Nicholas Golda, Surgery and Cutaneous Oncology Program Director, University of Missouri Health Care
Because scar size and appearance are related to initial tumor size, using tissue-sparing techniques—such as Mohs micrographic surgery—to treat skin cancer are ways to achieve a patient’s desire for a smaller and less noticeable scar.
We make smaller skin defects with Mohs surgery than with conventional excisions. The idea is that Mohs would yield a smaller defect and provide an opportunity for a smaller scar. With Mohs, we are doing all of the laboratory work, the examination and the excision all bundled into the same procedure. Per incidence, it seems costly, but when you start looking at recurrence rates and the cost of doing subsequent surgeries to treat recurrence, and the opportunity for smaller, less costly reconstructions on a population level—the cost levels out.
However, in the era of high-deductible plans, the out-of-pocket expenses may be more with a Mohs surgery—at least initially. We wanted to understand how patients assign value to avoiding larger or more noticeable scars.
"With Mohs, we are doing all of the laboratory work, the examination and the excision all bundled into the same procedure as healthcare costs continue to rise, University of Missouri Health Care is working to better understand how patients assign value to the cosmetic outcomes of medically necessary skin cancer procedures"
Our research team conducted a multi-site study of 912 skin cancer patients. Participants were randomly assigned to one of four scenarios: skin cancer on the cheek or back with a low risk of spreading or skin cancer on the cheek or back with a high risk of spreading.
Our research, published in the October 2019 edition of the Journal of the American Academy of Dermatology, found patients desired and were willing to pay more for smaller and less visible scars. In addition, the patient’s willingness to pay for a smaller or less noticeable scar was higher when the surgery affected the face rather than the back.
We also looked at income levels and learned that lower income patients were willing to pay a greater proportion of their total income for less-noticeable scars than high income earners, even though the higher income patients were willing to pay a higher dollar amount overall. We thought that data was particularly compelling in that it illustrates that the issue of cosmesis following skin cancer surgery holds significant value across all income levels.
As medicine zeroes in on being patient-centered, our decisions must reflect patient preferences. We must ask ourselves, “What do our patients value and how do they wish to be treated?” Using data to better understand these preferences will not only improve patient satisfaction, it will help us navigate the challenges associated with the growing costs of innovative treatments.