title: Underutilization of Mohs Micrographic Surgery for Less Common Cutaneous Malignancies in the United States.
abstract: BACKGROUND
  Consensus guidelines have defined select less common skin cancers appropriate for Mohs micrographic surgery (MMS), as these tumors are characterized by asymmetric growth patterns that challenge conventional surgical extirpation of disease.
  
  
  OBJECTIVE
  The authors aimed to define surgical patterns of care and to identify factors affecting treatment selection in the United States.
  
  
  METHODS
  Retrospective cohort analysis of nonmetastatic nonmelanoma skin cancers deemed appropriate for MMS by American Academy of Dermatology/American College of Mohs Surgery/American Society for Dermatologic Surgery Association/American Society for Mohs Surgery appropriate use criteria from the National Cancer Data Base from 1998 to 2012.
  
  
  RESULTS
  Of the included 15,121 patients, 8% received MMS, 30% primary excision, 12% narrow re-excision, and 50% wide re-excision. Utilization of MMS was negatively influenced by community cancer programs, Northeast region, lower education, uninsured status, and administration of radiotherapy. High-risk face areas, lower comorbidity score, and microcystic adnexal carcinoma were associated with higher likelihood of receiving MMS. After adjusting for tumor size, tumor location, and histology, MMS remained an independent predictor of achieving negative surgical margins (odds ratio 3.15, 95% CI 2.27-4.36, and p < .0001).
  
  
  CONCLUSIONS
  There is considerable variation in surgical treatment patterns by both sociodemographic, treatment, and tumor characteristics. Despite low utilization, patients receiving MMS are more likely to achieve negative surgical margins and less likely to receive radiotherapy.
authors.affiliation: *Department of Medicine, Section of Dermatology, West Virginia University, Morgantown, West Virginia; †University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; ‡Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania; §Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania.
authors.forename: Erica R
authors.initials: ER
authors.lastname: Ghareeb
authors.forename: Brittany O
authors.initials: BO
authors.lastname: Dulmage
authors.forename: John A
authors.initials: JA
authors.lastname: Vargo
authors.forename: Goundappa K
authors.initials: GK
authors.lastname: Balasubramani
authors.forename: Sushil
authors.initials: S
authors.lastname: Beriwal
mesh_terms: D006801:Humans; D015994:Incidence; D015580:Mohs Surgery / Q000706:statistics & numerical data*; D018579:Patient Selection; D012042:Registries; D012189:Retrospective Studies; D012878:Skin Neoplasms / Q000453:epidemiology / Q000601:surgery*; D014481:United States / Q000453:epidemiology