Two-thirds of patients may not require review after Mohs micrographic surgery

One of the many challenges facing the department during the COVID-19 pandemic was how to provide follow-up safely for Mohs surgical patients. With the need to practice social distancing and avoid unnecessary face-to-face (F2F) follow-up, we felt the system could be improved to ensure patient and staff safety. We created, reviewed and adapted a new system to follow-up on patients. We designed a questionnaire that was sent out to patients 3 months postprocedure. This included questions on aesthetic and functional outcomes, and postoperative complications, including bleeding and infection. Recording these outcomes is a requirement for all Mohs surgical patients, outlined by the British Society for Dermatological Surgery. Information collected via the questionnaire allowed us to identify those who required further follow-up and those who could be discharged. A patient was felt to be suitable for discharge if they reported no postoperative complications, their scar bothered them 'a little' at most and they had no functional complications besides paraesthesia. Otherwise, patients were invited for medical photography and an appointment was arranged for them, either by telephone, or if necessary, F2F. Patients were given the option to request a consultation even if they did not meet the criteria for one. Data were collected for 131 patients who had Mohs micrographic surgery between April 2020 and July 2020. Sixty-six per cent did not require follow-up as defined by the criteria. Eighty-nine per cent of patients found the questionnaire 'acceptable' or 'somewhat acceptable'. Feedback from staff has been positive and the questionnaire continues to be our first step in follow-up. Patients are informed of this new format at the time of surgery. Our next step is to identify factors that predict the requirement for review so these patients can have a suitable appointment scheduled. We intend to review the process after the pandemic, as while this approach is considered acceptable in the current climate, we understand that it may be less so once the pandemic is over. We have demonstrated a novel approach to the follow-up of Mohs surgical patients during the COVID-19 pandemic. Our data suggest that two-thirds of postoperative reviews may not be required and propose a sustainable method to identify these cases. This is significant, not only in relation to the pandemic, but in the long term. Appointments should be reserved for a clinical need to ensure efficient use of clinicians' time.

Evaluation of telephone consultations prior to Mohs surgery: the importance of informed consent

The updated General Medical Council (GMC) guidance on consent (2020) states that 'decision making is an ongoing process focused on meaningful dialogue: the exchange of relevant information specific to the individual patient'. In the UK there are several barriers to this process in dermatology, including short clinic appointments and loss of continuity of care (the surgeon may not have seen the patient in clinic). Many barriers have been exacerbated by the COVID-19 pandemic with the additional challenges of telephone consultations. In light of the GMC guidance we conducted a survey to see what patients recalled of their clinic discussion prior to surgery. Seventy-six responses were received over 2 weeks from patients attending day surgery. The results showed that although the majority of patients received an information sheet on skin surgery there were significant inconsistencies in what was discussed in clinic with regard to alternative options, risks and benefits of surgery and the likely repair. We addressed the problem of inadequate preparation for complex surgery by implementing a new process for patients awaiting Mohs surgery. A senior registrar on the Mohs team contacted patients by telephone 2-3 days before surgery. During the telephone call the process of Mohs surgery, the risks and benefits (including the risk of attending the department during the COVID-19 pandemic), and alternative options to Mohs were discussed. The repair options were discussed in detail. Patients were also advised on transport, provision of victuals, postoperative wound care and the potential necessity of future appointments. The telephone calls lasted 5-12 min (average 6 min 48 s). When patients attended for surgery they were asked to complete a patient survey to evaluate their telephone consultation. Seventeen responses were received from the second survey over 2 weeks. Fifteen patients recalled alternative options to Mohs surgery being discussed prior to attending surgery and 15 recalled the risks of surgery being discussed. All patients recalled discussing the potential options for repair, and all patients felt that they had received adequate information prior to attending their surgical appointment. On a scale of 1-5 (1 being very uncertain and 5 being very confident) patients were asked to rate their confidence in the procedure after their telephone call with the surgeon. The majority rated 5 (n = 13), three scored 4 and one scored 2. Shared decisionmaking and fully informed consent is critical to effective patient care. It is particularly important prior to complex skin surgery such as Mohs, and patients should have the opportunity to discuss their procedure with a Mohs specialist before surgery. We demonstrated that a telephone call before surgery is an effective and time-efficient method that ensures patients are fully informed and increases their confidence in the procedure.

