Cost effectiveness of intermediate-risk squamous cell carcinoma treated with Mohs micrographic surgery compared with wide local excision

Mohs Micrographic Surgery for Cutaneous Squamous Cell Carcinoma

BACKGROUND

The first-line treatment of the localized form of cutaneous squamous cell carcinoma (cSCC) remains surgical excision. Either conventional excision (CE) with margins or Mohs micrographic surgery (MMS) may be preferred, depending on the risk factors of cSCC, the characteristics of the tumor, and the available technical facilities.

METHODS

This article presents a systematic review of the current literature spanning from 1974 to 2023, comparing outcomes of cSCC treated with MMS versus cSCC treated with conventional excision.

RESULTS

Out of the 6821 records identified through the database search, a total of 156 studies were screened, of which 10 were included in the review. The majority of the included studies showed that treatment of cSCC with MMS consistently exhibits a significantly lower risk of recurrence compared to treatment with CE. In addition, MMS is emerging as the preferred technique for the resection of cSCC located in aesthetically or functionally challenging anatomical areas.

CONCLUSION

The studies generally demonstrate that MMS is a safer and more effective treatment of cSCC than CE. Nevertheless, outcomes such as recurrence rates and cost-effectiveness should be assessed more precisely, in order to allow for a more tailored approach in determining the appropriate indication for the use of MMS.

Cost-effectiveness analysis of margin-controlled surgery for vulvar Paget's disease

Objectives

To determine the cost of two surgical treatment approaches for vulvar Paget's disease and model the cost-effectiveness considering differences in recurrence and reoperation over time.

Methods

We assessed cost-effectiveness between excision guided by Mohs micrographic surgery (MMS-E) and traditional wide local excision (WLE). We examined billing data from patients with vulvar Paget's disease who underwent MMS-E (cases, n = 24, 2018-2022) or WLE (controls, n = 64, 1990-2020). We created typical treatment bundles incorporating physician-administered services and facility costs standardized to Medicare reimbursements in 2022 United States Dollars (USD). The primary measure of effectiveness was disease-free years of life. A secondary analysis estimated quality-adjusted life years (QALY). A Markov model simulated treatment pathways over a 10-year time horizon. Transition probabilities were based on institutional recurrence rates (3-year RR 6.7 % for MMS-E vs 34.1 % for WLE). We used a willingness-to-pay threshold of 100,000 USD per QALY.

Results

The cost of a single surgical episode was 34,664 USD for MMS-E and 14,969 USD for WLE. In the setting of lower recurrence rates with MMS-E, the incremental cost was 12,789 USD per disease-free year gained. A secondary analysis incorporating QALY showed an incremental cost of 72,820 USD per QALY.

Conclusions

MMS-E appears to be a cost-effective treatment for vulvar Paget's disease compared to historic standard of care. Our ability to estimate quality of life gained by avoiding disease recurrence was limited by scant data for this rare condition; thus, future studies incorporating health utility values are needed to facilitate a more comprehensive analysis.

Intralesional 5-Fluorouracil in the Treatment of Squamous Cell Carcinoma in an Elderly Patient

Squamous cell carcinoma (SCC) is the second leading form of skin cancer. In the elderly population, surgery may carry more risk and significant morbidity in comparison to less invasive forms of treatment. This case report describes the successful use of intralesional 5-fluorouracil (IL5-FU) to treat cutaneous squamous cell carcinoma (cSCC). A 98-year-old white woman presented in early May 2017 with a 3.5-cm rapidly growing crusted nodule on her left proximal-lateral arm. She had a past medical history of chronic obstructive pulmonary disease, atrial fibrillation, and heart failure. The patient also had a frail body habitus and weighed 80 pounds. Physical examination revealed a large, ulcerated, crateriform mass on the left proximal-lateral arm. A shave biopsy was performed, which revealed a well-differentiated SCC, composed of nodular masses of neoplastic squamous cells with atypical nuclei, keratin pearl formation, and scattered mitotic figures with surrounding fibrosis and inflammation. The patient was wheelchair-bound and oxygen-dependent and, thus, not considered a good surgical or radiation candidate. Treatment was decided with 5-fluorouracil. At a four-week follow-up appointment, there was no visible or palpable evidence of the tumor. There was no sign of recurrence at three months, indicating treatment success. The patient later died due to cardiac arrest in September 2017. The elderly population with cSCC can benefit from intervention and treatment with IL5-FU when surgery is not an option due to patient comorbidities. IL5-FU can potentially be used in areas where access to a dermatologist, surgeon, or surgical services is limited.

Management of Cutaneous Squamous Cell Carcinoma of the Scalp: The Role of Imaging and Therapeutic Approaches

Cutaneous squamous cell carcinoma (cSCC) is the second most common subtype of skin cancer. The scalp is one of the most frequently affected locations and is associated with a higher rate of complications, compared to other locations. In addition, it has a characteristic thickness and anatomical structure that may influence both growth pattern and treatment of primary cSCC; while clinical peripheral margins may be easily achieved during the surgery, vertical excision of the tumor is limited by the skull. Despite having a unique anatomy, current guidelines do not contemplate specific recommendations for scalp cSCC, which leads to inconsistent decision-making in multidisciplinary committees when discussing tumors with high risk factors or with close margins. This article provides specific recommendations for the management of patients with scalp cSCC, based on current evidence, as well as those aspects in which evidence is lacking, pointing out possible future lines of research. Topics addressed include epidemiology, clinical presentation and diagnosis, imaging techniques, surgical and radiation treatments, systemic therapy for advanced cases, and follow-up. The primary focus of this review is on management of primary cSCC of the scalp with localized disease, although where relevant, some points about recurrent cSCCs or advanced disease cases are also discussed.

