Lack of access to a local Mohs surgeon who treats melanoma with MMS was the most common barrier impeding general dermatologists from referring MIS/LM for MMS
Clinical Pearls
Preference of staged excision over MMS was a primary deterrent impeding head and neck melanoma referral to MMS providers
When referring head and neck MIS/LM, responders preferred MMS with intraoperative MART-1 immunostaining compared to other treatment modalities
Lack of access to a local Mohs surgeon who treats melanoma with MMS was the most common barrier impeding general dermatologists from referring MIS/LM for MMS
Discussion:
This cross-sectional survey performed by Neill et al aimed to better understand the practice habits and referral preferences of general dermatologists regarding Mohs micrographic surgery (MMS) for head and neck melanoma. The use of MMS for melanoma has increased over time and prior studies have suggested it leads to lower recurrence rates when compared to wide local excision.
The authors used an anonymous, 49-question survey sent to 2007 members of the American Academy of Dermatology. Participants (general dermatologists) were asked whether they personally treat head and neck melanoma, what subtypes of head and neck melanoma they referred, their preferred treatment modalities including perceived advantages in treating head and neck melanoma, and referral access to a Mohs surgeon who can treat head and neck melanoma with MMS.
402 participants completed the survey yielding a response rate of 20%. 294 (73.5%) of respondents had access to a Mohs surgeon who treats head and neck melanoma with MMS. The most common reasons for not referring melanoma in situ (MIS) or lentigo maligna (LM) on the head and neck for MMS were lack of local access to a Mohs surgeon and the preference to treat with staged excision. Of those who chose not to refer for MIS or LM due to lack of local access to MMS, 64 (87.7%) reported they would refer if this treatment was available locally.
Respondents of the survey were also most inclined to refer patients with head and neck MIS/LM for MMS with MART-1 immunostaining (251, 63.9%) compared to wide local excision (25, 6.4%), staged excision (102, 26%), and traditional MMS without immunostaining (10, 2.5%). MMS was also perceived to be superior to wide local excision and staged excision regarding recurrence rates (258, 64.2%), survival outcomes (260, 64.7%), cosmetic results (297, 73.9%), and patient morbidity (299, 74.4%).
Overall, this survey provides extensive data on referral patterns and preferences of general dermatologists when managing head and neck melanoma. Future studies could provide more complete data by including referral preferences from other providers who refer melanomas such as family physicians or advance practice providers.
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