A Team Approach to Nonmelanotic Skin Cancer Procedures

For the very small specimens excised from cosmetically or biologically critical areas, such as the head and neck region, the pathologist could use the classic Mohs sampling technique of freezing the entire specimen as is and sectioning parallel to the skin surface until free margins were reached or the entire specimen was exhausted. The pathologist could use serial cross-sectioning at 2 mm intervals in medium-sized excisions, or limited sampling of peripheral and deep margins in very large specimens. In these latter sampling approaches, at least 6 sections are cut from each slice (block), each 5 µm to 10 µm thick. The sections were mounted on glass slides, stained with hematoxylin-eosin (H&E), and examined thoroughly under a microscope before rendering a diagnosis (assessment of the resection margin).

The diagnosis was communicated directly to the surgeon by the pathologist who walked into the OR or while viewing the slides with the surgeon at a double-headed microscope located in the FS room. Remnants of any frozen or unprocessed tissue were submitted for permanent section, and the findings of both the FS and permanent diagnosis were compared the following day. Similar to the main laboratory procedures, 10% of cases were subjected to retroactive peer review for quality assurance.

Freeze section duty was handled by a pathologist and a histotechnician. Once the FS case was completed, the pathologist and histotechnician returned to the main laboratory to attend to other routine duties.

The patient’s state of comfort and satisfaction was assessed informally but routinely by the surgical team before discharge and at the follow-up visit. The patient was asked about the overall experience and invited to submit written comments to the RRVAMC patient representative. A generic mailback card was also available for feedback.

For the cost analysis, budgeting for the recurrent annual cost of labor and supplies was based on a presumed maximum workload of 300 cases/year (3-4 cases/day; 2 days/week or 0.4 full-time equivalent employee [FTEE] for each member of the team) and estimated additional OR and histology laboratory supplies of about $500/case. At the end of the fiscal year, the budgeted estimates were reconciled with the actual expenses or the added financial burden that was associated with the program to calculate the expense per case, which then was compared with the average CMS (Centers for Medicare and Medicaid Services) reimbursement rate for Mohs procedures as usually billed by private practitioners.

Results

From 2006 to 2007, 439 procedures were performed at the RRVAMC program. Patients were followed up for recurrence or other complications through the end of 2012. No serious complications were encountered during any of these procedures. Patients’ comments after each procedure indicated complete satisfaction with the process, and no negative feedback or complaint was received. More than 5 years of follow-up on the initial 439 procedures yielded a rate of cancer recurrence of about 0.5% (2 patients, a 30-year-old woman and a 77-year-old man, both with basal cell carcinoma [BCC] of the nose), which is comparable or slightly better than that reported in relevant literature for the various methods, including the classic Mohs.^10,11

Table 1 shows the distribution of the cases by age, gender, specimen size, and type of cancer. Most patients were white men (98.5%), and almost all (99%) cancers were from the head and neck region. Basal cell carcinoma was the diagnosis in 80% of the cases; the remainder were squamous cell carcinomas (SCCs). Both types of cancer were prevalent in the older age groups (> 50 years). Basal cell carcinoma was more prevalent in the group aged 51 to 70 years, whereas SCC predominated in patients aged > 70 years. The patients ranged in age from 30 to 89 years. The majority of specimens were medium sized (86%); 11% were large and the remaining 3% were small specimens. These demographics of patient’s age, cancer location, and prevalent diagnosis, were comparable to those of most VAMCs.

All acrediatation standards of the Clinical Laboratory Improvement Amendments of 1988 (CLIA 88) and College of American Pathologists (CAP) were observed in the RRVAMC FS laboratory, including monitoring frozen vs permanent tissue diagnosis and 10% retroactive peer review. Those indicators were always well below established thresholds or reasonable pathology practice community standards. The RRVAMC laboratory overall error (major discrepancy) rate has been < 0.2%. The FS laboratory has also been in compliance with the technical quality CAP accreditation standards, such as those for equipment, reagents, personnel, and environment controls.

Cost analysis data are presented in Table 2. The data are based on realistic estimates in a hospital setting. The provided numbers for the FTEE salaries are average local estimates (based on VA-wide pay scale for employees according to their grades and within grade steps), though actual salary structure varied widely among institutions. Although budgeted estimates suggest an average expense of about $1,500 per case (including cases with multiple lesions that could be removed at the same session), the actual or realistic expense is far less, because some of the resources were preexisting or shared across the Surgical and Pathology Services, including FTEE time commitments. The RRVAMC planning strategy assumed 200 to 300 cases/year at $1,000 to $2,000/case.