EVIDENCE-BASED DERMATOLOGY: ORIGINAL CONTRIBUTION

Mohs Micrographic Surgery vs

Traditional Surgical Excision
A Cost Comparison Analysis
Tracy L. Bialy, MD, MPH; James Whalen, MD; Emir Veledar, PhD; Denis Lafreniere, MD;
Jeffrey Spiro, MD; Timothy Chartier, MD; Suephy C. Chen, MD, MS

Objective: To compare the cost and margin adequacy
of Mohs micrographic surgery (Mohs) and traditional sur-
gical excision (TSE) for the treatment of facial and au-
ricular nonmelanoma skin cancer (NMSC).
Design: Prospective cost analysis with each patient serv-
ing as his or her own control.
Setting: Study was performed from 1999 to 2001 at the
University of Connecticut dermatology clinic, a tertiary
care referral center.
Patients: A total of 98 consecutive patients with a pri-
mary diagnosis of NMSC on the face and ears.
Main Outcome Measures: The average cost of Mohs
and TSE per patient for the treatment and repair of NMSC;
adequacy of TSE margins after the initial procedure
(because this outcome affects overall cost).
Results: Mohs was cost comparable to TSE when the
subsequent procedure for inadequate TSE margins after
permanent section was Mohs ($937 vs $1029; P=.16) or
a subsequent TSE ($937 vs $944; P=.53). When facility-
based frozen sections were requested for TSE, Mohs was
significantly less costly ($956 vs $1399; P⬍.001). The
cost difference between Mohs and TSE was sensitive to
the type of repair chosen.
Conclusions: If the end point is clear margins, Mohs
is cost comparable to TSE performed by otolaryngo-
logic surgeons. Some caution is needed when evaluat-
ing the cost of facial and auricular NMSC treatment
because the choice of repair can significantly affect the
cost conclusions.
Arch Dermatol. 2004;140:736-742

From the Departments of
Dermatology (Drs Bialy and
Chen) and Medicine, Division
of Cardiology (Dr Veledar),
Emory Center for Outcomes
Research, Emory University
School of Medicine, and the
Department of Health Services
Research and Development,
Division of Dermatology,
Atlanta Veterans Affairs
Medical Center (Dr Chen),
Atlanta, Ga; and the
Departments of Dermatology
(Drs Whalen and Chartier) and
Otolaryngology (Drs Lafreniere
and Spiro), University of
Connecticut School of Medicine,
Farmington. The authors have
no relevant financial interest in
this article.
S
KIN CANCER IN THE UNITED
States is a large and growing
public health concern. Non-
melanoma skin cancers
(NMSCs), including basal cell
carcinoma (BCC) and squamous cell car-
cinoma (SCC), are the most common can-
cers in the United States, accounting for
more than 1 million new cases per year.1,2
Fortunately, NMSCs rarely metastasize and
are usually curable if treated early. Al-
though the overall metastatic rate for NMSC
is small (0.003%-0.55% for BCC3,4 and
approximately 5% for SCC),5 NMSCs may
cause significant local tissue destruction and
potential disfigurement and dysfunction in
involved sites. Furthermore, certain higher-
risk NMSCs (eg, recurrent SCC or SCC with
lip involvement or perineural invasion) carry
significantly higher risks of local recur-
rence and metastasis.6-10 Once NMSC me-
tastasizes, the overall 5-year survival for both
metastatic BCC and SCC is less than 33%.11
Nonmelanoma skin cancer most com-
monly affects chronically sun-exposed sites,
including the head, neck, trunk, and up-
per extremities. The head and neck are af-
fected in 80% to 90% of the cases. More than
65% of all BCCs and SCCs affect facial sites8
For editorial comment
see page 743
and create cosmetic and functional se-
quelae. Therefore, a major goal of NMSC
treatment is to remove the cancer while pre-
serving maximal function and cosmesis.
