Frustrated by AUC

[doctalaughs]

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I've said this before but I'm continually frustrated by the appropriate use criteria for mohs because they don't go far enough.

Who thinks it's totally appropriate ( not even uncertain) to treat a 3mm primary SCCis on the shin with mohs? How did all those committee members agree on things like that?

It's kind of like the dysplastic nevi over-treatment epidemic. I get patients surprised that I don't biopsy 5-10 moles at their first visit with me (which will then probably generate 2-3 excisions for the "pre-melanomas" they were getting treated for before)

We have to police ourselves better if we don't want regulations to completely eliminate (or stop paying for) derm services that actually make a difference.

/endrant


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[username456789]

I've said this before but I'm continually frustrated by the appropriate use criteria for mohs because they don't go far enough.

Who thinks it's totally appropriate ( not even uncertain) to treat a 3mm primary SCCis on the shin with mohs? How did all those committee members agree on things like that?

It's kind of like the dysplastic nevi over-treatment epidemic. I get patients surprised that I don't biopsy 5-10 moles at their first visit with me (which will then probably generate 2-3 excisions for the "pre-melanomas" they were getting treated for before)

We have to police ourselves better if we don't want regulations to completely eliminate (or stop paying for) derm services that actually make a difference.

/endrant


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I run into this all the time as a new attending in PP. I have a few PAs who definitely in the past have over treated DNs. Almost daily I hear "wow this is the first skin check where I didn't need a biopsy."

And yes they all think they are "pre-melanoma." If I could bill just for the time it takes to try to explain this, it would be nice. I suppose for others it's easier to just biopsy and charge.

 

[username456789]

I will also add that there's a pretty good paper/consensus statement on the appropriate use criteria from 2012 I believe. It's been a while since I've looked at it, but it gives a decent rundown of the different types of cancers and locations and the justification for Mohs.

 

[doctalaughs]

I will also add that there's a pretty good paper/consensus statement on the appropriate use criteria from 2012 I believe. It's been a while since I've looked at it, but it gives a decent rundown of the different types of cancers and locations and the justification for Mohs.

I believe that is the paper that established the AUC. What frustrates me is that the authors established criteria that are so lenient on performing mohs (it basically only excludes AKs which is basically criminal if you were doing that) that the criteria are useless.




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[asmallchild]

I've said this before but I'm continually frustrated by the appropriate use criteria for mohs because they don't go far enough.

Who thinks it's totally appropriate ( not even uncertain) to treat a 3mm primary SCCis on the shin with mohs? How did all those committee members agree on things like that?

It's kind of like the dysplastic nevi over-treatment epidemic. I get patients surprised that I don't biopsy 5-10 moles at their first visit with me (which will then probably generate 2-3 excisions for the "pre-melanomas" they were getting treated for before)

We have to police ourselves better if we don't want regulations to completely eliminate (or stop paying for) derm services that actually make a difference.

/endrant


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I've heard this from multiple people now. If you were an honest / conscientious Mohs surgeon before the AUC was established, the AUC probably expanded your scope of practice.

 

[username456789]

I believe that is the paper that established the AUC. What frustrates me is that the authors established criteria that are so lenient on performing mohs (it basically only excludes AKs which is basically criminal if you were doing that) that the criteria are useless.




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I think you're right.

I definitely see Mohs in my own PP be performed in settings where, as a resident in academia, I have excised in a straight forward manner.

 

[doctalaughs]

I think you're right.

I definitely see Mohs in my own PP be performed in settings where, as a resident in academia, I have excised in a straight forward manner.

Or even Ed&c or topical treatment - I see innumerable things sent to mohs all the time that could be successfully scraped in 15 seconds with very little risk and probably a patient grateful not undergo a more invasive procedure.

The main problem was I used to think it was a very small proportion of mohs people that were doing this. I think as mohs has become more saturated though there is now a significant number (in my town I'd guess half) that will perform mohs on literally everything that has the word carcinoma in the path report.

This is less of a problem for mohs that only treat referrals given they are pre-screened (unless they try to steal the patient and start doing their skin checks). More of a problem if they are doing general derm in the same group where every tiny ditzel can be sent to mohs.


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[username456789]

All good points and I agree once again. One of the problems I face in my general area is the perception that everything should be treated with Mohs. This is obviously a product of the current environment and the attitudes of Mohs surgeons in the area.

Whereas I scraped a ton of skin cancers in residency, I have a difficult time convincing anybody in my area that it is an appropriate treatment, despite doing what I think is a good job selling it. They are just so used to having skin cancers treated by excision, even the small superficial basal cells, that nothing else will do.

 

[doctalaughs]

All good points and I agree once again. One of the problems I face in my general area is the perception that everything should be treated with Mohs. This is obviously a product of the current environment and the attitudes of Mohs surgeons in the area.

Whereas I scraped a ton of skin cancers in residency, I have a difficult time convincing anybody in my area that it is an appropriate treatment, despite doing what I think is a good job selling it. They are just so used to having skin cancers treated by excision, even the small superficial basal cells, that nothing else will do.

Yep. In my town (medium southeast costal city) the algorithm for the most successful practices seems to be mix of 3-8 genderm and PAs and 1-2 mohs. Visits usually consist of 1-4 biopsies and every single positive report goes to mohs with zero exception, every (even mild) DN goes to excision. No Ed&c or topical. Yes - zero.

If you ask one of those practices to manage something like vasculitis it goes straight to university. It's sad.


