Evolution of Excisional Surgery Practices for Melanoma in the United States

Lee, Michael P.; Sobanko, Joseph F.; Shin, Thuzar M.; Howe, Nicole; Barbieri, John S.; Miller, Christopher J.; Etzkorn, Jeremy R.

doi:10.1001/jamadermatol.2019.2346

Cited by 36 publications

(38 citation statements)

References 28 publications

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“…Previous studies have described wide variation in use rates and practice patterns amongst Mohs surgeons, prompting the American College of Mohs Surgery to develop appropriate use criteria (AUC) for MMS in 2012. [9][10][11] Yet, the results of this study suggest that the use rate of MMS continued to increase despite the adoption of AUC. However, numerous factors beyond economic incentives may have also contributed to this trend.…”

Section: Resultsmentioning

confidence: 68%

Use of Skin Cancer Procedures, Medicare Reimbursement, and Overall Expenditures, 2012-2017

Puri

Baliga

Pittelkow

et al. 2020

Preprint

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The treatment of skin cancers represents a growing share of healthcare expenditures. At the same time, Medicare reimbursement rates for physician services have declined with respect to inflation. The objective of this study was to describe the economic effects of declining Medicare reimbursement for skin cancer procedures. In this ecological study, we used the Medicare Physician Supplier and Other Provider Public Use File (POSPUF) to analyze trends in Medicare reimbursement rates, use rates, and overall Medicare expenditures for skin cancer procedures from 2012 to 2017. We adjusted reimbursement rates for inflation by converting payment amounts into units of 2017 dollars. From 2012 to 2017, overall inflation-adjusted Medicare expenditure on skin cancer procedures increased 9%. Over this time period, inflation-adjusted Medicare reimbursement rates declined for each procedure class, with the exception of shave excision. Concurrently, the use rate of Mohs micrographic surgery increased 23%, while the use rate for all other skin cancer procedure classes declined. In summary, this study describes trends suggesting declining Medicare reimbursement rates have been associated with increasing use rates for higher cost skin cancer procedures. Clinicians and policy makers should collaborate to develop value-based payment models that incentivize patient outcomes rather than procedural volumes.

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Section: Resultsmentioning

confidence: 68%

Use of Skin Cancer Procedures, Medicare Reimbursement, and Overall Expenditures, 2012-2017

Puri

Baliga

Pittelkow

et al. 2020

Preprint

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“…This risk is mitigated by taking an incisional biopsy from the most atypical appearing area of the tumor at the first stage of excision to check for any invasive component. The use of Mohs surgery with immunostains, which is increasingly used for melanoma in the United States, 39 could help to avoid these drawbacks.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of Staged Excision With Circumferential en Face Margin Control for Lentigo Maligna of the Head and Neck

et al. 2020

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Background Treatment practices vary for lentigo maligna (LM). Staged excision with circumferential margin control (SECMC) has the potential to achieve low recurrence rates. Objectives To evaluate the clinical outcomes of SECMC using permanent, paraffin-embedded sections and delayed reconstruction. Methods We conducted a retrospective, uncontrolled, observational cohort study involving patients who underwent staged excision for LM of the head and neck at Women’s College Hospital in Toronto, Canada, from September 2010 to March 2013. Recurrence and infection rates were ascertained from patient charts and postal surveys. Results One hundred and two patients (45 female, 57 male) were included with a median follow-up time of 1410.5 (IQR 260-1756) days. The median age was 69 (IQR 61-79) years. Approximately one-fifth (21%, 21/102) of patients required greater than 0.5 cm margins to achieve histological clearance. One patient (1/102) upstaged to invasive melanoma based on the initial stage of excision. The infection rate was 6% (6/102) and the 5-year cumulative recurrence rate was 1.4% (95% CI 0.2-9.6%). Conclusion SECMC using permanent sections and delayed reconstruction appears to be a safe and effective treatment method for LM on the head and neck. Randomized trials are needed to help define the optimal treatment.

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“…13,22 A recent survey of Mohs surgeons and database analysis suggests wide-spread use of MART-1 in MMS for CM. 23,24 With techniques in MMS for treating melanocytic lesions evolving, there is an impetus to continue to evaluate emerging research for further clinical guideline development. To date, no systematic reviews have specifically examined the utilization of MART-1 staining in frozen sections for CMparticularly its effect on local recurrence.…”

Section: In-depth Review Melanoma Recurrence After Mohs Micrographic Surgery With Mart-1: a Systematic Review And Meta-analysismentioning

confidence: 99%

“…Twenty-seven percent of the MMS cases reported use of Immunohistochemistry stains (IHC), with an increase in utilization over recent years with further acceptance of its benefit. 24 In addition to ease of use/interpretability and outcome improvement, it is important to investigate financial feasibility. Wilson et al demonstrated that among comprehensive margin assessment techniques for MIS/IM, staged excision using en-face margin assessment (SEEM) and MMS with MART-1 were similar in cost for the healthcare system.…”

Section: Risk Of Biasmentioning

confidence: 99%

Melanoma Recurrence after Mohs Micrographic Surgery with MART-1: A Systematic Review and Meta-analysis

Long¹,

Dunn²,

Arndt³

et al. 2021

J of Skin

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Background: Surveys suggest wide-spread use of MART-1 in MMS for CM among Mohs surgeons, but no previous systematic review has investigated the efficacy of this specific procedure. Methods: A systematic search and meta-analysis of retrospective studies on MMS with MART-1 was performed from Pubmed, Medline, and Cochrane databases for articles published from their inception to October 30, 2020. We performed a chi-squared analysis of homogenized data to examine the relationship between recurrence location and rate of recurrence. A risk of bias was obtained with the ROBINS-I tool. [PROSPERO ID: CRD42020221826] Results: Among the included studies, there were a total of 15 (0.52%) local recurrences of melanoma in-situ and invasive melanoma after MMS with MART-1. Conclusions: This review has served to demonstrate that MMS with MART-1 immunostaining in frozen sections is a technique that produces satisfactory recurrence rates for melanoma in-situ and invasive melanoma.

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Evolution of Excisional Surgery Practices for Melanoma in the United States

Cited by 36 publications

References 28 publications

Use of Skin Cancer Procedures, Medicare Reimbursement, and Overall Expenditures, 2012-2017

Use of Skin Cancer Procedures, Medicare Reimbursement, and Overall Expenditures, 2012-2017

Outcomes of Staged Excision With Circumferential en Face Margin Control for Lentigo Maligna of the Head and Neck

Melanoma Recurrence after Mohs Micrographic Surgery with MART-1: A Systematic Review and Meta-analysis

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