Many treatment modalities for NMSC
have been developed, each with a differ-
ent efficacy and cost. Currently accepted
treatments for NMSC include traditional
surgical excision (TSE), radiotherapy,
cryosurgery, electrodesiccation and cu-
rettage, photodynamic therapy, topical
chemotherapy agents, and Mohs micro-

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graphic surgery (Mohs). Traditional surgical excision has
a 5-year recurrence rate of 10.1% for primary BCC12 and Table 1. Actual Dollar Amounts (Connecticut Medicare
from 10.9% (lip) to 18.7% (ear) for SCC.6 An alterna- Reimbursements) Corresponding to an Office/Outpatient
Setting vs a Facility Setting for Each CPT Code18 Used
tive, Mohs, has a 5-year recurrence rate of 1% for pri-
mary BCC12 and from 3.1% (lip) to 5.3% (ear) for SCC.6 CPT Outpatient/Office Reduced MD Fee Facility
Because the cost of these procedures is substantial, Codes Reimbursement (When in Facility) Fee
direct comparison of both cost and efficacy of each treat-
11640 166.69 115.63 214.81
ment modality is essential for health care policy design. 11641 221.02 172.47 214.81
Given the constantly changing health care landscape, the 11642 258.68 202.61 214.81
presence of managed care, and the uncertainty of Medi- 11643 x 238.51 429.63
care reimbursements, the dermatologic community has 11644 x 307.93 x
made several published requests for definitive cost analy- 88305 104.74 x x
sis studies for the use of Mohs in cases of NMSC that meet 88331 84.08 x x
88332 43.49 x x
established criteria warranting such surgery.13,14 How- 99212 39.98 x x
ever, there is a paucity of research determining the least 12051 229.62 161.83 116.06
costly technique to effectively treat facial NMSC. 12052 236.77 172.74 116.06
Two retrospective studies have compared the cost of 12053 259.49 193.79 116.06
Mohs with TSE for the treatment of NMSC.15,16 Cook and 14040 660.39 580.04 642.41
Zitelli15 compared total procedure costs of Mohs with those 14060 705.26 642.07 642.41
15240 747.56 674.75 642.41
of TSE for many types of tumors, including primary and
15260 781.44 728.29 642.41
recurrent NMSC, melanoma, and extramammary Paget dis- 15576 x 629.57 642.41
ease in multiple anatomic locations (including torso and 15630 x 294.35 642.41
extremities). They found Mohs to be marginally more ex- 17304 624.44 x x
pensive than TSE when performed in the office with per- 17305 263.17 x x
manent sections (PS) and less expensive than ambulatory 17306 264.84 x x
17307 264.01 x x
surgery–based TSE with frozen sections (FS). Our study
focuses on facial and auricular NMSC and is limited to the
Abbreviations: CPT, Current Procedural Terminology18; x, treatment event
published indications for Mohs.13 did not occur in this study.
Bentkover et al16 compared the cost of Mohs with that
of TSE using rapid cross-sectional FS for treatment of BCC rolled in this study. The subjects included men and women 18
on the head and neck and found a cost savings for TSE over years and older.
Mohs for their capitated practice setting. As their practice The cost comparison analysis was performed using the
setting did not include a Mohs surgeon, all Mohs was out- American Medical Association 2002 Current Procedural Ter-
sourced as fee-for-service procedures and so resulted in cost minology (CPT) codes.18 We converted the CPT codes into dol-
outcomes specific to this capitated setting. lar amounts using the Connecticut Medicare reimbursement
The purpose of our study was to compare the cost rates for 2002.19 The actual dollar amounts (Connecticut Medi-
of Mohs and TSE performed by otolaryngologic (ENT) care reimbursements) corresponding to the CPT codes cited
below are listed in Table 1.
surgeons for the treatment of facial and auricular NMSC. This study was conducted prospectively, and each pa-
We chose ENT surgeons for comparison because they are tient served as his or her own control. The data were collected
among several nondermatologic physician specialists to at the University of Connecticut, Departments of Dermatol-
perform TSE procedures for NMSC.17 A secondary goal ogy and Otolaryngology, and analyzed at Emory University, De-
was to examine the frequency of positive margins after partment of Dermatology.
