AVAHO

Although historically associated with a low risk of malignancy, hyperthyroidism is no longer thought to be protective against the occurrence of thyroid cancer. The incidence of malignancy has been reported in Graves disease at 2% and as high as 9% in toxic multinodular goiters.^1,2

In evaluating patients with thyroid nodules and low thyroid stimulating hormone (TSH), which may indicate hyperthyroidism, the American Thyroid Association (ATA) recommends a radioiodine thyroid scan to determine whether a thyroid nodule is autonomous (hot) or nonfunctional (cold).³ Hot thyroid nodules are nodular areas of hyperfunctioning activity on radioiodine scan where tracer uptake is greater than the surrounding normal thyroid.

Historically, hot nodules have been associated with a low risk of malignancy and typically did not receive further ultrasound evaluation. However, recent studies have documented that the incidence of thyroid cancer in hot nodules may be underestimated. Mirfakhraee and colleagues performed a literature review in 2013 that revealed the prevalence of thyroid carcinoma in hot nodules managed by thyroidectomy ranged from 0% to 12.5% and averaged 3.1%.⁴ These findings may underestimate the prevalence of malignancy, because most hot nodules are not managed by thyroidectomy.

Given findings of hot nodules harboring malignancy, the authors investigated the role of thyroid ultrasound in patients with hyperthyroidism to identify suspicious features concerning for possible malignancies. The study objective was to estimate the prevalence of hot nodules with sonographic features concerning for malignancy in patients with hyperthyroidism in a Department of Veterans Affairs (VA) health care system.

Methods

This retrospective chart review consisted of 149,549 patients seen between January 2010 and December 2015 at the VA Northern California Health Care System (VANCHCS). The institutional review board approved the study and informed consent was waived.

Seven hundred sixty veterans were identified in the Computerized Patient Record System (CPRS) using the following ICD-9 codes: 242.9 (hyperthyroidism), 242.2 (toxic multinodular goiter), 242.3 (toxic nodular goiter), 242.1 (toxic uninodular goiter), and 241.9 (adenomatous goiter) (Figure 1). 

Manual review of thyroid ultrasound scans for suspicious characteristics concerning for thyroid carcinoma were based on the 2015 ATA Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer.³ Per the ATA guidelines, sonographic patterns that are highly suspicious for malignancy were solid hypoechoic nodule or solid hypoechoic component of a partially cystic nodule with one or more of the following features: irregular margins (infiltrative, microlobulated), microcalcifications, taller than wide on transverse view, and rim calcifications with small extrusive soft-tissue component. Sonographic patterns with intermediate suspicion were hypoechoic solid nodule with smooth margins without microcalcifications, extrathyroidal extension, or taller than wide shape.³

Results

Of the 760 identified veterans, 230 had thyroid ultrasounds, and 113 had radioiodine thyroid scans. Of these, 70 patients had both ultrasound and radioiodine thyroid scans. This cohort consisted of 84.3% (59) males and 15.7% women (11). Ages ranged from 32 to 93 (mean age 62.9) years.

A total of 121 nodules were identified among the remaining 43 patients (11 individuals with cold thyroid scans and 16 individuals with no nodules were excluded). Of the 121 nodules, 44 were hot nodules, 29 were coexisting nodules found in patients with hot nodules, and 48 were other nodules found in patients without coexisting hot nodules (Figure 2). 

Of the 44 hot nodules, the analysis identified 16 hot nodules with suspicious features on ultrasound and 28 nodules without suspicious findings. Breakdown of specific suspicious features included 11 that were solid hypoechoic, 3 nodules that had microcalcifications, and 2 nodules that had both characteristics (Table). 

Twelve patients had hot nodules with suspicious ultrasound findings. Of this group, 6 patients had no further workup, 1 patient was lost to follow-up, and 1 patient was planned for fine needle aspiration (FNA) biopsy. Four patients underwent FNA, and all results were benign.