Risk factors for developing depressive symptoms in the immediate postoperative period after Mohs micrographic surgery.

PURPOSE: Mohs micrographic surgery (MMS) is a highly efficacious, tissue sparing method of skin cancer removal. Nevertheless, in the months to years after MMS, psychosocial distress has been described. The present study addressed the immediate period after MMS and assessed the frequency and risk factors for development of depressive symptoms. METHODS: Subjects undergoing MMS at two physician practices (JL, FS) were included in this prospective cohort study. Preoperatively, a standardized depression screening, the Patient Health Questionnaire-8 (PHQ-8), was administered. After MMS, the PHQ-8 was readministered at weeks 1, 2, 4, 6, and 12. Average PHQ-8 score by week and change from baseline PHQ-8 score were the primary outcomes. RESULTS: Sixty-three subjects were included of which 49 (78%) had a facial site. Twenty-two subjects (35%) had some increase in score during the 12-week follow-up period, of which 18 had a facial site. The oldest subjects (83-99 years, n = 14) had significantly higher PHQ-8 scores at week 4 (p < 0.01) and week 6 (p = 0.02) than all other age groups. There were no differences in scores between location groups. CONCLUSIONS: One-third of subjects had some increase in score during the follow-up period. Those in the oldest age cohort were at highest risk of increased score. In contrast to prior literature, those with facial sites were not at higher risk. This difference may be explained by increased masking during the ongoing COVID-19 pandemic. Ultimately, consideration of patients' psychologic status in the immediate postoperative period after MMS, particularly in the elderly population, may enhance perceived patient outcomes.

Rates of Dermatology Follow-Up and New Skin Cancer Diagnosis Among Solid Organ Transplant Recipients During the COVID-19 Pandemic

Purpose: Solid organ transplant recipients (SOTRs) are at an elevated risk of developing non-melanoma skin cancers. Routine dermatologic surveillance has been shown to improve skin cancer outcomes in SOTRs. However, the COVID-19 pandemic has had a profound impact on delivery of care. Among the general population, recent studies have found an increase in the number of teledermatology visits despite an overall decrease in dermatology visits, a decline in treatment adherence, and a stated preference for in-person care. The impact of the ongoing pandemic on dermatologic care in SOTRs, a high-risk population, remains largely unexplored. We sought to compare rates of usage of dermatology in-person and telemedicine services and new skin cancer diagnoses among SOTRs before and during the first wave of the COVID-19 pandemic in Los Angeles, CA. Method(s): A retrospective study was performed on patients who received solid organ transplants at Keck Hospital of USC between 2013-2018. The number of visits to our dermatology department during two 17-month time periods was counted: 1) prepandemic, October 2018-March 2020 and 2) peri-pandemic, April 2020-September 2021. Each visit was categorized based on 1) general dermatology vs. Mohs surgery or follow-up and 2) in-person vs. telemedicine. Lastly, the number of new skin cancer diagnoses during these two time periods was counted. Result(s): Among a total of 1569 SOTRs, 154 patients had at least 1 dermatology visit in the pre-COVID 19 pandemic period, compared to 135 in the peri-pandemic period (p=0.241). While there was no significant decline in the mean number of general dermatology in-person visits per patient (p=0.266), there was a significant increase in general telemedicine visits during the same timeframe (p=0.026). Lastly, 11 new skin cancer diagnoses were made pre-pandemic, compared to 13 peri-pandemic (p=0.270). Conclusion(s): Our findings suggest our high-risk population of SOTRs did not experience significant disruption to routine delivery of dermatologic care during the first wave of the COVID-19 pandemic. Like prior studies, we found an increased reliance on teledermatology services, however without a concomitant decline in access to in-person care. Furthermore, the similar pre- and peri-pandemic rates of new skin cancer diagnoses do not raise concern for a future surge in skin cancer morbidity and mortality. By continuing to investigate the usage of dermatology services by SOTRs during the ongoing pandemic, we hope to address barriers to dermatologic care and prevent a rise in skin cancer morbidity and mortality. (Table Presented).