TSE and to determine the additional costs incurred to es- Initially, the Mohs surgeon (J.W.) independently exam-
tablish clear margins. Additionally, as a point of inter- ined and photographed the lesion. The planned Mohs margins
est, we determined the total area of tissue removed by were marked on the photograph to minimize the bias that may
each method to report if either surgical procedure of- have been created by the surgical markings of the ENT surgeon.
fered a tissue-sparing technique. Area as opposed to vol- Next, an ENT surgeon (D.L. or J.S.) independently examined the
patient, measured the tumor, and documented its size. He then
ume was measured because, as a result of our study de- drew his surgical margins on the patient with a surgical marker.
sign, the depth of our TSE procedures could not be The tumor size plus the planned surgical margins represented
determined. We hypothesized that the treatment of fa- the “theoretical” size of the defect if a TSE were to be per-
cial and auricular NMSC with Mohs would be compa- formed. The ENT surgeon then documented his choice of mar-
rable in terms of cost to TSE because Mohs is typically gin analysis: PS or FS. He also documented his preferred surgi-
performed in the office setting, while nondermatolo- cal setting: office, ambulatory surgical center, or formal operating
gists typically utilize ambulatory surgery centers and for- room. Finally, the ENT surgeon recorded a proposed recon-
mal operating rooms for TSE. struction based on the theoretical surgical defect.
After these data were recorded, Mohs surgery and subse-
quent repair were performed by the Mohs surgeon (J.W.) on
METHODS each patient. After complete tumor extirpation, the real size of
the surgical defect was documented to represent the actual de-
DESIGN fect size resulting from Mohs. As a result of this approach, a
documented theoretical size of the TSE defect as determined
Consecutive patients referred for Mohs surgery with biopsy- by the ENT surgeons and an actual size of the Mohs defect cre-
proven primary NMSC involving the face and ears were en- ated by the Mohs surgeon was available for all patients.

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 Costs for TSE were calculated for each patient based on
Results — Scenario 1
the theoretical plan by the ENT surgeon. The cost of the exci-
sion (1164X) was charged with intermediate closures and grafts
Mohs + Mohs (1205X, 152XX) but not with adjacent tissue transfer (140XX),
Repair since the excision is bundled with the flap. Additionally, TSE
22 Inadequate costs included the charges for pathologic analysis, PS or FS
Margins (32%)
67 Permanent
(88305, 88331, 88332); reconstruction (1205X, 140XX, and
Sections 152XX series); and the facility fee when indicated (Table 1).
In 2003, the method of determining lesion or excision size
Additional Costs $$ changed. We used the existing method of measuring the le-
sion and not the excision size because this corresponded to the
current technique for correct coding. Starting in August 2000,
the facility fees included preoperative laboratory tests and ra-
98 Cases Additional diographs. The excision and reconstruction costs were appro-
Frozen Section
12 Inadequate priately reduced when a facility fee was charged, and the ex-
Margins (39%)
31 Frozen
cision or reconstruction costs were reduced according to the
Sections multiple surgery reduction policy. For each FS examination
(88331, 88332), a PS examination and report (88305) are also
Results — Scenario 2 generated; this is the standard of care. We assumed that these
PS reports would confirm the clear margins. When the ENT
Second TSE surgeon chose healing by granulation, only 1 follow-up visit
+ Additional (99212) was charged because the TSE had a 10-day global pe-
Permanent Section
22 Inadequate riod. A separate intravenous sedation fee was added as an ad-
Margins (32%) ditional cost in 4 cases as anticipated by the ENT surgeon.
67 Permanent
Sections
For the TSE cases where a positive FS margin would re-
quire the ENT surgeon to excise more tissue before repair, a
Additional Costs $$ single subsequent FS was billed (88331+88305). We assumed
that the negative margins would be confirmed after this 1 sub-
sequent FS. We did not alter the reconstructive plan of the ENT
surgeon for those cases with positive FS margins (Figure 1).
