ORLANDO – Assessment, education, and a judicious dose of medication can make a big difference to patients who are feeling anxious about undergoing Mohs surgery.
No studies or guidelines lay out a step-by-step management plan for anxious patients. But a little bit of common sense and empathy go a long way in easing the feeling, according to presenters at the annual meeting of the American College of Mohs Surgery.
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Dr. Joseph Sobanko with patient
“We don’t have an algorithm for reducing anxiety,” said Dr. Joseph Sobanko of the University of Pennsylvania, Philadelphia. “But we do have a lot of studies showing that better psychosocial health is related to better surgical outcomes.”
The lack of definitive guidance means that anxious patients might be identified and assessed by gut instinct, he continued. “Those of you who see patients probably have a gestalt technique of identifying the anxious ones. I would suggest this might not be the best way.”
Instead of guessing, he recommends assessing all patients with a validated screening tool, and dealing with anxiety proactively.
Assessing anxiety
Although anxiety assessment may not be part of a typical Mohs surgery intake, it probably should be, Dr. Sobanko said. There are a number of excellent, well-validated tools, and none of them require expertise in psychology to administer.
The Beck Anxiety Inventory is a 21-question index that takes about 10 minutes to complete. It assesses subjective, somatic, and panic-related symptoms of anxiety, and has been validated in a variety of clinical settings. It focuses quite a bit on strong physical symptoms, however, which Dr. Sobanko feels “may not be as relevant for our patients.”
The State-Trait Anxiety Inventory consists of 40 questions and takes about 15 minutes to complete. “I like it because it not only assesses how they generally feel, but how they feel at the moment,” he said. “We think it’s good and we do use it, but it takes a while to complete.”
The Hospital Anxiety and Depression Scale is short, with only 14 questions, and takes only about 5 minutes to complete. “It’s validated for hospital patients, but we are often working with patients who are less sick than that,” Dr. Sobanko said.
The Skin Cancer Index is his go-to anxiety screen for Mohs patients. It includes 15 questions that “really get to the heart of things that matter to our patients: emotional, social, and appearance issues,” he noted. Created in 2006, it was validated in a large cohort of Mohs surgery patients (Arch Facial Plast Surg. 2006;8[5]:314-318). The questions probe patients’ feelings about the seriousness of their skin cancer, its long-term health effect, and the impact the lesion – and its treatment – will have on appearance.
Tackling anxiety
Dr. Sobanko described his own, soon-to-be-published study of 104 Mohs surgery patients, who were randomized to receive a presurgical phone call to discuss anxiety, or the usual presurgical consultation. It was easy to implement the call, he said, noting that 70% were reached on the first try, and the interaction only took about 7 minutes.
Anxiety was common, with 43% reporting being anxious about the procedure. A frequent worry (25%) was whether their skin cancer would threaten their health over the long term. But both groups reported about the same reduction in anxiety after their discussion with the provider, whether it occurred over the phone or in person. After surgery, they expressed similar levels of satisfaction with the experience.
Clearly, the most effective method of dealing with patient anxiety has yet to be identified, Dr. Sobanko noted. Others are being explored, including music and educational videos.
In 2013, he and colleagues published a small study showing that music significantly reduced anxiety during Mohs surgery (Dermatol Surg. 2013 Feb;39[2]:298-305). It randomized 100 patients to surgery without music, or to listening to a playlist they had selected for themselves. Anxiety was measured using the State-Trait Anxiety Inventory and on a visual analog scale. Subjects in the music group experienced statistically significantly lower scores on both measures, Dr. Sobanko said.
A study presented at the meeting found that a preoperative education video helped as well. Dr. Sidney Smith of the Georgia Skin and Cancer Clinic, Savannah, examined the benefit of a 9-minute video created by the American College of Mohs Surgery. The video interviews patients about their experiences, describes the surgery and overall cure rates, and touches on reconstruction and follow-up.
The study comprised 200 patients; 100 saw the movie, and then completed a 24 question survey about their perception of the procedure. Almost all (94%) of those who viewed it said the video answered their questions; 85% said it relieved their fear about undergoing the surgery.