NEW YORK — Mohs micrographic surgery (MMS) is the standard of care for treating certain types of keratinocyte carcinoma (KCs), but it has not been uniformly accessible to veterans treated by the VHA, according to a recent research letter.
That has been the case, the letter authors reported in the Journal of the American Academy of Dermatology, even though KC is one of the most prevalent conditions among VHA patients.1
“Standard excision has been utilized for more timely treatment of KCs when MMS is not easily accessible,” explained the researchers from the New York University Grossman School of Medicine and the VA New York Harbor Healthcare System, both in New York. “Prior studies have shown that standard excision can lead to higher rates of re-excision and recurrence due to inadequate margin control.”
The study team sought to demonstrate how the implementation of on-site MMS at the VA New York Manhattan Harbor Healthcare System (VA) eliminated reexcision and rerepair of Mohs-appropriate KCs and decreased time to treatment.
Their retrospective and prospective cohort study was conducted at that single VAMC medical center for patients with Mohs-appropriate KCs who underwent MMS and standard excision from 2015 to 2022.
“Prior to the initiation of on-site MMS, patients with KCs that met Mohs Appropriate Use Criteria either underwent standard excision at the VA or were referred to a community Mohs micrographic surgeon,” according to the letter. “In the 3 years prior to the implementation of on-site MMS, 264 tumors underwent standard excision at the VA. Tumors were comprised of basal cell carcinomas (46.2%) and squamous cell carcinomas (53.8%). Re-excision and re-repair due to positive margins occurred in 8.3% of standard excision cases.”
That changed after initiation of on-site MMS, however. The study noted that MMS was performed on 423 keratinocytic carcinomas in a weekly dermatologic surgery clinic at the VA from 2017 to 2022. “Re-excision and rerepair due to positive margins occurred in 0% of cases that underwent MMS,” the authors advised. “Therefore, on-site MMS at the VA resulted in a decrease in the burden of procedures for an already vulnerable population.”
The report stated that implementation of MMS at the VA also decreased time to treatment, defined as the time interval from the date of the biopsy to the surgical removal of the malignancy.
“In the 6 months preceding on-site MMS, 20 Mohs appropriate KCs were referred to community surgeons, and the average time to treatment was 89.8 days,” the authors pointed out. “Comparatively, following the initiation of on-site MMS, 423 tumors underwent MMS at the VA, and the average time to treatment was 53 days. This resulted in a statistically significant decrease in treatment time by 36.8 days (P < .001).”
They added that all procedures at the VA were supervised by a fellowship-trained Mohs surgeon, and that the rates of common MMS complications (bleeding: 2.1%; infection: 1.2%) remained similar to those reported in clinical studies.
“In summary, the implementation of on-site MMS, even at a once weekly frequency, enhanced access to standard-of-care treatments for Mohs-appropriate KCs among veterans,” the study team concluded. “On-site MMS eliminated the need for re-excision and re-repair, as well as decreased time to treatment by 41%. There were low rates of complications, demonstrating enhanced quality of care for veterans, without compromising safety.”
- Himeles JR, Steuer AB, Sally R, Gutierrez D, Zampella JG, Stevenson ML, Carucci JA, Lee N. Implementation of Mohs micrographic surgery at the VA New York Manhattan Harbor Healthcare System eliminated need for re-excision and decreased time to treatment: A retrospective and prospective cohort study. J Am Acad Dermatol. 2024 Apr;90(4):822-824. doi: 10.1016/j.jaad.2023.11.035. Epub 2023 Dec 26. PMID: 38149943.