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[asmallchild]

Yep. In my town (medium southeast costal city) the algorithm for the most successful practices seems to be mix of 3-8 genderm and PAs and 1-2 mohs. Visits usually consist of 1-4 biopsies and every single positive report goes to mohs with zero exception, every (even mild) DN goes to excision. No Ed&c or topical. Yes - zero.

If you ask one of those practices to manage something like vasculitis it goes straight to university


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Sad and true.

I used to work for a group like this. The sad part is, they've got the providers so brainwashed that they seem to think they're doing a favor for the patient. You would not believe the pushback I used to get from referring dermatologists and midlevels when I told them I would do something else besides Mohs for treatment.

I would outline my plan in each consult letter (essentially handing them a roadmap on how to treat future lesions/patients, increase their own revenue, and take money out of my own pocket) and I would get an angry phone call to just do as I was asked and complete the surgery.

Sad.

 

[doctalaughs]

Sad and true.

I used to work for a group like this. The sad part is, they've got the providers so brainwashed that they seem to think they're doing a favor for the patient. You would not believe the pushback I used to get from referring dermatologists and midlevels when I told them I would do something else besides Mohs for treatment.

I would outline my plan in each consult letter (essentially handing them a roadmap on how to treat future lesions/patients, increase their own revenue, and take money out of my own pocket) and I would get an angry phone call to just do as I was asked and complete the surgery.

Sad.

Thats typical for the midlevels although surprising for the genderms. I mean, they trained in a residency at some point -you'd think they would have developed a sense of what is high risk and actually needs mohs.

Now that the medicare total reimbursement is publicly released, if you look at the top few in each state they are universally the ones that are slimy (running a mill doing mohs for every tiny thing) not the conscientious ones.

It's really sad. We complain about govt over-regulation (happens in other specialties too) but really have only ourselves to blame.


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[Hotei]

Now that the medicare total reimbursement is publicly released, if you look at the top few in each state they are universally the ones that are slimy (running a mill doing mohs for every tiny thing) not the conscientious ones.


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How do you look this up?

 

[reno911]

Thats typical for the midlevels although surprising for the genderms. I mean, they trained in a residency at some point -you'd think they would have developed a sense of what is high risk and actually needs mohs.

Now that the medicare total reimbursement is publicly released, if you look at the top few in each state they are universally the ones that are slimy (running a mill doing mohs for every tiny thing) not the conscientious ones.

It's really sad. We complain about govt over-regulation (happens in other specialties too) but really have only ourselves to blame.


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Overwhelmingly, for sure. Universally? Definitely not. I can think of a few exceptions of conscientious guys that have a high reimbursements due to insane volume and working a ton of hours. But they are the exception for sure.

I agree that, if anything, AUC is much more liberal on what is appropriate than I was prior to AUC.

The whole concept of appropriateness is an interesting one. If we take cost out of the equation, Mohs is always superior to standard excision. I can't think of a single skin malignancy for which I would prefer excision to Mohs if I had it on my own body. However, since we live in a world with scarce resources, that's not how I actually practice.

Comparing Mohs to ED&C or topicals is a different story. There are certainly tumors for which I'd prefer one of those over Mohs (if we forget about cost).

AUC is certainly not perfect, but I think it was a step in the right direction. I'm sure it will continue to be refined.

 

[Vandalia]

How do you look this up?

https://projects.propublica.org/treatment/

Select state, then select specialty, and then select an individual and it provides total Medicare payment and a breakdown of procedures billed.

 

[doctalaughs]

Overwhelmingly, for sure. Universally? Definitely not. I can think of a few exceptions of conscientious guys that have a high reimbursements due to insane volume and working a ton of hours. But they are the exception for sure.

I agree that, if anything, AUC is much more liberal on what is appropriate than I was prior to AUC.

The whole concept of appropriateness is an interesting one. If we take cost out of the equation, Mohs is always superior to standard excision. I can't think of a single skin malignancy for which I would prefer excision to Mohs if I had it on my own body. However, since we live in a world with scarce resources, that's not how I actually practice.

Comparing Mohs to ED&C or topicals is a different story. There are certainly tumors for which I'd prefer one of those over Mohs (if we forget about cost).

AUC is certainly not perfect, but I think it was a step in the right direction. I'm sure it will continue to be refined.

I agree for the most part. Mohs would always be preferable to excision if money (and time) were no object, which of course they are.

However I personally would FAR prefer an ED&C for almost all primary in-situ lesions and small low-risk invasive SCC/BCC (which is probably 95% of lesions encountered, of which I bet 75% goes to mohs right now). I've said this before but I don't believe the recurrence rates in the literature for ED&C. I dont know if thats because the studies were done mostly at academic centers with residents who haven't done 10,000 ED&Cs or if they were selecting the wrong (ie higher risk lesions) or doing partial biopsies and missing the mixed path. But In my fairly loyal/reliable patient population for the past 10 years I'd guess 1-2% of the BCC I scrape recur and almost zero SCC ( I can literally think of maybe 1 or 2 cases and I've easily treated 10-20 thousand). Of course you have to triage the high risk lesions but I'm WAY more liberal than most are. And mind you, these recurrences don't have a bad outcome because they then go to mohs.




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[Hotei]

https://projects.propublica.org/treatment/

Select state, then select specialty, and then select an individual and it provides total Medicare payment and a breakdown of procedures billed.

Thank you

 

[MOHS_01]

I agree for the most part. Mohs would always be preferable to excision if money (and time) were no object, which of course they are.