Discussion

Although most veterans identified with hyperthyroidism did not undergo imaging studies, of those who did, a remarkable number had unexpected ultrasonographically suspicious nodules. Of the 44 hot nodules identified on radioiodine studies, 16 had suspicious ultrasound findings that raised concern for malignancy based on the most recent ATA guidelines. In contrast to recent studies that have suggested an increased incidence of thyroid carcinoma in hot nodules, no cancers were detected in this cohort.⁴ However, only 4 patients in this study underwent FNA.

Worth noting is that the most common suspicious feature found in this study’s cohort was hypoechoic solid nodules, which is a feature that has a sensitivity of 81% however a low specificity of 53% in detecting thyroid malignancy.⁵ This appearance also is found in 55% of benign thyroid nodules.⁶ The overlap of hypoechoic nodules as a feature in both benign and malignant thyroid nodules can present as a diagnostic challenge in differentiating between the two.

The 2015 ATA guideline recommends that low TSH warrants a radioiodine scan, and FNA should be considered for isofunctioning or nonfunctioning nodules with suspicious sonographic features. Hot nodules found on scintigraphy need no further cytologic evaluation because they are mostly benign.³ There is no clear stance on the use of ultrasound in hot nodules.

The answer to whether patients with hot nodules should undergo ultrasound still remains unclear. This study showed a surprising number of hot nodules with worrisome architecture found on ultrasound. However, whether that correlates to actual malignant findings remains unknown as most individuals in the cohort did not undergo biopsy. Also, given the high prevalence of suspicious findings, it may be difficult to use ultrasound as a diagnostic tool in patients with hot nodules as false positives may lead to unnecessary interventions such as biopsy.

Limitations

The patient population consisted mostly of men (84.3%) and cannot be applied to the general population. Thyroid nodules are 4 times more common in women than they are in men.⁷ Another limitation was the lack of data on patients’ radiation exposure while in military service or as civilians. Finally, as a retrospective study, there was unavoidable selection bias.

Conclusion

The prevalence of suspicious findings concerning for malignancy in hot nodules was 36.3% (16/44) based on the 2015 ATA guidelines. This study’s preliminary observation suggests that although ultrasound is a noninvasive and relatively inexpensive diagnostic modality, it has a limited role in the evaluation of hot nodules given the high prevalence of suspicious findings. Clinicians may still consider its use in patients who also have high-risk historic features. This was a thought-generating, retrospective study, and further prospective studies in larger populations are needed to validate the study’s results.

Although historically associated with a low risk of malignancy, hyperthyroidism is no longer thought to be protective against the occurrence of thyroid cancer. The incidence of malignancy has been reported in Graves disease at 2% and as high as 9% in toxic multinodular goiters.^1,2

In evaluating patients with thyroid nodules and low thyroid stimulating hormone (TSH), which may indicate hyperthyroidism, the American Thyroid Association (ATA) recommends a radioiodine thyroid scan to determine whether a thyroid nodule is autonomous (hot) or nonfunctional (cold).³ Hot thyroid nodules are nodular areas of hyperfunctioning activity on radioiodine scan where tracer uptake is greater than the surrounding normal thyroid.

Historically, hot nodules have been associated with a low risk of malignancy and typically did not receive further ultrasound evaluation. However, recent studies have documented that the incidence of thyroid cancer in hot nodules may be underestimated. Mirfakhraee and colleagues performed a literature review in 2013 that revealed the prevalence of thyroid carcinoma in hot nodules managed by thyroidectomy ranged from 0% to 12.5% and averaged 3.1%.⁴ These findings may underestimate the prevalence of malignancy, because most hot nodules are not managed by thyroidectomy.

Given findings of hot nodules harboring malignancy, the authors investigated the role of thyroid ultrasound in patients with hyperthyroidism to identify suspicious features concerning for possible malignancies. The study objective was to estimate the prevalence of hot nodules with sonographic features concerning for malignancy in patients with hyperthyroidism in a Department of Veterans Affairs (VA) health care system.