Mohs surgeon workforce survey: a spectrum of clinical, academic, and leadership activities

Workforce adequacy for Mohs micrographic surgery (MMS) is not fully understood. The purpose of this study was to describe the current spectrum of clinical, academic, advocacy and leadership activities through a survey of members of the American College of Mohs Surgery (ACMS). The ACMS membership was electronically sent a 43-question anonymous survey between January and May 2023 and there was a 10.7% response rate representing 184 members across 37 states. Nearly 90% are board certified in micrographic dermatologic surgery and 10.3% indicate that they practice in a rural setting (57.1% suburban and 32.6% urban). The median number of half-day surgeons performed Mohs surgery is 6 and nearly half of Mohs surgeons work in a dermatology-only medical group (48.4%), do no use immunohistochemical stains (60.3%), and do not participate in a multidisciplinary tumor board (58.7%). Many respondents indicate they have capacity in their clinical schedules to accommodate more cases and the reasons are multifactorial.

Retrospective analysis shows the cost of Mohs surgery decreases when adjusted for medical inflation

BACKGROUND

Mohs surgery (MS) is the gold standard for treating nonmelanoma skin cancers in cosmetically sensitive areas.

OBJECTIVE

To investigate MS costs over time when adjusting for medical inflation while considering the perspective of patients, payers, and health care systems.

METHODS

A retrospective claim analysis using data from the International Business Machines MarketScan Commercial Claims and Encounters Database from 2007 through 2019 was performed. A query of the database for any instance of a MS-specific Current Procedural Terminology (CPT) code in adults (17311, 17312, 17313, 17314, and 17315) was conducted. Aggregate data per claim regarding coinsurance, total cost, deductible, copay, and insurance payout were provided for each CPT code annually.

RESULTS

The total adjusted cost per claim decreased significantly (P < .001) for 4 of the 5 MS-specific CPT codes between 2007 and 2019: 17311 (-25%), 17312 (-15%), 17313 (-25%), and 17314 (-18%). The patient's adjusted out-of-pocket expense increased significantly (P < .0001) for 4 of the 5 MS-specific CPT codes: 17311 (33%), 17312 (45%), 17313 (34%), and 17314 (43%).

CONCLUSION

Among the 4 most used MS-specific CPT codes (17311, 17312, 17313, and 17314), the total cost per claim decreased and the patient's out-of-pocket expense increased from 2007 to 2019.

European consensus-based interdisciplinary guideline for invasive cutaneous squamous cell carcinoma: Part 2. Treatment-Update 2023

In order to update recommendations on treatment, supportive care, education, and follow-up of patients with invasive cutaneous squamous cell carcinoma (cSCC), a multidisciplinary panel of experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), the European Society for Radiotherapy and Oncology (ESTRO), the European Union of Medical Specialists (UEMS), the European Academy of Dermatology and Venereology (EADV), and the European Organisation of Research and Treatment of Cancer (EORTC) was formed. Recommendations were based on an evidence-based literature review, guidelines, and expert consensus. Treatment recommendations are presented for common primary cSCC (low risk, high risk), locally advanced cSCC, regional metastatic cSCC (operable or inoperable), and distant metastatic cSCC. For common primary cSCC, the first-line treatment is surgical excision with postoperative margin assessment or micrographically controlled surgery. Achieving clear surgical margins is the most important treatment consideration for patients with cSCCs amenable to surgery. Regarding adjuvant radiotherapy for patients with high-risk localised cSCC with clear surgical margins, current evidence has not shown significant benefit for those with at least one high-risk factor. Radiotherapy should be considered as the primary treatment for non-surgical candidates/tumours. For cSCC with cytologically or histologically confirmed regional nodal metastasis, lymph node dissection is recommended. For patients with metastatic or locally advanced cSCC who are not candidates for curative surgery or radiotherapy, anti-PD-1 agents are the first-line systemic treatment, with cemiplimab being the first approved systemic agent for advanced cSCC by the Food and Drugs Administration/European Medicines Agency. Second-line systemic treatments for advanced cSCC, include epidermal growth factor receptor inhibitors (cetuximab) combined with chemotherapy or radiotherapy. Multidisciplinary board decisions are mandatory for all patients with advanced cSCC, considering the risks of toxicity, the age and frailty of patients, and co-morbidities, including immunosuppression. Patients should be engaged in informed, shared decision-making on management and be provided with the best supportive care to improve symptom management and quality of life. The frequency of follow-up visits and investigations for subsequent new cSCC depends on underlying risk characteristics.

A review of Mohs Micrographic Surgery for skin cancer: Part 3 - Squamous Cell Carcinoma

This review is part three of a series assessing the evidence for Mohs micrographic surgery (MMS) for treatment of cutaneous malignancies. The evidence for using MMS to treat cutaneous squamous cell carcinoma (cSCC) is presented and discussed. Medline, Embase and Cochrane databases were searched and 39 papers were identified. We included all clinical trials and observational studies including retrospective reports. We excluded editorials and systematic reviews or meta-analyses. We categorised the evidence under the following headings: tumour recurrence, specific site outcomes (ear, lip, scalp and periocular), cSCC with PNI, and cost effectiveness. Whilst there are many observational studies indicating the potential benefits of MMS in the management of certain cSCCs, no randomised controlled trials (RCT) were identified. This evidence suggests that MMS has a lower recurrence rate than other treatments for cSCC, including standard excision. Many studies were single-armed, having no comparator but do demonstrate a low to very low recurrence rate of cSCC following MMS. Further methodologically robust studies with comparator arms are needed, including RCT evidence, given the overall quality of included studies was low and highly heterogeneous.