However I personally would FAR prefer an ED&C for almost all primary in-situ lesions and small low-risk invasive SCC/BCC (which is probably 95% of lesions encountered, of which I bet 75% goes to mohs right now). I've said this before but I don't believe the recurrence rates in the literature for ED&C. I dont know if thats because the studies were done mostly at academic centers with residents who haven't done 10,000 ED&Cs or if they were selecting the wrong (ie higher risk lesions) or doing partial biopsies and missing the mixed path. But In my fairly loyal/reliable patient population for the past 10 years I'd guess 1-2% of the BCC I scrape recur and almost zero SCC ( I can literally think of maybe 1 or 2 cases and I've easily treated 10-20 thousand). Of course you have to triage the high risk lesions but I'm WAY more liberal than most are. And mind you, these recurrences don't have a bad outcome because they then go to mohs.




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Probably a little selection bias as we never really know how many of our recurrences exist - people move, change insurances, change providers, etc. I agree that the AUC is very lenient toward the justification of Mohs - but remember, it is just that - a defense of rather than a requirement to.

I see, probably weekly, examples of previous Mohs for SCCi by an outside provider. Similarly, I see (at about the same frequency) infiltrating BCC's on the mid face that were treated with ed&c or xrt without any defensible rationale.

There are offenders on both sides of the coin. It's funny that everyone knows who the offenders are locally, but nothing changes. I clean up some people's screw up weekly - at time it seems daily. I have two referring providers who only send recurrent disease - they have told me that they get the first crack at it and I can clean up whatever is left. I have one who will treat with either local destruction, superficial xrt, or simple excision before they consider Mohs. Then there is the group across town who does Mohs on every little "ak with possible micro invasion" BS read they get - depending upon their in office xrt scheduling, of course.

Truthfully, when it comes down to it, one group does more measurable harm than the other... and it's not the Mohs group.


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[doctalaughs]

Truthfully, when it comes down to it, one group does more measurable harm than the other... and it's not the Mohs group.


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You certainly have some valid points although I'm not totally sure I totally agree. It sounds to me like you have some selection bias in that your mohs practice sounds pretty atypical - doing tons (majority?) of large highly aggressive cases that really should have been sent to mohs in the first place.

At least in the 2 states/locations I've practiced in the typical mohs practice, 80% cases are those that a general dermatologist could have appropriately and reasonably treated (ie small primary low-risk tumors) whereas 20% really needed mohs. And maybe this is regional but I've not met more than 1 or 2 dermatologists that are treating willy nilly with radiation and inappropriate excision/ed&c for high risk tumors (out of the many hundreds I know well).

The problem is (in my opinion) doing a high volume of mohs for low risk stuff IS probably doing harm- 1. Financial setbacks to the patients with high deductible plans. 2. Reducing access to patients that really need mohs. 3. Harming specialty image particularly to other surgical specialties who see tiny cases being done. 4. Many patients getting mohs like 5-10x or more a year get frustrated and then refuse, decline or defer getting more important things treated.

If the number of high risk stuff NOT going to mohs was equal to the huge number of low risk stuff getting mohs then I would agree with you. However in my personal experience the latter cases are 100x more frequent than the former.




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[reno911]

You certainly have some valid points although I'm not totally sure I totally agree. It sounds to me like you have some selection bias in that your mohs practice sounds pretty atypical - doing tons (majority?) of large highly aggressive cases that really should have been sent to mohs in the first place.

At least in the 2 states/locations I've practiced in the typical mohs practice, 80% cases are those that a general dermatologist could have appropriately and reasonably treated (ie small primary low-risk tumors) whereas 20% really needed mohs. And maybe this is regional but I've not met more than 1 or 2 dermatologists that are treating willy nilly with radiation and inappropriate excision/ed&c for high risk tumors (out of the many hundreds I know well).

The problem is (in my opinion) doing a high volume of mohs for low risk stuff IS probably doing harm- 1. Financial setbacks to the patients with high deductible plans. 2. Reducing access to patients that really need mohs. 3. Harming specialty image particularly to other surgical specialties who see tiny cases being done. 4. Many patients getting mohs like 5-10x or more a year get frustrated and then refuse, decline or defer getting more important things treated.

If the number of high risk stuff NOT going to mohs was equal to the huge number of low risk stuff getting mohs then I would agree with you. However in my personal experience the latter cases are 100x more frequent than the former.




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Bolded is highly atypical in my experience. I guess it depends on how far you want to stretch reasonable. You can reasonably perform a simple excisional surgery on an 7 mm nodular basal cell on the cheek. But if it were on my cheek I'd want Mohs. I treat my patients the same way.

 

[MOHS_01]

You certainly have some valid points although I'm not totally sure I totally agree. It sounds to me like you have some selection bias in that your mohs practice sounds pretty atypical - doing tons (majority?) of large highly aggressive cases that really should have been sent to mohs in the first place.

At least in the 2 states/locations I've practiced in the typical mohs practice, 80% cases are those that a general dermatologist could have appropriately and reasonably treated (ie small primary low-risk tumors) whereas 20% really needed mohs. And maybe this is regional but I've not met more than 1 or 2 dermatologists that are treating willy nilly with radiation and inappropriate excision/ed&c for high risk tumors (out of the many hundreds I know well).

The problem is (in my opinion) doing a high volume of mohs for low risk stuff IS probably doing harm- 1. Financial setbacks to the patients with high deductible plans. 2. Reducing access to patients that really need mohs. 3. Harming specialty image particularly to other surgical specialties who see tiny cases being done. 4. Many patients getting mohs like 5-10x or more a year get frustrated and then refuse, decline or defer getting more important things treated.

