COMMENTARY Commentary on Mohs Appropriate Use Criteria: Retrospectively Applied to Nonmelanoma Skin Cancers at a Single Academic Center Chong and colleagues1 describe the retrospective application of the Mohs Appropriate Use Criteria (AUC) to nonmelanoma skin cancers over a 3-month period at a single academic center. They found that 96.9% of the tumors treated with Mohs micrographic surgery (MMS) were deemed “appropriate” by the AUC. At the same time, over 50% of the nonmelanoma skin cancer (NMSC) treated with a modality other than MMS were deemed appropriate by the AUC. Although the broad application of these results may be precluded by factors such as referral pattern, practice setting, and institutional resources, their conclusions highlight unanswered questions and evolving paradigms related to the management of the estimated 5.4 million skin cancers per year in the United States.2 In their discussion, Chong and colleagues conclude that their use of MMS is highly appropriate based on the nearly 97% of cases of MMS categorized as appropriate. This conclusion seems reasonable, and the rate of appropriate use of MMS is encouraging. At the same time, the discussion affords an opportunity to review the language and intent of the MMS AUC. The intent of the MMS AUC is “to guide clinical decision making regarding dermatologic treatment.”3 The MMS AUC, as Chong and colleagues point out, is based on 270 clinical scenarios. The criteria “should not be interpreted as setting the standard of care,”3 rather “the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician when considering an individual patient’s specific and unique characteristics.”3 Although the MMS AUC was a welcome and necessary tool to aid clinical decision making and

payment policy, it is not necessarily the final arbiter of the appropriate use of MMS. That decision still resides within the joint decision making of the physician and the patient. Thus, the author would argue that the 60% of NMSC deemed appropriate for MMS but treated by Chong and colleagues by another modality speaks just as much to their judicious and appropriate use of MMS as any other data in the article. A second conclusion drawn by Chong and colleagues, based on these same data, is the possible underutilization of MMS for certain NMSCs in their practice. The AUC, as mentioned above, is not the arbiter of appropriateness nor should it necessarily drive the utilization of MMS. The authors aptly reference an opinion by Coldiron that MMS AUC should, in effect, limit cases inappropriately treated with MMS rather than increase MMS utilization.4 Among the factors that should influence the selection of a treatment modality for NMSC are patient preference, physician recommendations, and clinical guidelines such as AUC, the comparative efficacy of the treatment modalities, and the cost and availability compared with reasonable alternative options. Of these, comparative efficacy is the most objective factor but is currently lacking robust data. Chong and colleagues astutely recognize this shortcoming and should be encouraged in their plans to analyze the outcomes based on treatment modalities in this cohort. The MMS AUC is a necessary step forward in defining tumors that may be considered appropriate for MMS but, by design, remains a consensus document created by a defined methodology, heavily influenced by group

The author has indicated no significant interest with commercial supporters. © 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 1076-0512 Dermatol Surg 2015;41:896–897 DOI: 10.1097/DSS.0000000000000435

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© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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expert opinion. In the short term, it should serve as a guide for individual physician–patient decision making. From a larger perspective, as illustrated by Chong and colleagues, it has the potential to serve as a tool that may shed light on the practice patterns of clinicians who perform MMS across the country. Going forward, it is imperative that we critically analyze the impact of the MMS AUC on MMS utilization and payment policy, while at the same time, generate the data necessary to make more informed decisions about the “appropriate” use of all modalities in the treatment of NMSC.

References 1. Chong T, Tristani-Firouzi P, Bowen GM, Hadley ML, et al. Mohs appropriate use criteria: retrospectively applied to non-melanoma

skin cancers at a single academic center. Dermatol Surg 2015;41: 889–95. 2. Rogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence Estimate of Nonmelanoma Skin Cancer (Keratinocyte Carcinomas) in the US Population, 2012. JAMA Dermatol [published ahead of print April 30, 2015] doi: 10.1001/jamadermatol.2015.1187. 3. American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, American Society for Mohs Surgery, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. Dermatol Surg 2012;38:1582–603. 4. Coldiron B. Commentary: Implementation of the appropriate-use criteria will not increase Mohs micrographic surgery utilization. J Am Acad Dermatol 2014;71:36–7.

Christian L. Baum, MD Department of Dermatology Mayo Clinic Rochester, Minnesota

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© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Commentary on Mohs appropriate use criteria: retrospectively applied to nonmelanoma skin cancers at a single academic center.

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