For some skin cancers, clinicians must consider less expensive options than Mohs surgery

Miami Beach, Fla. - Although Mohs micrographic surgery represents the gold standard for treatment of many skin cancers, says an expert, healthcare reform dictates that dermatologists also consider less costly options when appropriate.

“As a resident working at a community hospital in Dallas,” says Adewole Adamson, M.D., M.P.P., “I see many patients who are uninsured or underinsured. We can’t send the majority of patients with basal cell carcinoma (BCC) to Mohs surgery, which would provide the highest cure rates for cancer on the head and neck.” Dr. Adamson, who is a first-year resident in the dermatology training program at the University of Texas Southwestern, Dallas, spoke at the 71^st annual American Academy of Dermatology meeting.

Additionally, Dr. Adamson says that with the advent of accountable care organizations (ACOs), “Practicing population management - being able to take care of our patients with skin cancer very cost effectively - may be in our future.”

Fortunately, he says, “There are many ways besides Mohs surgery to treat BCCs, even on the head and neck.”

Cost comparisons

For starters, a study from the Netherlands has compared surgical excision of a wide variety of primary and recurrent BCCs versus Mohs surgery (using at least 3 mm margins). Five years postsurgery, researchers observed no significant and differences in outcomes, complications or aesthetic results between the two treatments for primary BCCs (Smeets NW, Krekels GA, Ostertag JU, et al. Lancet. 2004;364(9447):1766-1772. Mosterd K. Lancet Oncol. 2008;9(12):1149-1156).

“Also, costs favored excision, by about 250 euros. For recurrent BCCs, there was still a cost benefit for excision,” although investigators judged Mohs more effective here, given the increased recurrence rate, he says.

Similarly, Dr. Adamson says, a study that compared excision versus photodynamic therapy (PDT) in nodular BCC showed no significant differences at five years (Rhodes LE, de Rie MA, Leifsdottir R, et al. Arch Dermatol. 2007;143(9):1131-1136). “However, the study was somewhat underpowered. If it had included a larger number of patients or followed patients for a year or two longer, you probably would see a difference” between the therapies.

As for electrodesiccation and curettage (EDC), he says, few trials compare it head-to-head against other surgical modalities. In a single-center, retrospective study, investigators concluded that diameter and anatomic site were strong independent risk factors for recurrence (Silverman MK, Kopf AW, Grin CM, et al. J Dermatol Surg Oncol. 1991;17(9):720-726).

Specifically, “For BCCs smaller than 9 mm, EDC alone can clear nine of 10 patients. But interestingly, age, sex and lesion duration didn’t affect recurrence rates,” Dr. Adamson says.

Comparative trials of cryosurgery for BCC are similarly rare, Dr. Adamson says. In several noncontrolled, prospective trials, “Recurrence rates range from zero - and I’m not sure I believe that – to around 20 percent.”

Recurrence rates

A few comparative trials show recurrence rates of 6 to 39 percent, he adds, “But none of these studies have great follow-up, although cosmesis was pretty good with cryosurgery.”

Results with 5-fluorouracil (5-FU) also are mixed. One such study in superficial BCC showed a clearance rate of 90 percent (Gross K, Kircik L, Kricorian G. Dermatol Surg. 2007;33(4):433-439), Dr. Adamson says, “But no clinical follow-up was provided.”

Regarding imiquimod for superficial BCC, a systematic review uncovered three Class A studies, which together showed an 81 percent clearance rate six to 12 weeks post-treatment (Love WE, Bernhard JD, Bordeaux JS. Arch Dermatol. 2009;145(12):1431-1438). Based on these studies, “It appears that if a patient uses imiquimod twice daily for 12 weeks, the patient achieves 100 percent clearance.” However, Dr. Adamson notes, 30 to 40 percent of patients drop out due to tolerability issues. Accordingly, “You’ll probably have to do a lot of hand-holding if you treat patients with imiquimod, and these visits would add to cost.”

For imiquimod in nodular BCC, he says, “There’s one Class A study, showing that patients can achieve up to 76 percent clearance (Shumack S, Robinson J, Kossard S, et al. Arch Dermatol. 2002;138(9):1165-1171). What was most interesting about this paper is that comparing the six-week and 12-week treatment regimens reveals only a small difference in clearance rates. That’s very important in terms of cost.”

Cost breakdown

In this regard, he says that on average, Mohs surgery (single-stage) costs around $1,000, including repair services, with additional charges for additional stages. Excision costs roughly $600, Dr. Adamson says, with additional lab processing fees that can range from $100 to $200, making it a more affordable option.

However, he says, “I was blown away by the fact that topical therapy is actually in many ways more expensive.” For example, he says, a 12-week course of imiquimod typically costs $1,600 (or $800 for six weeks). Also, 5-FU costs $750 for 12 weeks.”"Destruction, either with cryosurgery or EDC, is cheapest,” costing $277.

“I’m not trying to say that Mohs surgery is not a viable option, and that patients shouldn’t have it. But if we’re trying to be the most cost-effective, consider excision and destruction - also taking into account the cosmetic outcome.”

Disclosures: Dr. Adamson reports no relevant financial interests.