Cost effectiveness of Mohs micrographic surgery: review of the literature.

BACKGROUND: A number of treatment modalities are currently in existence for non-melanoma skin cancer, including microscopically controlled surgical excision (e.g., Mohs micrographic surgery [MMS]), traditional surgical excision, radiation therapy, electrodessication and curettage, cryosurgery, photodynamic therapy and topical chemotherapeutic agents. MMS has the significant advantage of the lower recurrence rates of all treatment modalities, where five-year cure rates for MMS for primary BCCs are 1% relative to surgical excision (10.1%), electrodessication and curettage (7.7%), radiation therapy (8.7%) and cryotherapy (7.5%). Previous studies have also indicated, across specialties, that dermatologists have the highest rates for complete removal of non melanoma skin cancer (NMSC) which are significantly greater than those for otolaryngologists (P>0.02) and plastic surgeons (P<0.0008).

OBJECTIVE: To evaluate and compare the results of recent studies comparing the cost effectiveness of MMS to other treatment modalities performed by dermatologists and other physicians performing treatment of NMSC (otolaryngologic (ENT) surgeons, plastic surgeons, general surgeons).

RESULTS: MMS is equivalent in cost to excision with permanent sections, 12% less costly than office based excision with frozen sections and 27% less costly than excision with frozen sections in an ambulatory surgical center (ASC). The most significant difference between MMS and surgical excision was the facility fee of excision with frozen sections in an ASC, (differential of $443-$555). With surgical excision, 32-39% of cases require a second procedure for clear margins. Additionally, with subsequent procedures for surgical excision cases, there is likely a greater volume of tissue removed and ramifications on functional preservation and cosmesis, which are difficult to quantify.

CONCLUSION: Analysis of the existing literature on MMS relative to surgical excision confirms the value of MMS in both obtaining the highest initial cure rates and lowest recurrence rates. This analysis confirms that MMS is a cost effective treatment, which is lower in cost than surgical excision, which often includes an ASC facility fee and a subsequent re-excision procedure. Cost effectiveness analysis demonstrating the outcomes based efficiency of MMS are critical in the current health care climate with heightened sensitivity to financial pressures and declining reimbursement rates which may challenge our ability to provide patients with the optimal treatment for NMSC.