98 Cases Additional For TSE cases where PS margins were determined to be
Frozen Section inadequate, we assumed that those cases would require an ad-
12 Inadequate
Margins (39%) ditional procedure (Figure 1). We calculated the cost of 2 pos-
31 Frozen sible retreatment pathway outcomes: scenario 1 entailed re-
Sections
treatment with Mohs for the cases with inadequate margins and
Figure 1. Adequacy of margins and margin control plan: 67 of 98 cases were repair chosen by the Mohs surgeon. The additional Mohs and
recommended for permanent section (PS) and 31 of 98 for frozen section repair costs were determined by using the actual Mohs data from
(FS). Twenty-two (32%) of the PS cases had inadequate margins and the same case less 1 Mohs stage. Scenario 2 consisted of a sec-
required a second procedure. In scenario 1, inadequate traditional surgical ond excision via TSE with PS margin analysis and repair cho-
excision (TSE) cases with PS were re-treated with Mohs micrographic sen by the ENT surgeons. We assumed subsequent clear mar-
surgery (Mohs). In scenario 2, inadequate margins in TSE cases with PS
were treated with reexcision. Twelve (39%) of the FS cases had inadequate
gins with this additional TSE and estimated the cost by
margins and required additional FS. duplicating the original TSE costs.
We also performed a sensitivity analysis on our results. A
sensitivity analysis explores variables that may influence the
ANALYSES results of the original cost analysis, also called the baseline case.
Our baseline case comparison for scenario 1 was Mohs with
Margin analysis for TSE affects the cost of the procedure, both Mohs repair vs TSE with repairs chosen by the ENT surgeon
in terms of the type of analysis (FS or PS) and whether the (ENT-chosen repair) plus Mohs and Mohs repair for positive-
margins were clear after the initial procedure. Margin control margin cases. For scenario 2, the baseline case was Mohs with
of TSE was determined by comparison of the theoretical TSE Mohs repair vs TSE with ENT-chosen repair plus a second TSE
margins to the actual Mohs surgical margins. If the Mohs mar- for positive-margin cases and a subsequent ENT-chosen re-
gin analysis documented tumor at any point beyond the gen- pair for these cases only. We varied the values assigned to vari-
tian violet markings of the ENT surgeon, the TSE margins ables in the baseline cases that we felt would most likely alter
were considered positive (inadequate). All deep margins for the baseline results.
TSE were assumed to be clear because the depth of the theo- Analysis of the data was conducted using S-Plus 6 for Win-
retical TSE cases could not be determined. If the TSE margins dows Statistical Package (Insightful Corp, Seattle, Wash; ver-
were inadequate, these patients would require additional sur- sion 6.2). The distribution of our data for both cost and area of
gery to definitively remove their cancers and thus incur addi- tissue removed was not normally distributed. Since each of the
tional costs. patients served as both the case and control, each datum was con-
We determined the average total cost of treatment per pa- sidered paired, and the Wilcoxon signed-rank test was used.
tient in the following manner. The cost of the initial evalua-
tion and biopsy was excluded because these costs were in-
RESULTS
curred in both the TSE and Mohs approaches equally. The total
Mohs cost was determined from the actual CPT codes used in
each case (17304-17310) including reconstruction (1205X, PATIENTS, MARGINS, AND COST
131XX, 14XXX, and 15XXX series). For those cases in which
healing by granulation was chosen, 2 follow-up visits were billed We enrolled 98 consecutive patients (mean age, 67.8
(2 units of 99212). years), 56 men (57%) and 42 women (43%). The BCC/

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SCC ratio was 77:21. The average number of Mohs stages
per case was 1.5 (range, 1-5 stages). The location of the Table 2. Descriptive Study Characteristics
facial NMSC, setting of TSE procedures, and the distri-
bution of repairs for both procedures are illustrated in Characteristic No. (%) of Procedures
Table 2. Location of NMSC
Of the 98 patients in the study, the ENT surgeon Nasal/perinasal 40 (41)
Cheek 16 (16)
recommended 67 for PS and 31 for FS pathologic analy-
Auricular/periauricular 14 (15)