Methods

This retrospective chart review consisted of 149,549 patients seen between January 2010 and December 2015 at the VA Northern California Health Care System (VANCHCS). The institutional review board approved the study and informed consent was waived.

Seven hundred sixty veterans were identified in the Computerized Patient Record System (CPRS) using the following ICD-9 codes: 242.9 (hyperthyroidism), 242.2 (toxic multinodular goiter), 242.3 (toxic nodular goiter), 242.1 (toxic uninodular goiter), and 241.9 (adenomatous goiter) (Figure 1). 

Manual review of thyroid ultrasound scans for suspicious characteristics concerning for thyroid carcinoma were based on the 2015 ATA Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer.³ Per the ATA guidelines, sonographic patterns that are highly suspicious for malignancy were solid hypoechoic nodule or solid hypoechoic component of a partially cystic nodule with one or more of the following features: irregular margins (infiltrative, microlobulated), microcalcifications, taller than wide on transverse view, and rim calcifications with small extrusive soft-tissue component. Sonographic patterns with intermediate suspicion were hypoechoic solid nodule with smooth margins without microcalcifications, extrathyroidal extension, or taller than wide shape.³

Results

Of the 760 identified veterans, 230 had thyroid ultrasounds, and 113 had radioiodine thyroid scans. Of these, 70 patients had both ultrasound and radioiodine thyroid scans. This cohort consisted of 84.3% (59) males and 15.7% women (11). Ages ranged from 32 to 93 (mean age 62.9) years.

A total of 121 nodules were identified among the remaining 43 patients (11 individuals with cold thyroid scans and 16 individuals with no nodules were excluded). Of the 121 nodules, 44 were hot nodules, 29 were coexisting nodules found in patients with hot nodules, and 48 were other nodules found in patients without coexisting hot nodules (Figure 2). 

Of the 44 hot nodules, the analysis identified 16 hot nodules with suspicious features on ultrasound and 28 nodules without suspicious findings. Breakdown of specific suspicious features included 11 that were solid hypoechoic, 3 nodules that had microcalcifications, and 2 nodules that had both characteristics (Table). 

Twelve patients had hot nodules with suspicious ultrasound findings. Of this group, 6 patients had no further workup, 1 patient was lost to follow-up, and 1 patient was planned for fine needle aspiration (FNA) biopsy. Four patients underwent FNA, and all results were benign.

Discussion

Although most veterans identified with hyperthyroidism did not undergo imaging studies, of those who did, a remarkable number had unexpected ultrasonographically suspicious nodules. Of the 44 hot nodules identified on radioiodine studies, 16 had suspicious ultrasound findings that raised concern for malignancy based on the most recent ATA guidelines. In contrast to recent studies that have suggested an increased incidence of thyroid carcinoma in hot nodules, no cancers were detected in this cohort.⁴ However, only 4 patients in this study underwent FNA.

Worth noting is that the most common suspicious feature found in this study’s cohort was hypoechoic solid nodules, which is a feature that has a sensitivity of 81% however a low specificity of 53% in detecting thyroid malignancy.⁵ This appearance also is found in 55% of benign thyroid nodules.⁶ The overlap of hypoechoic nodules as a feature in both benign and malignant thyroid nodules can present as a diagnostic challenge in differentiating between the two.

The 2015 ATA guideline recommends that low TSH warrants a radioiodine scan, and FNA should be considered for isofunctioning or nonfunctioning nodules with suspicious sonographic features. Hot nodules found on scintigraphy need no further cytologic evaluation because they are mostly benign.³ There is no clear stance on the use of ultrasound in hot nodules.

