Cost Analysis of Mohs Micrographic Surgery in High-Risk Facial Basal Cell Carcinoma
a Servicio de Dermatología, Empresa Pública Hospital Costa del Sol, Marbella, Málaga, Spain
b CIBER Epidemiología y Salud Pública (CIBERESP), Empresa Pública Hospital Costa del Sol, Marbella, Málaga, Spain
c Laboratorio de Anatomía Patológica, Empresa Pública Hospital Costa del Sol, Marbella, Málaga, Spain
d Departamento de Económico, Empresa Pública Hospital Costa del Sol, Marbella, Málaga, Spain
e Unidad de Investigación, Empresa Pública Hospital Costa del Sol, Marbella, Málaga, Spain
KeywordsMicrographic surgery. Mohs. Cost analysis. Cost-effectiveness.
Mohs micrographic surgery (MMS) is the treatment of choice for high-risk facial basal cell carcinoma (BCC) as it offers the greatest chance of cure with maximum preservation of healthy tissue. Its use in Spanish public health care hospitals is still limited, however, due to the controversy surrounding its cost.Objectives
To determine the cost of MMS with fresh tissue to treat high-risk facial BCC and compare this to the estimated cost of conventional surgery in a Spanish public hospital. A secondary objective was to identify cost-optimization strategies for MMS.Material and methods
Cross-sectional study of a consecutive series of patients with high-risk facial BCC who underwent MMS at the Department of Dermatology at Hospital Costa del Sol in Malaga, Spain between July 2006 and December 2007. We performed a descriptive analysis of the clinical characteristics of the patients and surgical factors. We calculated the total and mean cost of MMS and compared the results to the estimated costs of conventional surgery using patients as their own controls. Differences were analyzed according to tumor site and size, histologic subtype, and recurrence.Results
Seventy-nine patients (mean age, 62 years) with 81 high-risk facial BCCs, 97.5% of which were primary tumors, underwent MMS. The most common tumor site was the nose (57%) followed by the orbital region (25%). Histology showed that 64% of the tumors were infiltrative or micronodular carcinomas. Tumor-free margins were achieved in all patients, with no more than 2 stages required in 88% of the cases. The most common surgical reconstruction techniques were direct closure (21%) and closure with a local skin flap or graft (71%); the corresponding estimates for conventional surgery were 2% and 89%, respectively. The total and mean cost of MMS was €106 129.07 and €1325.80, respectively (compared to €97700 and €1208.70 for conventional surgery). The difference in mean costs between MMS and conventional surgery was not significant (P=.534).Conclusions
MMS is a viable, effective technique that does not generate significantly higher costs than conventional surgery in selected patients with high-risk facial BCC. Certain technical and organizational strategies could contribute to optimizing the cost of MMS.
Bibliography1.Mosterd K, Krekels GA, Nieman FH, Ostertag JU, Essers BA, Dirksen CD, et al. Surgical excision versus Mohs’ micrographic surgery for primary and recurrent basal cell-carcinoma of the face: a prospective randomised controlled trial with 5-years’ follow-up. Lancet Oncol. 2008; 9:1149-56.
2.Bath-Hextall FJ, Perkins W, Bong J, Williams HC. Interventions for basal cell carcinoma of the skin. Cochrane Database Syst Rev. 2007; 1:CD003412.
3.Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Basal cell carcinoma treated with Mohs surgery in Australia II. Outcome at 5-year follow-up. Journal of the American Academy of Dermatology. 2005; 53:452-7.
4.Rowe DE, Carroll RJ, Day CL. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol. 1989; 15:315-28.
5.Telfer NR, Colver GB, Morton CA. Guidelines for the management of basal cell carcinoma. Br J Dermatol. 2008; 159:35-48.
6.Cook J, Zitelli JA. Mohs micrographic surgery: a cost analysis. J Am Acad Dermatol. 1998; 39(5 Pt 1):698-703.