sis. Of the 67 patients with PS, 22 (32%) had inadequate Forehead 12 (12)
margins. Of the 31 patients recommended for FS, 12 Canthus/periorbital 7 (7)
(39%) had inadequate margins and so required further Temple 7 (7)
extirpation (Figure 1). Lip 2 (2)
The mean Mohs cost per patient for removal of fa- Setting for TSE Procedure
cial and auricular NMSC was $937 (95% confidence in- Office 56 (57)
terval, $889.50-$984.50) compared with the mean TSE Ambulatory surgery center 38 (39)
cost per patient of $831 (95% confidence interval, Operating room 4 (4)
$724.90-$937.10) (P= .04), not accounting for the ad- Repair Technique Used
ditional cost of a second procedure required for positive Mohs TSE
margins (inadequate TSE) when PS was used. To ac- Primary closure 48 (49) 55 (56)
Local flap 4 (4) 28 (29)
count for the cost of complete tumor extirpation after in-
Granulation 44 (45) 12 (12)
adequate PS TSE, we calculated the cost of the 2 pos- Skin graft 2 (2) 2 (2)
sible treatment pathway outcomes. In scenario 1, the Forehead flap 0 1 (1)
inadequate TSE cases were treated with Mohs and Mohs
repair, and the mean cost per patient became $1029. Com- Abbreviations: NMSC, nonmelanoma skin cancer; TSE, traditional surgical
pared with Mohs alone ($937 per patient), the cost of excision.
TSE plus Mohs for the TSE positive-margin cases ($1029
per patient) was more expensive by a difference of $92
(P=.16). In scenario 2, the PS TSE inadequate cases were 3000
P =.16
re-treated with a second TSE. We found that the mean
cost per patient for TSE + TSE and ENT repair was com-
2500
parable to Mohs alone, $944 vs $937, respectively (P=.53).

SUBGROUP AND 2000

SENSITIVITY ANALYSES
Cost, US $

We performed a subgroup analysis, examining the dif-
ference between TSE cases sent for FS margin analysis
vs Mohs. When comparing the cost in the subgroup of
patients where FS were requested (n=31), we found that
the average Mohs cost for this subgroup was $956, while
the average cost of TSE with FS was $1399 (a difference
of $443; P⬍.001).
We conducted several sensitivity analyses to ad-
dress potential biases in our study design. The variable
with the most potential to alter the baseline cases was
the cost of the repair chosen by both the Mohs and ENT
surgeons. In the Mohs group, there was a greater pro-
portion of defects that were allowed to heal by second
intention compared with the repair choices of the ENT
surgeons (Table 2).
To explore potential reconstruction biases, the data
were reevaluated after substituting ENT-chosen repair and
Mohs repair in various combinations. We then deter-
mined whether these substitutions altered the results of the
original cost analysis, also called the baseline case (Mohs
with Mohs repair vs TSE with ENT-chosen repair plus Mohs
and Mohs repair for positive-margin cases). We per-
formed these sensitivity analyses for scenarios 1 and 2. In
scenario 1, all positive margins after the initial TSE were
treated with Mohs, while in scenario 2, inadequate TSE cases
were treated with a second TSE (Figure 1).
When we substituted the cost of Mohs repairs with
that of ENT repairs we found that the results of our origi-
1500
1000
500
P =.02
0
Baseline Mohs Modified Mohs Baseline TSE
Procedure and Repair
Figure 2. Sensitivity analysis of repairs (scenario 1) in inadequate traditional
surgical excision (TSE) cases re-treated with Mohs micrographic surgery
(Mohs) (N = 98). Baseline Mohs (mean cost for Mohs + Mohs repair, $937)
and modified Mohs (mean cost for Mohs + otolaryngologic surgical repair,
$1110) compared with baseline TSE (mean cost for TSE with repairs chosen
by the otolaryngologic surgeon + Mohs and Mohs repair for positive margins,
$1029). The light shaded area represents the lower quartile of data
containing 25% to 50% of the cost data; dark-shaded area, the upper
quartile, containing 50% to 75% of the cost data; and the error bars, data
range beyond the quartiles.
nal cost analysis or baseline case were sensitive to the
choice of repairs for scenario 1. For example, as demon-
strated in Figure 2, when we substituted Mohs repair
with ENT repair (Mohs procedure with ENT repair, here-
inafter “modified Mohs”) and compared this with base-
line TSE (TSE with ENT repair plus Mohs and Mohs re-
pair for positive-margin cases) we found that the modified
Mohs was significantly more expensive than baseline TSE
($1110 vs $1029; P =.02).