The answer to whether patients with hot nodules should undergo ultrasound still remains unclear. This study showed a surprising number of hot nodules with worrisome architecture found on ultrasound. However, whether that correlates to actual malignant findings remains unknown as most individuals in the cohort did not undergo biopsy. Also, given the high prevalence of suspicious findings, it may be difficult to use ultrasound as a diagnostic tool in patients with hot nodules as false positives may lead to unnecessary interventions such as biopsy.

Limitations

The patient population consisted mostly of men (84.3%) and cannot be applied to the general population. Thyroid nodules are 4 times more common in women than they are in men.⁷ Another limitation was the lack of data on patients’ radiation exposure while in military service or as civilians. Finally, as a retrospective study, there was unavoidable selection bias.

Conclusion

The prevalence of suspicious findings concerning for malignancy in hot nodules was 36.3% (16/44) based on the 2015 ATA guidelines. This study’s preliminary observation suggests that although ultrasound is a noninvasive and relatively inexpensive diagnostic modality, it has a limited role in the evaluation of hot nodules given the high prevalence of suspicious findings. Clinicians may still consider its use in patients who also have high-risk historic features. This was a thought-generating, retrospective study, and further prospective studies in larger populations are needed to validate the study’s results.

Although historically associated with a low risk of malignancy, hyperthyroidism is no longer thought to be protective against the occurrence of thyroid cancer. The incidence of malignancy has been reported in Graves disease at 2% and as high as 9% in toxic multinodular goiters.^1,2

In evaluating patients with thyroid nodules and low thyroid stimulating hormone (TSH), which may indicate hyperthyroidism, the American Thyroid Association (ATA) recommends a radioiodine thyroid scan to determine whether a thyroid nodule is autonomous (hot) or nonfunctional (cold).³ Hot thyroid nodules are nodular areas of hyperfunctioning activity on radioiodine scan where tracer uptake is greater than the surrounding normal thyroid.

Historically, hot nodules have been associated with a low risk of malignancy and typically did not receive further ultrasound evaluation. However, recent studies have documented that the incidence of thyroid cancer in hot nodules may be underestimated. Mirfakhraee and colleagues performed a literature review in 2013 that revealed the prevalence of thyroid carcinoma in hot nodules managed by thyroidectomy ranged from 0% to 12.5% and averaged 3.1%.⁴ These findings may underestimate the prevalence of malignancy, because most hot nodules are not managed by thyroidectomy.

Given findings of hot nodules harboring malignancy, the authors investigated the role of thyroid ultrasound in patients with hyperthyroidism to identify suspicious features concerning for possible malignancies. The study objective was to estimate the prevalence of hot nodules with sonographic features concerning for malignancy in patients with hyperthyroidism in a Department of Veterans Affairs (VA) health care system.

Methods

This retrospective chart review consisted of 149,549 patients seen between January 2010 and December 2015 at the VA Northern California Health Care System (VANCHCS). The institutional review board approved the study and informed consent was waived.

Seven hundred sixty veterans were identified in the Computerized Patient Record System (CPRS) using the following ICD-9 codes: 242.9 (hyperthyroidism), 242.2 (toxic multinodular goiter), 242.3 (toxic nodular goiter), 242.1 (toxic uninodular goiter), and 241.9 (adenomatous goiter) (Figure 1). 

Manual review of thyroid ultrasound scans for suspicious characteristics concerning for thyroid carcinoma were based on the 2015 ATA Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer.³ Per the ATA guidelines, sonographic patterns that are highly suspicious for malignancy were solid hypoechoic nodule or solid hypoechoic component of a partially cystic nodule with one or more of the following features: irregular margins (infiltrative, microlobulated), microcalcifications, taller than wide on transverse view, and rim calcifications with small extrusive soft-tissue component. Sonographic patterns with intermediate suspicion were hypoechoic solid nodule with smooth margins without microcalcifications, extrathyroidal extension, or taller than wide shape.³

Results

Of the 760 identified veterans, 230 had thyroid ultrasounds, and 113 had radioiodine thyroid scans. Of these, 70 patients had both ultrasound and radioiodine thyroid scans. This cohort consisted of 84.3% (59) males and 15.7% women (11). Ages ranged from 32 to 93 (mean age 62.9) years.

