Adverse events associated with mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers.

IMPORTANCE: Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. OBJECTIVES: To quantify adverse events associated with MMS and detect differences relevant to safety. DESIGN, SETTING, AND PARTICIPANTS: Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. EXPOSURE: Mohs micrographic surgery. MAIN OUTCOMES AND MEASURES Intraoperative and postoperative minor and serious adverse events. RESULTS: Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. CONCLUSIONS AND RELEVANCE: Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

Economic burden of melanoma in the elderly population: population-based analysis of the Surveillance, Epidemiology, and End Results (SEER)--Medicare data.

OBJECTIVE: To assess health care resources consumed by melanoma in the population 65 years or older, a group with comparatively poor outcomes. DESIGN: Database analysis. SETTING: The Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked population-based database for fiscal years 1991 through 1996. PARTICIPANTS: A total of 1858 subjects with pathological confirmation of melanoma. MAIN OUTCOME MEASURES: Resource consumption was examined by stage and treatment phase. Outcomes were measured in monthly charges obtained from the data set and costs were estimated by application of cost to charge ratios. Annual resource consumption by melanoma in patients 65 years or older in the United States was also estimated by incorporation of published SEER cancer statistics. RESULTS: Average monthly, per-patient melanoma charges were $2194 during the initial 4 months of treatment; they dropped by more than half to $902 during the interim phase, which varied in length depending on survival. Monthly charges increased to $3933 during the terminal 6 months of treatment. The estimated annual charge of treating melanoma in the population 65 years or older was $390 million. By using cost to charge ratios, we found the annual cost of melanoma to be up to $249 million and the per-patient lifetime costs to be $28 210 from the time of diagnosis to the time of death. CONCLUSIONS: Melanoma care presents a significant economic burden in the elderly population, particularly in late-stage disease. If effective, prevention and early detection efforts may reduce the economic burden.

Mortality of bullous pemphigoid: an evaluation of 223 patients and comparison with the mortality in the general population in the United States.

BACKGROUND: There are large discrepancies in reported mortality for bullous pemphigoid (BP). OBJECTIVE: We sought to determine the mortality of a large cohort of patients with BP and compare this with age-matched control subjects. METHODS: Data were collected on 223 patients with a new diagnosis of BP between 1998 and 2003 through our cutaneous immunofluorescence laboratory databases. The mortality of patients with BP was compared with that of age-matched control subjects in the general US population. RESULTS: The 1-, 2-, and 5-year mortality was 0.23 (95% confidence interval=0.18, 0.29), 0.37 (95% confidence interval=0.31, 0.44), and 0.50 (95% confidence interval=0.42, 0.57), respectively. However, relative to age-matched control subjects, no difference in expected mortality was detected. LIMITATIONS: This was a retrospective cohort analysis. CONCLUSIONS: Mortality of patients with BP is more likely related to advanced age and associated medical conditions than to disease-specific factors.

Melanoma outcomes for Medicare patients: association of stage and survival with detection by a dermatologist vs a nondermatologist.

OBJECTIVE: To determine whether a difference in melanoma outcomes exists in the United States between tumors detected by dermatologists vs those detected by nondermatologists. DESIGN: Retrospective analysis of linked data from the Medicare enrollment and claims files from the Centers for Medicare and Medicaid Services and the National Cancer Institute's Surveillance, Epidemiology, and End Results program database from 1991 to 1996. The registries are from 12 US sites. PATIENTS: A study sample comprised of 2020 subjects. MAIN OUTCOME MEASURES: Tumor characteristics (Breslow thickness and histologic ulceration), stage at diagnosis, and survival and mortality rates. RESULTS: Tumor detection by a dermatologist vs nondermatologist was associated with an earlier stage melanoma (stage 0, stage I, and stage II vs stage III and stage IV; chi(2) test, P<.01) and a thinner tumor (Breslow thickness, 0.86 mm vs 1.00 mm; P<.05). At all time points (6 months, 2 years, and 5 years), patients whose melanoma was detected by dermatologists had better survival rates (98%, 87%, and 74%, respectively, for those whose melanoma was detected by dermatologists vs 95%, 79%, and 69%, respectively, for nondermatologists; P<.05). Non-cancer-related mortality was similar for the 2 groups, but the patients whose tumors were detected by dermatologists had lower cancer-related mortality (13% vs 21%; P<.01) and overall mortality (29% vs 37%; P<.01). Multivariate analysis showed that age, sex, stage at diagnosis, and melanoma detection by a dermatologist were all significantly predictive of survival. CONCLUSIONS: Earlier stage melanoma and improved survival are associated with detection by a dermatologist rather than by a nondermatologist. Increasing access to dermatologists, particularly for older patients, may represent one approach to improving melanoma-related health outcomes.

Diagnosing and managing cutaneous pigmented lesions: primary care physicians versus dermatologists.

BACKGROUND: Primary care physicians (PCPs) are often expected to screen for melanomas and refer patients with suspicious pigmented lesions to dermatologists. OBJECTIVE: To assess whether there is a difference between dermatologists and PCPs in accurately diagnosing melanoma and appropriately managing (based on decisions to refer/biopsy) suspicious pigmented lesions. DESIGN, PARTICIPANTS: A survey based on a random sample of 30 photographs of pigmented lesions with known pathology was administered to 101 dermatologists and 115 PCPs from October 2001 to January 2003. MEASUREMENTS: Likelihoods that a photographed lesion was melanoma and that the lesion should be biopsied/referred were scored on a 1 to 10 scale. Accuracy of melanoma diagnosis and appropriateness of pigmented lesion management were compared between dermatologists and PCPs by using the areas under (AUC) the receiver operating characteristic (ROC) curves. RESULTS: Dermatologists were superior to PCPs in diagnosing melanomas (AUC 0.89 vs 0.80, P<.001) and appropriately managing pigmented lesions (AUC .84 vs 0.76, P<.001). PCPs who tended to biopsy lesions themselves did better at managing pigmented lesions than PCPs who did not perform biopsies. Dermatology training during residency did not significantly improve the diagnostic accuracy of PCPs nor their management of pigmented lesions. CONCLUSIONS: Dermatologists have both better diagnostic accuracy and ability to manage pigmented lesions than PCPs. Yet, there is a shortage of dermatologists to meet the demand of accurate melanoma screening. More innovative strategies are needed to better train PCPs and enhance skin cancer screening.

Baseline quality of life and anxiety in solid organ transplant recipients: a pilot study.

BACKGROUND: Solid organ transplant recipients on high doses of immunosuppression are at increased risk for the development of nonmelanoma skin cancer (NMSC). OBJECTIVE: The objective was to assess the possible factors impacting quality of life (QOL) in solid organ transplant recipients. METHODS: Patients were seen in a dermatology clinic integrated within the transplant center at a university-based hospital. One anxiety questionnaire and three QOL questionnaires were administered to each patient. A regression model was used to determine possible predictors of anxiety and lower QOL. RESULTS: The baseline scores on the QOL instruments and anxiety questionnaire indicate poor organ-specific and general QOL as well as high levels of anxiety. Time since transplant was predictive of lower QOL as measured by Skindex-16 (p<.01). While not significant, number of NMSCs correlated with higher anxiety as measured by the STAI (p=.055). CONCLUSIONS: While transplant patients enjoy longer survival, the quality of the extended life has room for improvement. Future studies will determine how QOL changes over time as these patients develop more numerous and aggressive skin cancers. Intervention with regular screening may not only lessen morbidity associated with skin cancer but may improve overall QOL in the posttransplant period.