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P =.53
3000
2500
2000
Cost, US $
1500
1000
500
P <.001
0
Baseline Mohs Modified Mohs Baseline TSE
Procedure and Repair
Figure 3. Sensitivity analysis of repairs (scenario 2) of inadequate traditional
surgical excision (TSE) cases treated with an additional excision (N = 98).
Baseline Mohs micrographic surgery (Mohs) (mean cost of Mohs + Mohs
repair, $937) and modified Mohs (mean cost of Mohs+repair by
otolaryngologic surgeon [ENT], $1110) compared with modified TSE
(mean cost of TSE + ENT-chosen repairs+TSE for positive margin
cases + ENT-chosen repairs, $944). The light-shaded area represents the
lower quartile of data containing 25% to 50% of the cost data; dark-shaded
area, the upper quartile containing 50% to 75% of the cost data; and the
error bars, data range beyond the quartiles.
For scenario 2, our baseline case was Mohs with
Mohs repair vs TSE with ENT-chosen repair plus a sec-
ond TSE for positive-margin cases and a subsequent ENT-
chosen repair for these cases only, the difference of which
was not statistically significant ($937 vs $944; P = .53)
(Figure 3). However, when we substituted ENT repair
for Mohs repair as illustrated in Figure 3, we found that
modified Mohs was significantly more expensive than TSE
(TSE with ENT-chosen repair plus a second TSE and ENT-
chosen repair for positive- margin cases): $1110 vs $944
(P⬍.001). Thus, our sensitivity analyses demonstrated
that the choice of repair affected the cost conclusions of
our study. There was no statistically significant differ-
ence in mean±SD area of the defect between Mohs and
TSE: 250.8±272.4 mm2 and 215.5 ± 204.7 mm2, respec-
tively (P=.59).
COMMENT
We compared the cost of Mohs and TSE for the treat-
ment of facial and auricular NMSC. Our study design was
based on the current clinical practice for TSE in which
the setting of the surgery and the type of margin analy-
sis, PS or FS, are chosen by individual physicians. Tra-
ditional surgical excision when conducted in an office
setting with PS would be the least expensive treatment
pathway if the margins were always clear. In our study,
32% of TSE cases were found to have inadequate mar-
gins. To fully compare the Mohs alone with the TSE ap-
proach, we needed to account for positive margins by TSE
and subsequent procedural costs to remove the remain-
ing tumor. We found Mohs alone to be comparable to
the TSE strategy both when the subsequent procedure
was Mohs ($937 vs $1029, respectively) and when the
subsequent procedure was another TSE ($937 vs $944).
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However, we must also consider a certain failure rate with
this second TSE, which would necessitate additional costs
and additional time incurred by the patient for another
surgery and repair. Additionally, we made an assump-
tion that all deep margins were clear with the TSE, which
if not true, would lead the TSE arm to require even more
subsequent procedures and possibly more complicated
repairs.
We hypothesized that treatment of NMSC with Mohs
was cost comparable to TSE because Mohs is typically
performed in the office setting rather than in ambula-
tory surgery centers and formal operating rooms. In our
subgroup analysis, we found that some of the most sig-
nificant differences in cost were seen when Mohs was com-
pared with facility-based TSE with FS. Mohs offered a cost
savings of $443 compared with facility-based TSE with
FS. The difference would have been even greater had we
not assumed clear margins on all second FS and subse-
quent PS confirmations. A large part of the ENT surgi-
cal expense when FS margin control was required was
that the ENT surgeon’s outpatient facility could not of-
fer FS, and so the cost of an ambulatory surgery center
was incurred. The result was a significant cost-savings
advantage for non–facility-based Mohs procedures.