A total of 121 nodules were identified among the remaining 43 patients (11 individuals with cold thyroid scans and 16 individuals with no nodules were excluded). Of the 121 nodules, 44 were hot nodules, 29 were coexisting nodules found in patients with hot nodules, and 48 were other nodules found in patients without coexisting hot nodules (Figure 2). 

Of the 44 hot nodules, the analysis identified 16 hot nodules with suspicious features on ultrasound and 28 nodules without suspicious findings. Breakdown of specific suspicious features included 11 that were solid hypoechoic, 3 nodules that had microcalcifications, and 2 nodules that had both characteristics (Table). 

Twelve patients had hot nodules with suspicious ultrasound findings. Of this group, 6 patients had no further workup, 1 patient was lost to follow-up, and 1 patient was planned for fine needle aspiration (FNA) biopsy. Four patients underwent FNA, and all results were benign.

Discussion

Although most veterans identified with hyperthyroidism did not undergo imaging studies, of those who did, a remarkable number had unexpected ultrasonographically suspicious nodules. Of the 44 hot nodules identified on radioiodine studies, 16 had suspicious ultrasound findings that raised concern for malignancy based on the most recent ATA guidelines. In contrast to recent studies that have suggested an increased incidence of thyroid carcinoma in hot nodules, no cancers were detected in this cohort.⁴ However, only 4 patients in this study underwent FNA.

Worth noting is that the most common suspicious feature found in this study’s cohort was hypoechoic solid nodules, which is a feature that has a sensitivity of 81% however a low specificity of 53% in detecting thyroid malignancy.⁵ This appearance also is found in 55% of benign thyroid nodules.⁶ The overlap of hypoechoic nodules as a feature in both benign and malignant thyroid nodules can present as a diagnostic challenge in differentiating between the two.

The 2015 ATA guideline recommends that low TSH warrants a radioiodine scan, and FNA should be considered for isofunctioning or nonfunctioning nodules with suspicious sonographic features. Hot nodules found on scintigraphy need no further cytologic evaluation because they are mostly benign.³ There is no clear stance on the use of ultrasound in hot nodules.

The answer to whether patients with hot nodules should undergo ultrasound still remains unclear. This study showed a surprising number of hot nodules with worrisome architecture found on ultrasound. However, whether that correlates to actual malignant findings remains unknown as most individuals in the cohort did not undergo biopsy. Also, given the high prevalence of suspicious findings, it may be difficult to use ultrasound as a diagnostic tool in patients with hot nodules as false positives may lead to unnecessary interventions such as biopsy.

Limitations

The patient population consisted mostly of men (84.3%) and cannot be applied to the general population. Thyroid nodules are 4 times more common in women than they are in men.⁷ Another limitation was the lack of data on patients’ radiation exposure while in military service or as civilians. Finally, as a retrospective study, there was unavoidable selection bias.

Conclusion

The prevalence of suspicious findings concerning for malignancy in hot nodules was 36.3% (16/44) based on the 2015 ATA guidelines. This study’s preliminary observation suggests that although ultrasound is a noninvasive and relatively inexpensive diagnostic modality, it has a limited role in the evaluation of hot nodules given the high prevalence of suspicious findings. Clinicians may still consider its use in patients who also have high-risk historic features. This was a thought-generating, retrospective study, and further prospective studies in larger populations are needed to validate the study’s results.

Skin cancer is one of the most prevalent conditions among VHA patients.¹ One of the largest U.S. health care systems, the VHA serves more than 9 million veterans.² In 2012, 4% of VHA patients had a diagnosis of keratinocyte carcinoma or actinic keratosis; 49,229 cases of basal cell carcinoma and 26,310 cases of squamous cell carcinoma were diagnosed.¹ With an aging veteran population and the incidence of skin cancers expected to increase, the development of cost-effective ways to provide easily accessible skin cancer treatments has become a priority for the VHA.