The Impact of COVID-19 on Periocular NonMelanoma Skin Cancer in the Veteran Population

Purpose : Despite an increasing incidence of skin cancer over the last decade, studies have reported a decline in the diagnosis and treatment of skin cancer during the COVID19 pandemic. We performed a retrospective cohort study using a large population-based cohort from the Veterans Health Administration (VHA) to determine how the pandemic has affected tumor size and morbidity in veterans with periocular non-melanoma skin cancer. Methods : Electronic health records from all VHA sites were accessed through the VA Informatics and Computing Infrastructure (VINCI). Data were stored in the Observational Medical Outcomes Partnership (OMOP) model and queried via SQL Server. ICD-10 and current procedural terminology codes were used to identify patients who received Mohs surgery for periocular basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) between 08/01/2018 and 09/10/2021. A combination of structured algorithms and manual review were used to extract patient demographics, lesion characteristics, and surgical outcome at three time points, ie. pre-COVID, early, and late COVID. Unpaired t-tests were used to assess statistical significance. Results : Patient characteristics were similar between pre- and post-COVID cohorts in terms of gender, age, race, and tumor type. The average number of Mohs periocular surgeries performed per week were 23.1% (7.31 vs 5.62) and 13.1% (7.49 vs 6.51) lower in the early and later pandemic, respectively, compared to similar pre-COVID timeframes by month (Figure 1). Mean lesion size (maximum diameter) was 1.35 cm larger post-COVID compared to pre-COVID (95% CI 0.19 2.51, P=0.022);however, the defect size remained similar (Figure 2). Stratifying by tumor type, the same trends were noted in BCC, particularly early in the pandemic. However, mean SCC lesion and defect sizes did not vary over time. Conclusions : Periocular Mohs surgery rates declined in the COVID pandemic across VHA. Lesions were larger particularly in the earlier phase of the pandemic for BCC. Future analyses using this cohort will attempt to determine if telehealth and travel time were associated with distinct outcomes.

Investigating the progression of melanoma and squamous cell carcinomas before and after the COVID-19 lockdown

Background: Delays due to COVID-19 impacted dermatology. Two Italian studies found significant decreases in melanoma diagnosis (MM) during the lockdowns, while a predicted growth model of cutaneous squamous cell carcinoma (cSCC) found delaying excision results in significant tumor upstaging. Objective: We hypothesized that the COVID-19 lockdown increased tumor severity and postoperative morbidity of MM and cSCC. Methods: This was a retrospective analysis of all newly diagnosed MM and cSCC treated with Mohs surgery during 2019 (pre-lockdown) and 2020 (post-lockdown) period. We collected data on the number of cases, tumor characteristics, extent of surgery, and time to treatment. Results: Our analysis (n = 554) found no significant difference in the number of cases of cSCC or MM between the 2 years (P =.675), the preoperative size of cSCCs or MMs (P =.68, P =.786), cSCC cases with flap or graft repairs (P =.076), or cSCC cases with aggressive histologic features (P =.243). There were significantly fewer days from biopsy to surgery in 2020 for MM (27.6 days compared with 23.8 days;P =.041) and cSCC (41.5 days compared with 33 days;P =.037);however, there were significantly more multistage Mohs surgeries for cSCC in 2020 (39 versus 69;P =.005). Conclusion: The COVID-19 lockdown resulted in a significantly increased number of multistage Mohs surgeries for the treatment of cSCC. For both cSCC and MM, the lockdown did not impact the number of cancers treated, the size of the tumors, the complexity of the repairs, or the presence of aggressive histology, while it did positively impact time to treatment.

Urgent safety considerations for dermatologic surgeons in the COVID-19 pandemic

Dermatologic surgeons are at increased risk of contracting coronavirus disease 2019 (COVID-19). At time of writing, there is no published standard for the role of pre-operative testing or the use of smoke evacuators, and personal protective equipment (PPE) in dermatologic surgery. Risks and safety measures in otolaryngology, plastic surgery, and ophthalmology are discussed. In Mohs surgery, cases involving nasal or oral mucosa are highest risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission;pre-operative testing and N95 masks should be urgently prioritized for these cases. Other key safety recommendations include strict control of patient droplets and expanded pre-clinic screening. Dermatologic surgeons are encouraged to advocate for appropriate pre-operative tests, smoke evacuators, and PPE. Future directions would include national consensus guidelines with continued refinement of safety protocols.