Our findings differed from those of Bentkover et al,16
who compared the cost of Mohs with the cost of TSE with
cross-sectional FS technique for BCC. They found a $150
to $454 cost-savings benefit to TSE over Mohs per tu-
mor.16 However, their study was conducted in a capi-
tated health maintenance organization setting in which
a contracted out-of-plan Mohs surgeon operated on a fee-
for-service basis. For TSE, all facility and excision fees
were covered under global capitation, which left only the
pathology fees to compare with the outsourced cost of
Mohs. This is probably the reason for our discordant find-
ings.
In our study, the proportion of positive margins in
the TSE cases was relatively high (32% of patients with
PS and 39% of the patients with FS) compared with other
studies.17,20-22 These differing rates may partially result from
the amount of margin actually analyzed. Traditional ver-
tical sectioning techniques with PS examine only a small
sample (usually ⬍1%) of the excised margin while Mohs
evaluates nearly 100% of the excised margin. Other pos-
sible reasons for the rate of positive margins are ex-
plored below.
As a point of interest, we determined the total area
of tissue removed by each method to determine
whether one surgical procedure was more efficient than
the other at tissue conservation. We found no signifi-
cant difference in area of tissue taken between the 2
procedures. The area of tissue taken and the frequency
of positive margins may be interrelated. As the surgeon
takes wider margins of normal-appearing tissue in TSE
and sacrifices tissue conservation, the likelihood of
clear margins increases. The attempt at TSE with con-
servative margins for facial NMSC may have resulted in
the 32% and 39% positive- margin rates in the PS and
FS cases, respectively.
The limitations of this study must be addressed. We
recognize that a randomized trial with the 2 surgical strat-
egies would be a superior methodologic design. How-
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ever, owing to patient recruitment and time constraints,
a prospective design was chosen with 98 consecutive pa-
tients enrolled, each patient serving as his or her own con-
trol. Consistent with this design, several assumptions were
made, including the decision that all deep margins in TSE
cases were considered to be clear. Additionally, assump-
tions based on choices made in current clinical practice
were made involving the type of subsequent surgical pro-
cedure used to remove remaining tumor in the event of
positive margins. Of note, other pathways for subse-
quent surgical procedures exist in practice, such as hav-
ing ENT reconstruction after Mohs procedure for in-
complete tumor removal. We did not address the other
potential pathways in our model; they may be pursued
in future research.
Another limitation to our study is the potential bi-
ases of the ENT and Mohs surgeons. It is possible that
because the ENT surgeons performing the TSE were aware
that the total area of tissue removed was a measured out-
come, they might have systematically underestimated the
total amount of tissue required to remove all of the can-
cer. This potential bias may explain the high rate of in-
adequate excision. However, the high rate of underesti-
mation of necessary tissue to remove is consistent with
reports in the literature. Studies have shown that most
incompletely excised BCCs are on the head and neck,20,22-24
including a large case series that found that 16% of BCCs
(58/353) extended to the margin of surgical excision and
74% of these (43/58) were on the head and neck.20 Ad-
ditionally, in a retrospective study of 143 excisions of pri-
mary BCCs on the face, 30% (42/143) were inad-
equately excised.24 It is possible that physicians, in an
attempt to minimize cosmetic morbidity in facial sites,
may excise NMSC with more conservative margins than
in other surgical locations. Additionally, studies have
shown that physician specialty might affect the fre-
quency of positive margins in the surgical management
of BCC. While the patient’s sex, age, and tumor size or
physician experience were not significantly related to the
presence of tumor in the surgical margin, when com-
pared with dermatologists and general surgeons, otolar-
yngologists and plastic surgeons were significantly more
likely to incompletely excise tumors.17
Another potential bias may have been with the Mohs
surgeon (J.W.). Since he was aware that costs were the
primary outcome of the study, he may have been pre-
disposed toward second-intention healing. As seen in our
sensitivity analysis (Figures 2 and 3), significant cost dif-
ferences are evident when the repair choices of the ENT
surgeons are switched with the repair choices of the Mohs
surgeon. The Mohs surgeon might have also taken wider
margins to reduce the number of stages. However, the
1.5-stage average was consistent with yearly averages of
the Mohs surgeon.