National Comprehensive Cancer Network (NCCN) guidelines recommend 3 types of surgical treatment for localized keratinocyte carcinoma: local destruction, wide local excision (WLE), and Mohs micrographic surgery (MMS). Tumors at low risk for recurrence may be treated with local destruction or WLE, and tumors at high risk may be treated with WLE or MMS.³

Mohs micrographic surgery involves staged narrow-margin excision with intraoperative tumor mapping and complete circumferential peripheral and deep margin assessment (CCPDMA). With the Mohs surgeon acting as both surgeon and dermatopathologist, it is possible to provide intraoperative correlation with the tissue bed and immediate additional margin resection precisely where needed. Relative to WLE, MMS yields improved histopathologic clearance rates and lower 5-year recurrence rates. It also provides improved preservation of normal tissue, optimized aesthetic outcomes, and high patient satisfaction.^4-7 All this is achieved in an outpatient setting with the patient under local anesthesia; therefore the cost of ambulatory surgical centers or hospital operating rooms are avoided.^5,8,9

The NCCN recommends WLE for high-risk tumors only if CCPDMA can be achieved. However, CCPDMA requires specialized surgical technique, tissue orientation, and pathology and is not equivalent to standard WLE with routine surgical pathology. Even with intraoperative bread-loafed frozen section analysis, WLE does not achieve the 100% margin assessment obtained with MMS.

In 2012, the American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery, and the American Society for Mohs Surgery developed the Mohs Appropriate Use Criteria,which are now widely used as part of the standard of care to determine which cases of skin cancer should be treated with MMS over other modalities.¹⁰ These criteria, which are based on both evidence and expert consensus, take into account tumor size, histology, location, and patient factors, such as immunosuppression.

Despite its established benefits, MMS has not been uniformly accessible to veterans seeking VHA care. In 2007, Karen and colleagues surveyed dermatology chiefs and staff dermatologists from 101 VHA hospitals to characterize veterans’ access to MMS and found MMS available at only 11 VHA sites in 9 states.¹¹ Further, access within the VHA was not evenly distributed across the U.S.

The VHA often makes payments, under “non-VA medical care” or “fee-basis care,” to providers in the community for services that the VHA is otherwise unable to provide. In 2014, Congress passed the Veterans Access, Choice, and Accountability Act and established the Veterans Choice program.^2,12 This program allows veterans to obtain medical services from providers outside the VHA, based on veteran wait time and place of residence.¹² The goal is to improve access. The present authors distinguish between 2 types of care: there are fee-based referrals managed and tracked by the VHA physician and the Veterans Choice for care without the diagnosing physician involvement or knowledge. In addition to expanding treatment options, the act called for reform within the VHA to improve resources and infrastructure needed to provide the best care for the veteran patient population.²

The authors conducted a study to identify current availability of MMS within the VHA and to provide a 10-year update to the survey findings of Karen and colleagues.¹¹ VHA facilities that offer MMS were surveyed to determine available resources and what is needed to provide MMS within the VHA. Also surveyed were VHA facilities that do not offer MMS to determine how VHA patients with skin cancer receive surgical care from non-VA providers or from other surgical specialties.

Related: Nivolumab Linked to Nephritis in Melanoma

Methods

This study, deemed exempt from review by the University of California San Francisco Institutional Review Board, was a survey of dermatology section and service chiefs across the VHA. Subjects were identified through conference calls with VHA dermatologists, searches of individual VHA websites, and requests on dermatology e-mail listservs and were invited by email to participate in the survey.

The Research Electronic Data Capture platform (REDCap; Vanderbilt University Medical Center) was used for survey creation, implementation, dissemination, and data storage. The survey had 6 sections: site information; MMS availability; Mohs surgeon, Mohs laboratory, and support staff; MMS care; patient referral; and Mohs surgeon recruitment.

