Awareness Effort Reduces Excessive Use of Skin Cancer Surgery

A new study from John Hopkins Medicine that included a “Dear Colleague,” performance evaluation letter has successfully led physicians across the United States to reduce the amount of tissue they remove in a common surgical treatment for skin cancer in order to meet a professionally recognized benchmark of good practice.

A study published in JAMA Dermatology reported an immediate positive change in surgical behavior over the course of a year, as 83% of the physicians reported removing more-than-necessary amounts of tissue on a regular basis during Mohs micrographic surgery (MMS), which is used to treat basal cell and squamous cell carcinomas.

"This study demonstrates the tremendous power of physicians within a specialty to create peer-to-peer accountability and of using that accountability to reduce unnecessary treatment and lower health care costs," said senior study author Martin A. Makary, MD, PhD.

Performed as an outpatient procedure, MMS involves a surgeon methodically removing cancerous tissue including the skin’s surface and all of its roots or extensions of the tumors that may exist under the skin or lie along the blood vessels, nerves, and cartilage.

The surgery is conducted in stages. Stage 1 involves physical removal of the visible cancer and the thin layer of surrounding tissue, while stage 2 involves the physician cutting the sample into pieces, staining it, and examining it microscopically. If the surgeon finds more tumorous tissue, they can elect to remove more. The process continues for as many stages as necessary.

The American College of Mohs Surgery (ACMS) considers a surgeon’s annual mean stages per MMS case as a measure of quality and appropriateness. The organization defines physicians whose practices are 2 standard deviations or more beyond the overall averages as outliers.

According to the press release, investigators evaluated approximately 2329 surgeons who each performed more than 10 MMS procedures during 2014. The study population was then divided into 4 groups: 53 outliers, each of whom would receive an intervention letter indicating his or her performance and urging an improvement in practice, 87 outliers, each of whom would not receive an intervention, 992 inliers who would receive a straightforward performance evaluation letter, and 1197 inliers who would not receive a letter.

The notified outlier group demonstrated a pre- to post-intervention decrease in mean stages per case from 2.55 to 2.31, with 44 of the 53 surgeons (83%) improving their MMS behavior. The non-notified outliers dropped from 2.56 to 2.46, with 69% making positive changes.

The researchers attribute the drop by non-notified outliers to 2 factors: an awareness campaign by ACMS around the time the intervention letters went out and possible communications between surgeons who received the letters and their colleagues who did not.