If the number of high risk stuff NOT going to mohs was equal to the huge number of low risk stuff getting mohs then I would agree with you. However in my personal experience the latter cases are 100x more frequent than the former.




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I readily - and have always - admitted that my current practice is atypical in that it is purely external referral in nature -- including a decent percentage of referral from groups that "do Mohs" or has a surgeon. I'm solo practice, hold a gratis university position, and do eyelid and full thickness nasal cases - results in my place being a dumping ground for the ish that no one else wants to deal with. This necessarily results in a lower volume, poorer payer mix, more "complicated" personalities, and cleaning up messes that people with a little sense should have never gotten themselves into.

I'm sure no one openly admits to doing things that are controversial.... but I see far too much of it from snowbirders or other travelers for it to be terribly isolated. I've even seen people trying 5-FU soaks - not Efudex, they actually compound their own mix.

Save these clear outliers, I can honestly say that a great number of the recurrences I see are previous ED&C sites. I cannot attest as to the quality of the destruction - but the typical non-aggressive histology recurrent BCC that makes its way to me is following both local destruction and increasingly ED&C followed by imiquimod treatment - seems someone presented this at a meeting a few years and, unfortunately, it caught on (at least locally).

The first problem that I noticed with this discussion is the different questions being asked: when is Mohs appropriate - vs when is it needed? These are two very different questions; Mohs is often appropriate without being required. There is but one argument against Mohs - and that is a financial one. Given the loss of the multiple procedure reduction exemption, that argument has lost much if its bite if and when the tumor is located in zone A and more than a centimeter in zone B. The next thing to be considered - beyond cost - is patient preference -- for both certainty / closure regarding treatment, cure rates, and cosmetic outcome. You have to be honest with the informed consent - and if someone wanted to basically put a cigar out on my face, not know if they got it all, and this results in a recurrence rate 5x what an alternative treatment that does not result in a cigar burn scar, I'd be pissed. That said, I've seen a couple of "surgeons" who graft 1cm defects in the mid-face... so it pays to know what product you're pushing I suppose.

The real problem that I have with destructive techniques is that it somewhat undermines the MMS technique altogether, but that's another discussion for another day.

 

[doctalaughs]

Bolded is highly atypical in my experience. I guess it depends on how far you want to stretch reasonable. You can reasonably perform a simple excisional surgery on an 7 mm nodular basal cell on the cheek. But if it were on my cheek I'd want Mohs. I treat my patients the same way.

Sure I agree a 7mm BCC on the cheek can easily go either way and no one would argue mohs is "wrong." However, if I were a 91 yo man with multiple medical issues and that BCC was my 8th skin cancer of the year, I would much rather have a quick shave ED&C at the time of visit. What about a 11mm SCCis on the shin? I would far rather have an Ed&c with partial thickness defect. What about a 70yo woman who comes in with four 5mm invasive well diff SCC on the dorsum of the feet and hands (which almost never go into fat or recur in my experience)?

All I'm saying is that in my town all those situations would likely go to mohs regardless of patient age, medical issues etc in most of the practices (that have mohs services in-house). And the AUC guidelines would back them up. The main motivation in these situations is money not whats best for the patient. Not ideal in my book.


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[asmallchild]

Sure I agree a 7mm BCC on the cheek can easily go either way and no one would argue mohs is "wrong." However, if I were a 91 yo man with multiple medical issues and that BCC was my 8th skin cancer of the year, I would much rather have a quick shave ED&C at the time of visit. What about a 11mm SCCis on the shin? I would far rather have an Ed&c with partial thickness defect. What about a 70yo woman who comes in with four 5mm invasive well diff SCC on the dorsum of the feet and hands (which almost never go into fat or recur in my experience)?

All I'm saying is that in my town all those situations would likely go to mohs regardless of patient age, medical issues etc in most of the practices (that have mohs services in-house). And the AUC guidelines would back them up. Not ideal in my book.


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I'll agree partially and I think a lot of our perspective tends to come from how we practice and where we practice.

I agree with the example of the 91yo man with multiple medical issues. I come across this issue quite a bit in my practice and I do give them the offer for less invasive treatment. Our practice is very efficient though and assuming a small pre-operative size (let's use the example of 7mm on the cheek), I can get the tissue processed and the pt repaired with dissolvable suture in under an hour. I do give them the option for less aggressive and quicker treatment though if desired.

The example on the shin is tricky. I agree an ED&C will heal better. I am fairly aggressive with the use of Efudex in these cases too. I have also seen my fair share of absolutely terrible results when SCCs (even in-situ) are not appropriately treated on the legs.

In my patient population of older, severely sun-damaged patients, I have seen multiple cases of recurrence with small (maybe not 0.5cm small but definitely in the 1 - 1.5cm range) well-diff SCCs on hands and feet. Small BCCs on the dorsal feet in particular seem to be routinely undertreated with ED&C and are a mess by the time they arrive in my office.

Again, I realize I am biased because of my own experience with these patients. But in all the examples you've listed, I do find Mohs to be appropriate. Whether or not it is the right treatment for the patient (based on age, other comorbities, etc) is something we have to be better at discussing with patients.

I don't have any statistical data to back this up but my partner and I were just discussing this last week. We've noticed an increased number of rejections of Mohs charges to start the year and I would suspect overutilization is still running rampant despite the implementation of the AUC and more restrictive LCDs. It wouldn't surprise me if LCDs were updated to fully restrict Mohs to the head/neck area in the future to simplify things. (I agree with this in terms of simplifying usage questions, I think it would be a terrible decision for patient care considering how many trainwreck leg cases get dumped to me every day)

 

[reno911]

Sure I agree a 7mm BCC on the cheek can easily go either way and no one would argue mohs is "wrong." However, if I were a 91 yo man with multiple medical issues and that BCC was my 8th skin cancer of the year, I would much rather have a quick shave ED&C at the time of visit.