Data were collected between June 20 and August 1, 2016. Collected VHA site information included name, location, description, and MMS availability. If MMS was available, data were collected on surgeon training and background, number of MMS cases in 2015, and facility and support staff. In addition, subjects rated statements about various aspects of care provided (eg, patient wait time, patient distance traveled) on a 6-point Likert scale: strongly disagree, moderately disagree, slightly disagree, slightly agree, moderately agree, or strongly agree. This section included both positive and negative statements.

If MMS was not available at the VHA site, data were collected on patient referrals, including location within or outside the VHA and patient use of the Veterans Choice program. Subjects also rated positive and negative statements about referral experiences on a Likert scale (eg, patient wait time, patient distance traveled).

Categorical data were summarized, means and standard deviations were calculated for nominal data, and data analysis was performed with Microsoft Excel (Redmond, WA).

Results

The authors identified and surveyed 74 dermatology service and section chiefs across the VHA. Of these chiefs, 52 (70.3%) completed the survey. Completed surveys represented 49 hospital sites and 3 community-based outpatient clinics (CBOCs), including an integrated community-based clinic-hospital.

Sites That Provided MMS

Of the 52 sites with a completed survey, 19 provided MMS. These 19 sites were in 13 states and the District of Columbia, and the majority were in major cities along the coasts. All 19 sites were hospital medical centers, not community-based outpatient clinics, and all provided MMS through the dermatology department. In 2015, an estimated 6,686 MMS cases were performed, or an average of 371 per site (range, 40-1,000 cases/site) or 4.9 MMS cases per day (range, 3-8). These 19 sites were divided by yearly volume: high (> 500 cases/y), medium (200-500 cases/y), and low (< 200 cases/y).

Physical Space. On average, each site used 2.89 patient rooms (SD, 1.1; range, 1-6) for MMS. The Table lists numbers of patient rooms based on case volume.

The MMS laboratory was adjacent to the surgical suite at 18 of the MMS sites and in the same building as the surgical suite, but not next to it, at 1 site. For their samples, 11 sites used an automated staining method, 7 used hand staining, and 2 used other methods (1 site used both automated and hand staining). Fourteen sites used hematoxlyin-eosin only, 1 used toluidine blue only, 3 used both hematoxlyin-eosin and toluidine blue, and 1 used MART-1 (melanoma antigen recognized by T cells 1) with hematoxlyin-eosin.

Related: Systemic Therapy in Metastatic Melanoma

Mohs Micrographic Surgeons. Sites with higher case volumes had more Mohs surgeons and more Mohs surgeons with VA appointments (captured as “eighths” or fraction of 8/8 full-time equivalent [FTE]). Information on fellowships and professional memberships was available for 30 Mohs surgeons: Ten (33.3%) were trained in fellowships accredited by both the American College of Mohs Surgery (ACMS) and the Accreditation Council for Graduate Medical Education (ACGME), 8 (26.7%) were trained in ACMS-recognized fellowships only, 7 (23.3%) were trained at ACGME-accredited fellowships only, 2 (6.7%) were trained elsewhere, and 3 (10.0%) had training listed as “uncertain.”

The majority of Mohs surgeons were members of professional societies, and many were members of more than one. Of the 30 Mohs surgeons, 24 (80.0%) were ACMS members, 5 (16.7%) were members of the American Society of Mohs Surgery, and 22 (73.3%) were members of the American Society of Dermatologic Surgery. Twenty-five (89.3%) were affiliated with an academic program.

Of the 30 surgeons, 19 (63.3%) were VHA employees hired by eighths, with an average eighths of 3.9 (SD, 2.7), or 49% of a FTE. Data on these surgeons’ pay tables and tiers were insufficient (only 3 provided the information). Of the other 11 surgeons, 10 (33.3%) were contracted, and 1 (3.3%) volunteered without compensation.

