” Dr. Mazori says. “Opponents of certification have argued that it could disenfranchise many dermatologists.”

Hosts: Elizabeth Mechcatie, Terry Rudd

Guests: Julie Ann Amthor Croley, MD (University of Texas Medical Branch at Galveston); Elisabeth (Libby) Tracey, MD (Cleveland Clinic Foundation); Daniel R. Mazori, MD (State University of New York, Brooklyn)

Show notes by: Jason Orszt, Melissa Sears, Elizabeth Mechcatie

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