Mohs surgery: Minimal scars vs. high cost

You may have seen it performed in real time on ABC's Good Morning America. Or maybe you caught actor Hugh Jackman telling David Letterman about having it.

Or you may be among the legions of people who have personally undergone it.

It is Mohs micrographic surgery, the preferred treatment for the two most common types of skin cancer: basal cell and squamous cell. Although rarely life-threatening, these tumors can become disfiguring without timely removal, and they are being diagnosed at the staggering clip of more than four million a year.

During Mohs surgery - named for Frederic E. Mohs, the Wisconsin surgeon who developed it in the 1940s - a thin disk of skin is cut out and, while the patient waits, examined under a microscope. This process is repeated until the entire malignancy and a border of healthy tissue have been removed.

Compared to conventional "excision" - cutting out the tumor plus a safety margin in one swoop - Mohs spares more tissue, produces better cosmetic results, and has superior cure rates.

Here's the rub: Mohs is also more expensive, and use soared 248 percent from 1996 to 2008, Medicare data show. About a quarter of patients with non-melanoma skin cancers are now treated with Mohs, compared to 10 percent in 1995.

In response to concerns about overuse, Medicare has tightened rules and cut reimbursement rates for Mohs, and medical groups have issued guidance about when to use it.

"Money definitely is a factor," said Clifford Perlis, director of Mohs and other dermatologic surgeries at Fox Chase Cancer Center. "So there's a built-in controversy about when is Mohs appropriate."

A related controversy involves who should do it.

You can go to a dermatologist who, like Perlis, spent a year or more being trained to do Mohs, which requires the surgeon to double as the pathologist, the specialist who evaluates cells under a microscope.

Or you can go to a dermatologist who took a four-day course on Mohs.

It's no news that skin cancer is increasingly common. The factors include overexposure to the sun's harmful rays, an aging population, the Earth's thinning ozone layer, maybe tanning-bed use.

Still, the magnitude of the epidemic is shocking. The average annual number of adults treated for skin cancer jumped from 3.4 million in 2002-06 to 4.9 million in 2007-11, while the costs more than doubled, from $3.6 billion to $8.1 billion, according to a recent study by the U.S. Centers for Disease Control and Prevention.

Melanoma, the deadliest skin cancer, is part of this upward trend. But it is non-melanomas - primarily basal-cell and squamous-cell lesions - that account for almost 90 percent of all skin malignancies.

Early on, these lesions may appear innocuous. Basal lesions often look like small sores, red patches, or shiny bumps, and squamous cancers may start as scaly red patches, open sores, or wartlike growths.

Usually, non-melanomas can be treated in a doctor's office under a local anesthetic. Therapeutic options include topical drugs, freezing, or lasering.

But when a biopsy confirms a non-melanoma on a cosmetically important area, Mohs is optimal. In 2012, expert groups including the American Academy of Dermatology and the American College of Mohs Surgery said the procedure was appropriate for non-melanomas on the head and neck, as well as those anywhere on the body that were recurrent or aggressive.

Mohs is usually not necessary, the groups say, for lesions on the torso.

To understand Mohs' advantages, consider that with traditional excision, the surgeon has to estimate how extensively to cut in hopes of nabbing a safety margin of healthy tissue. If the pathologist finds cancer in that margin, the patient has to return for a deeper excision.

Worse, the pathologist may conclude the surgery achieved "clear margins" when it actually didn't. This happens up to 10 percent of the time, studies show, because random samples of the excised tissue are examined, not the entire specimen.

With Mohs, in contrast, each layer of removed tissue is frozen by a technician, cut horizontally into micron-thin slices, and entirely examined under the microscope by the surgeon. This misses cancer only 1 percent to 2 percent of the time - a cure rate of 98 percent to 99 percent, studies show.

Mohs also has a system for color-coding and segmenting each disk of tissue so the surgeon can tell precisely where to cut deeper at the surgical site.

For patients, that means the smallest possible (or no) scar, plus immediate repair of the surgical wound.

Tina McDonnell, 62, of Palmyra went to Perlis just after Christmas for Mohs on her left ear. She is confident the results will be as good as on her nose, where she has had two squamous-cell lesions removed in the last decade.

"People cannot believe I had surgery on my nose," said McDonnell, operations director at the Ronald McDonald House in Philadelphia. "You would never know."

That's not to suggest Mohs is magical. Deborah Edmiston, 36, a busy mother of six in Northeast Philadelphia, put up with a raw, flaky, red spot on the corner of a nostril, assuming it was "just psoriasis." By the time it became painful in May, the basal-cell tumor was deep. Perlis removed it with Mohs, but enlisted a plastic surgeon for the multistep reconstruction, which is almost complete.

"Now I tell everybody: Make sure you cover up and use your sunscreen," said the fair-skinned redhead.

On average, Mohs costs about $1,100 per case, compared to about $900 for excision, said Howard W. Rogers, a Norwich, Conn., dermatologist, who sits on the public policy committee of the American College of Mohs Surgery.

He believes Mohs is "misperceived" as expensive, when it's actually a bargain, because a single payment is made to one doctor. With excision, reimbursement is spread out to the surgeon, pathologist, and lab.

Nonetheless, beginning in 2009, the Centers for Medicare and Medicaid made changes that cut payments for Mohs 9 percent to 25 percent.

Last year, Medicare's administrative contractor for Florida also proposed to limit reimbursement for Mohs to physicians who had completed a yearlong fellowship that included performing at least 500 cases. The fellowship program was created in the 1980s by the American College of Mohs Surgery.

Such a restriction would be a blow to Florida dermatologists who took a considerably shorter route - the four-day course offered by the American Society of Mohs Surgery. The society was founded in 1990, when demand for Mohs surgeons far outstripped the number being produced by the fellowship program.

The proposed restriction was dropped amid backlash from medical groups. But it highlighted a controversy within the evolving field of Mohs: Is the procedure just an arrow in the skin-cancer specialist's quiver? Or is Mohs a medical subspecialty by itself?

The latter, said Cincinnati dermatologist Brett Coldiron, president of the American Academy of Dermatology and an eminent Mohs surgeon. He envisions a time when Mohs surgeons will have to meet standards and pass a certification exam.

"The specialty is moving that way," Coldiron said, "but you can't do it overnight, or there will be an uproar."

Meanwhile, he advises patients to ask questions.

"I'd tell patients to look at their [doctors'] experience and ask how many cases they've done," Coldiron said. "I've done 30,000."

Here's a link to the American College of Mohs Surgery surgeon finder. These are

all fellowship-trained Mohs surgeons:

http://acms.execinc.com/edibo/SurgeonFinder

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