Despite these limitations, we have shown that Mohs
is cost comparable to 2 sequential TSEs with PS in the
office and much less costly than facility-based TSE with
FS for the treatment of facial and auricular NMSC. Mohs
alone offers a marginal ($92) cost savings over TSE plus
Mohs when a second procedure is needed to ensure com-
plete tumor removal. Our study had similar findings to
those of Cook and Zitelli15 in terms of the total proce-
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©2004 American Medical Association. All rights reserved.
Editor’s Comment
Economic analyses are just finding their way into the der-
matologic literature. Overviews of economic analyses can
be found in Chen SC. How to critically appraise phar-
macoeconomic studies. In: Williams HC, Bigby M, Diep-
gen T, Herxheimer A, Naldi L, Rzany B. Evidence-Based
Dermatology. London, England: BMJ Books; 2003:70-
75; Greenhalgh T. How to read a paper: papers that tell
you what things cost (economic analyses). BMJ. 1997;
315:596-599; and Detsky AS, Naglie IG. A clinician’s guide
to cost-effectiveness analysis. Ann Intern Med. 1990;113:
147-154. A more thorough guide to critical appraisal of
economic analyses can be found in Drummond MF,
Richardson WS, O’Brien BJ, Levine M, Heyland D, for
the Evidence-Based Medicine Working Group. Users’
guides to the medical literature, XIII: how to use an ar-
ticle on economic analysis of clinical practice, A: are the
results of the study valid? JAMA. 1997;277:1552-1557;
and O’Brien BJ, Heyland D, Richardson WS, Levine M,
Drummond MF, for the Evidence-Based Medicine Work-
ing Group. Users’ guides to the medical literature. XIII.
How to use an article on economic analysis of clinical
practice, B: what are the results and will they help me in
caring for my patients? JAMA. 1997;277:1802-1806.
Michael Bigby, MD
dure costs of Mohs vs TSE; however, our focus was spe-
cifically limited to NMSC and published criteria for Mohs
surgery.13,14
It should be noted, however, that our cost data were
sensitive to the type of repair chosen. In other words, when
we varied the cost of repair within plausible ranges, the
difference between Mohs with Mohs repair and the TSE
pathways changed significantly. Thus, our findings must
be interpreted with caution. Future work is necessary in
determining the choice of repairs by Mohs surgeons across
the country to generalize our study findings.
This study provides an evidence-based approach
to the least costly way to provide treatment for facial
and auricular NMSC. However, efficacy and outcomes
(survival and quality-of-life impact) must also be
taken into account when comparing the 2 procedures.
A cost-effectiveness analysis incorporates efficacy and
outcomes of the 2 therapies being compared 25 and
would be a preferable to a pure cost analysis because it
can quantify the value rather than just the costs of
these 2 procedures. Once the ratio of costs to effective-
ness is determined, therapeutic guidelines may be cre-
ated and a recommended treatment algorithm pro-
vided whereby the most cost-effective treatments can
be offered.
Accepted for publication March 4, 2004.
This project was supported in part by an American Skin
Association (ASA) Health Services Research Grant and
Emory Skin Disease Research Center Pilot and Feasibility
grant P30AR42687 from the National Institute on Arthri-
tis and Musculoskeletal and Skin Disease (NIAMS), Na-
tional Institutes of Health (NIH).
WWW.ARCHDERMATOL.COM
 Dr Bialy is supported by National Research Service
Award Training Grant T32 AR07587 from the NIH. Dr Chen
is supported in part by Mentored Patient-Oriented Career
Development Award K23AR02185-01A1 from NIAMS, NIH,
as well as an ASA David Martin Carter Research Scholar
Award.
Corresponding author and reprints: James Whalen, MD,
Department of Dermatology, University of Connecticut
School of Medicine, 263 Farmington Ave MC-6231, Farm-
ington, CT 06030-6231 (e-mail: jwhalen@nso1.uchc.edu).
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