Mohs Surgery Saves Costs, May Improve Outcomes in Melanoma

SEATTLE — Compared with standard surgical excision (SSE), Mohs surgery for melanoma in-situ (MIS) can be cost saving and more effective in reducing disease burden in patients, according to a new cost-effective analysis.

While upfront costs were higher for Mohs surgery, long-term costs were lower, because of a reduced incidence of local recurrence and subsequent long-term morbidity, according to the analysis.

“Upfront, theoretically, the standard incision was a little cheaper but downstream and in our 5-year model, there was a $410 savings with Mohs surgery, compared to standard incision,” said lead author Jeremy Udkoff, MD, Mohs surgery fellow at Tel Aviv Medical Center, Israel. “This can add up to a substantial amount of money.”

The study results were presented here at the American College of Mohs Surgery (ACMS) 2023 Annual Meeting.

Increasing evidence has demonstrated that Mohs surgery can improve rates of local recurrence compared with SSE, for MIS. The National Comprehensive Cancer Network (NCCN) has also recently recognized Mohs surgery as a treatment option for MIS.

Udkoff noted that he and his colleagues have previously investigated the cost-effectiveness of Mohs surgery for two other types of skin cancer. For cutaneous squamous cell carcinoma, they conducted an analysis, published in 2022, to determine whether Mohs was cost effective over wide local excision. Their results showed that Mohs was $333.83 less expensive than the standard surgery, and annualized savings of choosing Mohs over wide local excision would be $200 million. Moreover, even if Mohs cost 3.1 times its current rate, it would remain cost effective.

For dermatofibrosarcoma protuberans (DFSP), a locally aggressive soft-tissue sarcoma that has a high rate of recurrence when treated with wide local excision, they conducted a similar cost effectiveness analysis, also reported in 2022. Mean costs accrued throughout the 5-year model were $3924 for Mohs and $4414 for wide local excision, which was a cost difference in favor of Mohs of $490,240 per 1000 patients treated.

“We found that quality healthcare up front led to better patient outcomes and decreased overall costs,” Udkoff said, adding that currently, the limited cost-effectiveness literature for Mohs surgery solely focuses on nonmelanoma skin cancer with no formal melanoma analyses to date.

Study Details

In the current study, Udkoff and his team conducted the same type of research by creating a model for a cost effectiveness analysis of Mohs and SSE for MIS of the head and neck. Utilizing Markov model decision-tree analysis, the costs and effectiveness, as measured in quality-of-life or “quality adjusted life years” (QALYs), were calculated from a healthcare payer perspective over 5 years.

In the model, a person has MIS and from there they progress to either standard wide local excision or Mohs, with upfront costs for Mohs theoretically higher, he said. “The patient then progresses to a state of remission, and health utility increases. From there they can continue in a healthy state or have recurrences and transition to different health states and accumulate costs.”

Udkoff explained that QALYs are a generic measure of disease burden that includes both the quality and the quantity of life lived. Frequently used when making economic evaluations that assess the value of medical interventions, one QALY equates to one year in perfect health.

“We chose a conservative willingness-to-pay threshold of $50,000/QALY,” he said.

The results showed that upfront costs for Mohs were higher as compared with SSE: $1161 vs $917. However, Mohs was cost-effective 1-month after treatment (incremental cost-effectiveness ratio [ICER] = $16,600). Even if the main Mohs procedure costs increased by 69% to $1778, it would remain cost-effective, according to the analysis.

Over a 5-year period, Mohs was $410 less expensive ($2990 versus $3,400) and 0.008 QALY more effective (3.912 vs 3.904 QALY) than SSE (P ≤ .001). Mohs surgery saved $410,000 and 8.46 years of perfect health per 1000 patients over SSE, and when SSE was performed by nondermatologists in alternative surgical settings, it was $4021 more expensive than Mohs, the study found.

Sensitivity analyses showed that the main drivers of increased cost and decreased QALY for SSE were 5-year local recurrence rates (0.96% for Mohs vs 7.46% for SSE). There was an increased rate of positive margins after SSE requiring additional surgery as well as MIS recurrences, as invasive melanoma, which is associated with further disease progression, decreased QALY and increased costs (22.6%).

“Increasing Mohs utilization for melanoma could both reduce direct payer costs and improve patient outcomes,” Udkoff concluded.

Approached by Medscape Medical News for an independent comment, Vishal Patel, MD, director of cutaneous oncology at George Washington University, Washington, DC, reiterated that Mohs surgery has been shown to be cost effective in a variety of settings, most commonly non-melanoma skin cancer.

“Recently, there has been growing evidence of the superior outcomes of micrographic surgery of in situ and thin melanomas, especially in the head and neck region,” he said. “This study adds to the growing literature on the value of micrographic surgery for melanoma, this time highlighting the potential cost effectiveness of this approach.”

No external funding of the study was reported. Udkoff reports no relevant financial relationships. Patel is a consultant for Sanofi, Regeneron, and Almirall.

American College of Mohs Surgery (ACMS) 2023 Annual Meeting. Presented May 4, 2023.

Roxanne Nelson is a registered nurse and an award-winning medical writer who has written for many major news outlets and is a regular contributor to Medscape.

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