Mohs Surgery in a Post-COVID World: Improving Patient Outcomes in 2021

With skin cancer still the most common type of cancer in the country, with an estimated 9500 people diagnosed in the United States each day,¹ Mohs surgery and other similar techniques are vital for combating the continual prevalence of skin cancer. As I am sure you know, Mohs surgery specifically still offers the highest cure rate available (97%-99% for primary tumors and 94% for recurrent tumors) and the smallest surgical wound possible.²

The need for effective skin cancer treatment is even more evident now, as we still recover from the impact of COVID-19. Last year, when the stay-at-home order went into effect and medical practices had to greatly limit their ability to see patients in-office or close their doors to the public altogether, many patients experienced a delay in care. Even when practices started to open back up to the public, many people were likely fearful or hesitant to come back into medical practices (and many still may be today). I believe this combination of things has impaired dermatologists’ ability to identify and treat skin cancer early during the pandemic time frame. All skin cancers progress through a treatable phase, with early diagnosis and intervention being crucial to successful outcomes.

Last year’s delay of care (which has also spread into this year) may have led to larger and more complicated skin cancers. Over the past 6 to 9 months, the patients I have seen for Mohs surgery appear to be presenting with larger, deeper, and more complicated skin cancers compared with pre-COVID presentations.

Others are seeing this as well. In a study published in Journal of the American Academy of Dermatology, Marson and colleagues³ studied outpatient medical charts to determine if delays in the initial diagnosis and management of skin cancer during the COVID-19 pandemic made an impact. The team analyezd outpatient charts of 143 US dermatology practices (with 350 providers caring for 4.7 million patients in 13 states) from January 2019 to August 2020. They found that during the peak COVID-19 period, the average number of skin cancers diagnosed per month decreased compared with both the pre–COVID-19 time and the COVID-19 recovery period immediately following the peak. Skin cancer diagnoses seem to be lower in 2020 vs 2019, with the incidence of cutaneous melanomas, squamous cell carcinomas (SCCs), and basal cell carcinomas (BCCs) decreasing by 279, 6000, and 9914 cases, respectively. The largest diagnosis decreases occurred in April 2020. The authors of this study believed these results show that there is a large amount of undiagnosed skin cancers. At best, there may still be an average diagnostic delay of 1.8 months for cutaneous melanomas, 2.1 months for SCCs, and 1.9 months for BCCs. “These delays in initial diagnosis and treatment may lead to skin cancers presenting at more advanced stages, with potential increased morbidity and worse cutaneous melanoma survival outcomes,” the authors wrote.³

A similar study was published in PLoS One.⁴ Using a universal health care claims dataset from Ontario, a team from Queen’s University in Kingston, ON, Canada, examined skin biopsies from January 6, 2020, to September 27, 2020, and compared these with the same period for 2019. Patients who were diagnosed with anogenital cancers, younger than 20 years, residing out-of-province, and with lapses in coverage were excluded. They reported that a significant reduction in biopsies during the early part of the COVID-19 pandemic, particularly affecting women, older persons, and residents of certain regions. The authors also noted a significant backlog of biopsies, which continued past initial lockdown measures. Like Marson et al,³ Asai et al⁴ predicted that these observations will have major downstream implicates for skin cancer care and treatment.

Personal Practice Anecdotes
My practice experience reflects the findings of these studies.^3,4 The average preoperative size for tumors I have seen seems to be slightly larger compared with others in the last few years. Also, the number of multiple stage Mohs cases seems to have increased, and I am finding that the number of complex repairs, such as larger flaps and skin grafts, appears to have increased as well.

Although small in some cases, these additional complications create longer delays for patients, team members, and doctors. The ability to schedule effectively suffers. For example, what may have been a straightforward, single-stage BCC tumor on the medial cheek that could have been repaired with a linear closure in July of 2020 is now a more complex, infiltrative tumor that requires three stages of Mohs surgery and now involves multiple facial subunits over the cheek and nasal sidewall. While I have certainly seen patients requiring this level of treatment in the past, the proportion of “complex” Mohs patients seems to be higher over the last 6 to 9 months specifically, as patients have started returning to their dermatologists and Mohs surgeons for regular skin checks. This proportional increase in complex cases is surely a result of the delays in diagnosis and care from COVID-19 stay-at-home orders or the complete shutdown of nonemergency care.

