Yes - Surgeons Are Softening Criteria for Who Gets Mohs.

By David S. Becker, M.D.

The practice of Mohs micrographic surgery is in some cases drifting away from the classic indications that used to make up most of our practice.

There are different published criteria for cases indicated for Mohs surgery, but these often include patients with recurrent or incompletely excised skin cancers, aggressive histology, or poorly defined margins. Other classic indications include tumors larger than 0.4 cm in high-risk H-zone locations, larger than 1 cm elsewhere on the face, or larger than 2 cm on the trunk or extremities.

Some of these listed criteria would not include a 3-mm basal cell carcinoma on the nose or ear, an 8-mm basal cell carcinoma on the cheek or forehead, or a 1.5-cm lesion on the pretibial skin, but I often have had each of these referred to me for Mohs surgery.

What's driving us to soften these traditional indications for Mohs surgery? Patients, referring dermatologists, dermatopathologists, and Mohs surgeons each may play a role.

Patients love Mohs surgery for many reasons. For one, we do a good job. Perhaps they've had previous Mohs surgery with good results or their friends have, or they have looked online and found that Mohs has the best cure rate. Or, they may have had a bad experience with a prior treatment.

It's not uncommon for patients to do research, and then want to play a role in determining their medical care. If they demand Mohs surgery, and I don't think it's indicated, it can lead to a contentious consultation.

One young man with a squamous cell carcinoma on his chest recently told me that he had researched the cure rates of treatments and he wanted Mohs surgery. He was almost certainly correct that if the sole criteria for therapy were best cure rate, Mohs would be the choice.

There are only two downsides to Mohs versus excision in a case like this: One, the patient has to spend more time in the office for Mohs surgery; and two, it is perhaps overutilization of medical resources. Good luck trying to explain that to patients. They don't care about overutilization of resources.

Who else drives this drift toward enhanced Mohs utilization? Referring dermatologists. They may have an interest in maximizing utilization of a Mohs surgeon in their practice, while some dermatologists have truly been burned, that is, had a patient with a metastatic squamous cell carcinoma or difficult recurrences, and they want the greater certitude of cure from Mohs surgery.

Sometimes the referring dermatologist says the patient is a VIP or relative and asks me to make an exception. If you start making exceptions, pretty soon you're seeing a lot of patients who don't necessarily meet the classic criteria for Mohs surgery.

The next set of people who are driving this drift in overutilization is dermatopathologists. We have dermatopathologists being overly cautious and prudent in ways they may not have been 10-15 years ago. Something that might have been diagnosed as actinic keratosis 20 years ago might now be called actinic keratosis with extension to the base, "squamous cell carcinoma cannot be excluded," or superficially invasive squamous cell carcinoma.
Mohs surgeons also drive the drift in utilization. We do it because that's what we like to do, or because we work for someone and we want to do what they tell us to do, or we have a referring dermatologist whom we want to please. And we want to keep our patients happy too.

It may be time to reconceptualize the indications for Mohs surgery. Should patient demand or anxiety be an indication? Should the referring dermatologist's or Mohs surgeon's instincts about a given lesion be an indication? Should any small lesion on the face be an indication?
Finally, who should decide when to do Mohs surgery? Should it be patients? They want some autonomy and to play a role in managing their own care, and are often educated in doing so.

Should it be the referring dermatologist? They understand the history of a given lesion and know the patient and the response to prior therapies.
Should the Mohs surgeon decide? We have the most experience with cutaneous malignancies, and in many cases we're the best suited to decide who needs Mohs and who doesn't.

Or, finally, should it be the government or insurers? I think that because we have allowed this drift in utilization to go forward, that may be who ultimately is deciding.

Dr. Becker is a Mohs surgeon in private practice in New York. He said he has no relevant conflicts of interest. His comments were presented at the American College of Mohs Surgery meeting.