A review of the evidence for Mohs micrographic surgery. Part 2: basal cell carcinoma

Abstract

Mohs micrographic surgery (MMS) is considered the gold-standard treatment for basal cell carcinoma (BCC) particularly for sites with a high risk of incomplete excision such as the central face, for tumours with an aggressive growth pattern and consequent unpredictable subclinical extension and for recurrent tumours. However, the process is more time-consuming than for standard excision (SE), and the magnitude of benefit is uncertain. This article aims to provide a more complete picture of current evidence, including a review of cosmetic outcomes, tissue-sparing ability and cost-effectiveness of MMS. Although robust evidence is lacking, there is a large volume of observational data supporting a low recurrence rate after MMS. The risk of incomplete excision and higher recurrence rate of SE favours the use of MMS at high-risk sites. There is some low-certainty evidence that MMS results in a smaller defect size compared with SE, and that incomplete excision with SE results in larger defects. Larger defects may affect cosmetic outcome but there is no direct evidence that MMS improves cosmetic outcome compared with SE. There is conflicting evidence regarding the cost of MMS compared with SE, as some studies consider MMS less expensive than SE and others consider it more expensive, which may reflect the healthcare setting. A multicentre 10-year randomized controlled trial comparing MMS and SE in the treatment of high-risk BCC would be desirable, but is unlikely to be feasible or ethical. Collection of robust registry data capturing both MMS and SE outcomes would provide additional long-term outcomes.

The top 100 most cited articles in the treatment of basal cell carcinoma over the last decade: A bibliometric analysis and review

“…[11] MMS offers the benefits of minimized incomplete resections and reduced recurrence rates. [22] However, a prospective study on Spanish nonmelanoma skin cancer (NMSC) patients, 92% with BCC, from 2013 to 2020, indicated that 21% of BCC patients treated with MMS faced an elevated risk of a subsequent tumor. [23] Citation analysis, a more robust indicator of article quality and research trends than IF analysis, [24] has highlighted a growing focus on BCC treatments involving the Hh pathway, HPIs, and PDT over the past decade.…”

“…[ 11 ] MMS offers the benefits of minimized incomplete resections and reduced recurrence rates. [ 22 ] However, a prospective study on Spanish nonmelanoma skin cancer (NMSC) patients, 92% with BCC, from 2013 to 2020, indicated that 21% of BCC patients treated with MMS faced an elevated risk of a subsequent tumor. [ 23 ]…”

A review of Mohs micrographic surgery for skin cancer. Part 3: Squamous cell carcinoma

“…46 The cost analysis of MMS for BCC has been reported in our associated review of BCC. 47 The most recently published study was a US study using theoretical modelling based on the data from previously reported studies determined the costeffectiveness of MMS vs. WLE with conventional histopathology for T2a cSCC over 5 years, 45 and concluded that all-in costs per patient (including cost of treating incompletes/recurrences) were US$4365.57 for MMS and US$4699.41 for WLE, making MMS US $333.83 cheaper than WLE. The authors reported that MMS had a 99.9% probability of being more costeffective compared with WLE, and that MMS could cost over three times its current rate and still be more cost-effective than WLE.…”

“…All other reported studies in this area assessed either keratinocyte cancers jointly or BCC alone 46 . The cost analysis of MMS for BCC has been reported in our associated review of BCC 47 …”