I don't think it's a go either way kind of thing. Mohs is unequivocally better. You can contrive a situation where someone desires something clearly inferior. But we can do that for any procedure in medicine. Just because the patient may not want the best treatment for some personal reason, doesn't make it not the best.

In your example, I'd still have Mohs. My thin, but open ED&C wound will take at least a week or two to completely heal and I have to deal with some sort of wound care at home. Primary closure with some gut on top would be healed in 5 days with no wound care to do (I just tell them to keep it dry and undisturbed). As asmallchild says, this really wouldn't take that long to do Mohs on (and if for some reason it took multiple stages, then it probably wouldn't have been a good candidate for ED&C.).

What about a 11mm SCCis on the shin? I would far rather have an Ed&c with partial thickness defect.

If I were going to do Mohs on that, the patient could also be left with a partial thickness defect. Just take a very thin layer. My thinnest layers are roughly ED&C thickness and I can often let them heal secondarily. Most of my referring docs ED&C this already, so I probably wouldn't get a referral for this unless there was more to the story.

What about a 70yo woman who comes in with four 5mm invasive well diff SCC on the dorsum of the feet and hands (which almost never go into fat or recur in my experience)?

I will treat all of those with Mohs in most cases. I have seen enough ED&C failures on those types of tumors lead to horrible outcomes, that it's not worth messing around in my mind. I will say that a lot depends on what the tumor looks like clinically and what the biopsy slide looks like. Not all 5mm well diff squamous cells are the same.

All I'm saying is that in my town all those situations would likely go to Mohs regardless of patient age, medical issues etc in most of the practices (that have mohs services in-house). And the AUC guidelines would back them up. The main motivation in these situations is money not whats best for the patient. Not ideal in my book.

I would say that in all of those cases the patient is generally best served by referral to a Mohs surgeon. The Mohs surgeon, however, doesn't have to do Mohs. He should evaluate the patient's specific situation and desires and offer treatments (including Mohs) accordingly.

I would also disagree in the situations you have described that the "main motivation is money". Obviously, I can't speak to what any specific dermatologist's motivation happens to be. However, in the cases you have described, a doc who is only motivated by what's best for the patient, would perfectly fine referring all of those patients to a Mohs surgeon.

You're also going to have to flesh out a little be how exactly you think this money motivation works. Even if a dermatologist is in a practice with a Mohs surgeon, he or she will probably make more money by doing an ED&C themselves than sending it to the Mohs surgeon for Mohs. I'm sure one could contrive a crazy compensation scheme where this wasn't the case, but that would be unusual. This is even more true if the Mohs surgeon is outside the practice.

As others have described, the motivation for money often drives dermatologists to fail to refer for Mohs when they should. The times where you can most confidently point to someone possibly being inappropriately motivated by money are when they do the bx and then do the Mohs themselves (I guess having a spouse that does Mohs would also qualify). And I think that's where most of the abuses occur. Referral only Mohs surgeons, in general, don't really have as much opportunity to abuse the system, because the financial incentive of the referring doc (even one in the same practice) is AGAINST referring for Mohs. One exception to this would be the case where the Mohs surgeon is the owner of the practice and pressures the derms to refer for Mohs. There may be others that I'm not thinking of at the moment. But more often than not, if the guy doing the skin check and the biopsy is not the same guy doing the Mohs, the financial incentive is against Mohs referral.

 

[doctalaughs]

I don't think it's a go either way kind of thing. Mohs is unequivocally better. You can contrive a situation where someone desires something clearly inferior. But we can do that for any procedure in medicine. Just because the patient may not want the best treatment for some personal reason, doesn't make it not the best.

In your example, I'd still have Mohs. My thin, but open ED&C wound will take at least a week or two to completely heal and I have to deal with some sort of wound care at home. Primary closure with some gut on top would be healed in 5 days with no wound care to do (I just tell them to keep it dry and undisturbed). As asmallchild says, this really wouldn't take that long to do Mohs on (and if for some reason it took multiple stages, then it probably wouldn't have been a good candidate for ED&C.).


If I were going to do Mohs on that, the patient could also be left with a partial thickness defect. Just take a very thin layer. My thinnest layers are roughly ED&C thickness and I can often let them heal secondarily. Most of my referring docs ED&C this already, so I probably wouldn't get a referral for this unless there was more to the story.



I will treat all of those with Mohs in most cases. I have seen enough ED&C failures on those types of tumors lead to horrible outcomes, that it's not worth messing around in my mind. I will say that a lot depends on what the tumor looks like clinically and what the biopsy slide looks like. Not all 5mm well diff squamous cells are the same.



I would say that in all of those cases the patient is generally best served by referral to a Mohs surgeon. The Mohs surgeon, however, doesn't have to do Mohs. He should evaluate the patient's specific situation and desires and offer treatments (including Mohs) accordingly.

I would also disagree in the situations you have described that the "main motivation is money". Obviously, I can't speak to what any specific dermatologist's motivation happens to be. However, in the cases you have described, a doc who is only motivated by what's best for the patient, would perfectly fine referring all of those patients to a Mohs surgeon.