7.Bialy TL, Whalen J, Veledar E, Lafreniere D, Spiro J, Chartier T, et al. Mohs micrographic surgery vs traditional surgical excision. A cost comparison analysis. Arch Dermatol. 2004; 140:736-42.
8.Essers BAB, Dirksen CD, Nieman FHM, Smeets NW, Krekels GA, Prins MH, et al. Cost-effectiveness of Mohs micrographic surgery vs surgical excision of basal cell carcinoma of the face. Arch Dermatol. 2006; 142:187-94.
9.Then SY, Malhotra R, Barlow R, Kurwa H, Huilgol S, Joshi N, et al. Early cure rates with narrow-margin slow-Mohs surgery for periocular malignant melanoma. Dermatol Surg. 2009; 35:17-23.
10.Stenquist B, Ericson MB, Strandeberg C, Mölne L, Rosén A, Larkö O, et al. Bispectral fluorescence imaging of aggressive basal cell carcinoma combined with histopathological mapping: a preliminary study indicating a possible adjunct to Mohs micrographic surgery. Br J Dermatol. 2006; 154:305-9.
11.Redondo P, Marquina M, Pretel M, Aguado L, Iglesias ME. Methyl-ALA induced fluorescence in photodynamic diagnoses of basal cell carcinoma prior to Mohs micrographic surgery. Arch Dermatol. 2008; 144:115-7.
12.Jambusaria-Pahlajani A, Schmults C, Miller C, Shin D, Williams J, Kurd SK, et al. Test characteristics of high-resolution ultrasound in the preoperative assessment of margins of basal cell squamous cell carcinoma in patients undergoing Mohs micrographic surgery. Dermatol Surg. 2009; 35:9-16.
13.Karen JK, Gareu DS, Duzsa SW, Tudisco M, Rajadhyaksha M, Nehal KS. Detection of basal cell carcinomas in Mohs excisions with fluorescent confocal mosaicing microscopy. Br J Dermatol. 2009; 160:240-5.
14.Alkalay R, Alkalay J, Maly A, Ingber A, Fritsch C, Ruzicka T, et al. Fluorescence imaging for demarcation of basal cell carcinoma tumor borders. J Drugs Dermatol. 2008; 7:1033-7.
15.Chung VQ, Dwyer PJ, Nehal KS, Rajadhyaksha M, Menaker GM, Charles C, et al. Use of ex vivo confocal laser microscopy during Mohs surgery for non melanoma skin cancer. Dermatol Surg. 2004; 30:1470-8.
16.Downes RN, Walker NP, Collin JR. Micrographic (Mohs’) surgery in the management of periocular basal cell epitheliomas. Eye (Lond). 1990; 4:160-8.
17.Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Basal cell carcinoma treated with Mohs surgery in Australia. Outcome at 5-year follow-up. J Am Acad Dematol. 2004; 151:141-7.
18.Leiter C, Gaiber U. Epidemiology of melanoma and nonmelanoma skin cancer-the role of sunlight. Adv Exp Med Biol. 2008; 624:89-103.
19.Batra RS, Kelley LC. Predictors of extensive subclinical spread in nonmelanoma skin cancer treated with Mohs micrographic surgery. Arch Dermatol. 2002; 138:1043-51.
20.Orengo IF, Salasche SJ, Fewkes J, Khan J, Thornby J, Rubin F. Correlation of histologic subtypes of primary basal cell carcinoma and number of Mohs stages required to achieve a tumor-free plane. J Am Acad Dermatol. 1997; 37(Pt 1):385-7.
21.Alonso T, Sánchez P, González , Ingelmo J, Ruiz I, Delgado S, et al. Cirugía de Mohs: nuestros primeros 100 pacientes. Actas Dermosifiliogr. 2008; 99:275-80.
22.Rhee JS, Matthews BA, Neuburg M, Logan BR, Burzynski M, Nattinger AB. The skin cancer index: clinical responsiveness and predictors of quality of life. Laryngoscope. 2007; 117:399-405.