What Our Practices Can Do to Help
Considering my own recent experiences and the results of this studies,^3,4 there are likely many more people out there with advanced skin cancer in need of diagnosis and treatment. So how can we, as dermatologists, create better outcomes for these patients in 2021? At least right now, practices are seeing more and more people in the office again, allowing us to identify more cases of skin cancer early on and start treatment as soon as possible on advanced cases. Telehealth became prominent during the pandemic (and will likely remain a popular option), offering a convenient way for patients to still get the medical care they need remotely. For thorough skin checks, though, using a telehealth platform can be challenging. It can work well for a one-spot check, but it is still best for the patient to come in for a more comprehensive check and a biopsy if deemed necessary.

There are definitely still challenges to “catching up” on this essential care. With the nationwide shortage of labor, it is now increasingly difficult to fill important team member roles in our practices. Accommodating the added care needed for these patients, as well as more erratic scheduling due to more complicated cases, is an issue. Further complicating it, dermatologists and other physicians nationwide are facing a mandated 4% to 5% reduction in reimbursement in the face of the highest inflation we have seen in well over a decade. Facing this double whammy during a time when our patients need us the most is disheartening to say the least. Hopefully, as more continue to speak up and advocate for patient access and care, the Centers for Medicare & Medicaid Services and the federal government may be able to alleviate some of the burden in health care, as they have in many other industries.

There are things we can do right now in our practices to start closing the gap on delayed diagnosis. For patients who have delayed care, it is important to encourage them to come in as soon as possible. Encouraging regular skin checks is typically a common part of standard patient marketing and communications for dermatology practices, but highlight it even more so now. You can even specifically mention that if COVID-19 caused a patient to miss out on regular skin screenings before, they should not delay any further.

Whether you are a Mohs surgeon or not, identify key messaging about skin cancer treatment and incorporate it into your marketing and communications initiatives. Most patients will not recognize what Mohs surgery or other specific treatments are just from their names, so emphasize the what, how, and why behind them. If not present already, add a webpage dedicated to educational skin cancer information. You can feature this content or reference it in your direct mailings and digital (email, social media) marketing. You may even want to consider writing a few posts about the importance of skin cancer screenings if you have a professional blog, or you may want to explore creating educational videos explaining why skin health and cancer screenings are necessary. These informative and marketing materials are great for engaging with current and potential patients.

Final Thoughts
All in all, it appears we have an opportunity to help an even larger group of people affected by the impact of the COVID-19 pandemic. Over the coming year, I am interested to learn if this is just an anecdotal finding that I am seeing locally in my practice or if this trend is supported with more data across the nation. As a group, dermatologists and Mohs surgeons could look at the average number of stages performed for given time frames, the average number of complex repairs (such as flaps and skin grafts vs linear repairs) for a given time, and perhaps the number of patients treated nonsurgically with hedgehog inhibitors, other chemotherapy, or radiation. This could give us even more clarity on how the pandemic has impacted our ability to treat skin cancer

References
1. American Academy of Dermatology. Skin cancer incident rates. Updated June 21, 2021. Accessed June 23, 2021. https://www.aad.org/media/stats-skin-cancer
2. Robins P, Ebede T, Hale E. The evolution of mohs surgery. Skin Cancer Foundation. Accessed June 23, 2021. https://www.skincancer.org/treatment-resources/mohs- surgery/history-of-mohs/
3. Marson, JW, Maner BS, Harding TP, et al. The magnitude of COVID-19’s effect on the timely management of melanoma and nonmelanoma skin cancers. J Am Acad Dermatol. 2021;84(4):1100-1103. doi:10.1016/j.jaad.2020.12.065
4. Asai Y, Nguyen P, Hanna T. Impact of the COVID-19 pandemic on skin cancer diagnosis: a population-based study. PLoS One. Published March 31, 2021. doi:10.1371/ journal.pone.0248492