You're also going to have to flesh out a little be how exactly you think this money motivation works. Even if a dermatologist is in a practice with a Mohs surgeon, he or she will probably make more money by doing an ED&C themselves than sending it to the Mohs surgeon for Mohs. I'm sure one could contrive a crazy compensation scheme where this wasn't the case, but that would be unusual. This is even more true if the Mohs surgeon is outside the practice.

As others have described, the motivation for money often drives dermatologists to fail to refer for Mohs when they should. The times where you can most confidently point to someone possibly being inappropriately motivated by money are when they do the bx and then do the Mohs themselves (I guess having a spouse that does Mohs would also qualify). And I think that's where most of the abuses occur. Referral only Mohs surgeons, in general, don't really have as much opportunity to abuse the system, because the financial incentive of the referring doc (even one in the same practice) is AGAINST referring for Mohs. One exception to this would be the case where the Mohs surgeon is the owner of the practice and pressures the derms to refer for Mohs. There may be others that I'm not thinking of at the moment. But more often than not, if the guy doing the skin check and the biopsy is not the same guy doing the Mohs, the financial incentive is against Mohs referral.

I guess all I can say is I respectfully disagree with you. Just because something has a higher cure rate doesn't mean its unequivocally "better." The specific patient situation is everything - time and money are not insignificant things to patients, and if they are important to people, we should consider them in the "better" equation as well.

And I think you are overstating how many "train wrecks" result from careful selection of low risk tumors. Obviously I can understand your perspective if you are seeing frequent disasters that started as a tiny mistreated SCCis or well diff SCC on the leg but I cant think a single patient like that, personally. As a partner sharing in profits I benefit financially more from funneling low risk stuff to our (2) in-house mohs surgeons rather than doing ED&C myself. Excision vs mohs likely a wash for me personally. I suspect this is the case with many (most?) practices in the country. However, for examples similar to the tumors I've put above, I've never had or seen a bad outcome from many tens of thousands. Sure, a few recur (in my experience far fewer than the literature would suggest, almost never SCC- usually BCC) and then they go to mohs usually when its only slightly larger. Hell, a majority of those small SCC with positive margins there's nothing left on path after excision anyway. You can of course say I don't see my own recurrences, but I have trouble believing that with my fairly stable/loyal patient population.

I do know that I encounter daily patients that are "sick of going to mohs 5x a year" and financially really hurting. They usually haven't even heard of other treatment options. All they hear is they have "cancer" and "need" a $2000 dollar surgery. The most frequent situation I see is the sun damaged 80s male many getting between 5-15 low-risk lesions a year. These either are going to mohs 4-10x a year vs seeing me every quarter for 15 minutes where I shave-ED&C multiple lesions most requiring no further treatment when path returns.

I have nothing against mohs- it's a great technique. However we used to use it for the worst/ most aggressive cases and now we use it for everything. I'm not aware of any epidemiological evidence that we've reduced the percentage of bad outcomes for NMSC over the last 30 years despite skyrocketing use of mohs. And I suspect that is because we are treating mostly low risk stuff with the procedure.


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[reno911]

I guess all I can say is I respectfully disagree with you. Just because something has a higher cure rate doesn't mean its unequivocally "better." The specific patient situation is everything - time and money are not insignificant things to patients, and if they are important to people, we should consider them in the "better" equation as well.

I've never said that we shouldn't consider those things. I specifically said that we should. Also, Mohs doesn't just have a higher cure rate. There are other advantages as you well know.

And I think you are overstating how many "train wrecks" result from careful selection of low risk tumors. Obviously I can understand your perspective if you are seeing frequent disasters that started as a tiny mistreated SCCis or well diff SCC on the leg but I cant think a single patient like that, personally. As a partner sharing in profits I benefit financially more from funneling low risk stuff to our (2) in-house mohs surgeons rather than doing ED&C myself. Excision vs mohs likely a wash for me personally. I suspect this is the case with many (most?) practices in the country.

I have an extremely hard time believing bolded. Unless you guys are really gouging your Mohs surgeons (and/or your Mohs surgeons massively over-code). It make even less sense when you say that an excision is a wash. Most people can do at least several ED&Cs in the time it takes to do a single excision. In dollars per unit time ED&C is more profitable than excision (for most practitioners). So the when you say both of the folllowing are true:

1. It's a wash doing your own excisions vs profit sharing off of the Mohs (and let's remember that these are tiny Mohs cases, we're all agreed that the micronodular BCCs on the nose get referred)
2. You would some how lose money doing a ED&C vs profit sharing off of the Mohs

it is extremely hard to believe. I'm sure it's theoretically possible, but it is most definitely not the case in most practices in the country. Especially when in their own practices, most derms profit a lot more from ED&C vs Excision, since ED&C takes so much less time.

 

[MOHS_01]

I see these "train wrecks" weekly. Pretty sure that I'm not that special.

As for profit motive - for any given volume ED&C is more profitable. The revenue per hour would be higher, the costs would be lower, and more can be accomplished. It's fairly basic math. The singular metric that Mohs loses out on - selectively - is cost per episode of care. The econometrics of this comparison is fairly simple and straightforward, having been performed and published on more than one occasion.

Lastly... MMS guys will defend MMS. Non-MMS guys will defend the choice of alternative treatments. Both empirical evidence and sound theory favors one group over the other... but not everything in the world is a nail and I discourage Mohs cases referred to me on a fairly frequent basis if I believe the only person benefitting is yours truly. (okay - so it really pisses the staff off when I do this, too, because they know I'll add someone from the cancellation list when we have one - but it still happens. Ha)


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[doctalaughs]

I see these "train wrecks" weekly. Pretty sure that I'm not that special.

As for profit motive - for any given volume ED&C is more profitable. The revenue per hour would be higher, the costs would be lower, and more can be accomplished. It's fairly basic math. The singular metric that Mohs loses out on - selectively - is cost per episode of care. The econometrics of this comparison is fairly simple and straightforward, having been performed and published on more than one occasion.

Lastly... MMS guys will defend MMS. Non-MMS guys will defend the choice of alternative treatments. Both empirical evidence and sound theory favors one group over the other... but not everything in the world is a nail and I discourage Mohs cases referred to me on a fairly frequent basis if I believe the only person benefitting is yours truly. (okay - so it really pisses the staff off when I do this, too, because they know I'll add someone from the cancellation list when we have one - but it still happens. Ha)


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Agree with you that ED&C is more profitable per time; however in saturated competitive markets (more now than 15 years ago) there are a finite number of tumors/patients so the profit per episode of care or tumor is what drives motivation for some practices, at least in my market.

Regarding the evidence - the main problem is the studies on non-mohs alternatives vary wildly. For low-risk tumors there are studies showing an ED&C 5 or 10 year recurrence rate of 35%. There are other fairly large studies showing a recurrence rate of 2-3%! My admittedly anecdotal experience supports the latter and I suspect it's highly operator dependent (like any other procedure). I do think it makes little sense to believe recurrence rates of ED&C done mostly at academic centers probably by residents who have done very few.

But it's an interesting conversation in any case and I agree that mohs surgeons will usually tend to favor mohs whereas those that dont personally do it will tend to argue the opposite.


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[sore eye asses]

I've just taken to putting a bird on it.

 

[doctalaughs]

Here's are some fairly large studies showing ED&C recurrence rates for low-risk tumors approach if not equal to mohs. And mind you, some of these use "low-risk" very loosely (ie include many head/neck tumors as long as they are <1cm and not morpheaform/infiltrative/poor diff etc). And a lot of these results are from the VA where the ED&Cs are probably resident-performed. This is why I think the AUC is ridiculous.

Tumor recurrence 5 years after treatment of cutaneous basal cell carcinoma and squamous cell carcinoma. J Invest Dermatol. 2013 May;133(5):1188-96.
Prospective, 1,488 tumors, 7.4 years median followup: Unadjusted recurrence rates did not differ after treatments: 4.9% (2.3, 7.4) after destruction, 3.5% (1.8, 5.2) after excision, and 2.1% (0.6, 3.5) after Mohs surgery (P=0.26), and no difference was seen after adjustment for risk factors.

Recurrence after treatment of nonmelanoma skin cancer: a prospective cohort study. Arch Dermatol. 2011 May;147(5).
Prospective, 616 tumors. 21 tumors recurred (3.5% [95% confidence interval (CI), 2.2%-5.2%]): 2 after ED&C (1.6% [95% CI, 0.2%-5.6%]), 13 after excision (4.2% [95% CI, 2.2%-7.1%]), and 6 after Mohs surgery (3.5% [95% CI, 1.3%-7.4%]).

Treatment of basal cell carcinoma with curettage alone. J Am Acad Dermatol. 2006 Jun;54(6):1039-45.
Retrospective 302 tumors. 5-year cure rate of 96.03%


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[MOHS_01]

Here's are some fairly large studies showing ED&C recurrence rates for low-risk tumors approach if not equal to mohs. And mind you, some of these use "low-risk" very loosely (ie include many head/neck tumors as long as they are <1cm and not morpheaform/infiltrative/poor diff etc). And a lot of these results are from the VA where the ED&Cs are probably resident-performed. This is why I think the AUC is ridiculous.

Tumor recurrence 5 years after treatment of cutaneous basal cell carcinoma and squamous cell carcinoma. J Invest Dermatol. 2013 May;133(5):1188-96.
Prospective, 1,488 tumors, 7.4 years median followup: Unadjusted recurrence rates did not differ after treatments: 4.9% (2.3, 7.4) after destruction, 3.5% (1.8, 5.2) after excision, and 2.1% (0.6, 3.5) after Mohs surgery (P=0.26), and no difference was seen after adjustment for risk factors.

Recurrence after treatment of nonmelanoma skin cancer: a prospective cohort study. Arch Dermatol. 2011 May;147(5).
Prospective, 616 tumors. 21 tumors recurred (3.5% [95% confidence interval (CI), 2.2%-5.2%]): 2 after ED&C (1.6% [95% CI, 0.2%-5.6%]), 13 after excision (4.2% [95% CI, 2.2%-7.1%]), and 6 after Mohs surgery (3.5% [95% CI, 1.3%-7.4%]).

Treatment of basal cell carcinoma with curettage alone. J Am Acad Dermatol. 2006 Jun;54(6):1039-45.
Retrospective 302 tumors. 5-year cure rate of 96.03%


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I do not doubt the high cure rate for appropriately selected tumors. I do doubt cure rates that high for the majority of tumors I see -- even when doing general derm. I really just don't see many small nBCC's -- not sure if it is patient population, the fact that I no longer provide high volume general derm, or what... I will also say this -- it is amazing frequent that I get a biopsy report of something as nBCC and, on Mohs stage, find iBCC, micronodularBCC, or even mBCC. It might not be the majority of cases -- and I really no longer have a mechanism of tracking this (thanks HIPAA and MU), but it approach half at least. Mixed histology almost seems to be the norm for longstanding tumors.

As for the AUC --was I not tired, pissed off at the world, and lazy I would search my post history to point to the times that I have made the same argument about the leniency of the AUC to the point that I believe it undermines its utility. That does not change the fact, however, that you continue to misapply the purpose of the AUC (and I am not defending it as you are using it -- as an algorithm suggested to function as the end arbiter of whether Mohs constitutes the only appropriate treatment); it is not that -- at all. It's sole intended purpose is to serve as a benchmark whether the decision to perform Mohs was justifiable (appropriate) or not. Not required. Justifiable. These are, fundamentally, two very different concepts.

I get that this is an emotionally charged topic -- and as troubling as it is for the non-Mohs guys who occasionally have to field the question of "why was I not offered" or "why did I not get" following a visit to a less than courteous colleague who points out the differences, the real emotional temper tantrums are reserved for our brethren in other disciplines who deign themselves lords of all things surgical. And medical. And radiological. And pathological. And anesthesia. Hell -- everything medical. Nursing too. You know who. Ego combined with functional ignorance is a toxic milieu best reserved for surgery physician lounges... but internet forums suffice for some. heh. Somewhat more seriously, though, if I could ever devise a bedside technique that affords dependable in vivo imaging and decreases the mean number of stages for even high risk tumors, the ability to justify an ED&C will vanish almost instantly. All procedures are subject to the forces of innovation -- MMS, local destructive techniques, all of them.

What I find hard to defend is excisions or excisions with frozen section control. It does not mean that I don't do them -- but they're pretty damn hard to defend in an intellectually honest or consistent manner. Think about that one for a minute.

 

[doctalaughs]

I do not doubt the high cure rate for appropriately selected tumors. I do doubt cure rates that high for the majority of tumors I see -- even when doing general derm. I really just don't see many small nBCC's -- not sure if it is patient population, the fact that I no longer provide high volume general derm, or what... I will also say this -- it is amazing frequent that I get a biopsy report of something as nBCC and, on Mohs stage, find iBCC, micronodularBCC, or even mBCC. It might not be the majority of cases -- and I really no longer have a mechanism of tracking this (thanks HIPAA and MU), but it approach half at least. Mixed histology almost seems to be the norm for longstanding tumors.

As for the AUC --was I not tired, pissed off at the world, and lazy I would search my post history to point to the times that I have made the same argument about the leniency of the AUC to the point that I believe it undermines its utility. That does not change the fact, however, that you continue to misapply the purpose of the AUC (and I am not defending it as you are using it -- as an algorithm suggested to function as the end arbiter of whether Mohs constitutes the only appropriate treatment); it is not that -- at all. It's sole intended purpose is to serve as a benchmark whether the decision to perform Mohs was justifiable (appropriate) or not. Not required. Justifiable. These are, fundamentally, two very different concepts.

I get that this is an emotionally charged topic -- and as troubling as it is for the non-Mohs guys who occasionally have to field the question of "why was I not offered" or "why did I not get" following a visit to a less than courteous colleague who points out the differences, the real emotional temper tantrums are reserved for our brethren in other disciplines who deign themselves lords of all things surgical. And medical. And radiological. And pathological. And anesthesia. Hell -- everything medical. Nursing too. You know who. Ego combined with functional ignorance is a toxic milieu best reserved for surgery physician lounges... but internet forums suffice for some. heh. Somewhat more seriously, though, if I could ever devise a bedside technique that affords dependable in vivo imaging and decreases the mean number of stages for even high risk tumors, the ability to justify an ED&C will vanish almost instantly. All procedures are subject to the forces of innovation -- MMS, local destructive techniques, all of them.

What I find hard to defend is excisions or excisions with frozen section control. It does not mean that I don't do them -- but they're pretty damn hard to defend in an intellectually honest or consistent manner. Think about that one for a minute.

It sounds like overall we agree. And by all your posts it sounds like you absolutely have a practice that primarily does high risk tumors. I also lay no blame with MMS people that are primarily referral-based doing solely MMS, even if they get a lot of low-risk tumors. After all, you sort of have to do all the cases referring docs thought needed mohs, or they will stop sending to you.

However, I think the blame lies primarily with those that do both a lot of skin checks/ genderm and also do mohs (themselves or in house) funneling low risk stuff to themselves or their partners that could have easily been taken care of with a quicker, cheaper and nearly identical cure-rate procedure.

Regarding the mixed histology it drives me crazy how people do their biopsies. When I see a small tumor I think will end up appropriate for ED&C I look with dermoscopy, mark the edges then take the whole thing with a saucerization (similar to a melanocytic lesion) followed by an ED&C to the base/ edges. I don't take a tiny slice so I'm pretty sure the pathologist sees 99% of it. And no, I don't do this on a 27-year-old woman's cheek who will likely need MMS anyway. But as you know the 80 year old guy will barely see a scar in 2 months. Sure I get a few wrong that end up infiltrative and need mohs but I'm right about them being low risk 95% of the time and problem solved (sometime up to 5 tumors) in 10-15 minutes.

Mostly these are small well diff SCC or SCCis or nodular/ superficial BCC in old sun damaged skin. My experience is different than yours in that this comprises 90% of tumors I see and rest go to mohs.

And I wholeheartedly agree with you that MMS beats excision hands down. I find myself doing fewer and fewer excisions for skin cancer even though I like them and I'm fairly comfortable surgically for a gen derm. I end up doing a lot of cysts and a few melanocytic lesions.

I know the AUC was meant to be a tool to exclude egregious mis-uses of mohs but it has become a way for some (not all) to justify mohs for everything.


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