Support Staff. Of the 19 MMS sites, 17 (89.5%) used 1 histotechnician, and 2 (10.5%) used more than 1. Ten sites (52.6%) hired histotechnicians as contractors, 8 (42.1%) as employees, and 1 (5.3%) on a fee basis. In general, sites with higher case volumes had more nursing and support staff. Thirteen sites (68.4%) participated in the training of dermatology residents, and 5 sites (26.3%) trained Mohs fellows.

Wait Time Estimate. The survey also asked for estimates of the average amount of time patients waited for MMS. Of the 19 sites, 8 (42.1%) reported a wait time of less than 1 month, 10 (52.6%) reported 2 to 6 months, and 1 (5.3%) reported 7 months to 1 year. Seventeen (89.5%) of the 19 sites had a grading or triage system for expediting certain cancer types. At 7 sites, cases were prioritized on the basis of physician assessment; at 3 sites, aggressive or invasive squamous cell carcinoma received priority; other sites gave priority to patients with melanoma, patients with carcinoma near the nose or eye, organ transplant recipients, and other immunosuppressed patients.

Sites That Did Not Provide MMS

Of the 52 sites with a completed survey, 33 (63.5%) did not provide on-site MMS. Of these 33 sites, 28 (84.8%) used purchased care to refer patients to fee-basis non-VA dermatologists. In addition, 30 sites (90.9%) had patients activate Veterans Choice. Three sites referred patients to VA sites in another VISN.

Surgeon Recruitment

Five sites (9.6%) had an unfilled Mohs micrographic surgeon position. The average FTE of these unfilled positions was 0.6. One position had been open for less than 6 months, and the other 4 for more than 1 year. All 5 respondents with unfilled positions strongly agreed with the statement, “The position is unfilled because the salary is not competitive with the local market.”

Assessment of Care Provided

Respondents at sites that provided MMS rated various aspects of care (Figure 1). 

Respondents from sites that purchased MMS care from non-VA medical care rated surgery availability and ease of patient follow-up (Figure 2). 

Related: Getting a Better Picture of Skin Cancer

Discussion

Skin cancer is highly prevalent in the veteran patient population, and each year treatment by the VHA requires considerable spending.¹ The results of this cross-sectional survey characterize veterans’ access to MMS within the VHA and provide a 10-year update to the survey findings of Karen and colleagues.¹¹ Compared with their study, this survey offers a more granular description of practices and facilities as well as comparisons of VHA care with care purchased from outside sources. In outlining the state of MMS care within the VHA, this study highlights progress made and provides the updated data needed for continued efforts to optimize care and resource allocation for patients who require MMS within the VHA.

Although the number of VHA sites that provide MMS has increased over the past 10 years—from 11 sites in 9 states in 2007 to 19 sites in 13 states now—it is important to note that access to MMS care highly depends on geographic location.¹¹ The VHA sites that provide MMS are clustered in major cities along the coasts. Four states (California, Florida, New York, and Texas) had > 1 MMS site, whereas most other states did not have any. In addition, only 1 MMS site served all of the northwest U.S. To ensure the anonymity of survey respondents, the authors did not further characterize the regional distribution of MMS sites.

Despite the increase in MMS sites, the number of MMS cases performed within the VHA seemed to have decreased. An estimated 8,310 cases were performed within the VHA in 2006,which decreased to 6,686 in 2015.¹¹ Although these are estimates, the number of VHA cases likely decreased because of a rise in purchased care. Reviewing VHA electronic health records, Yoon and colleagues found that 19,681 MMS cases were performed either within the VHA or at non-VA medical care sites in 2012.¹ Although the proportions of MMS cases performed within and outside the VHA were not reported, clearly many veterans had MMS performed through the VHA in recent years, and a high percentage of these cases were external referrals. More study is needed to further characterize MMS care within the VHA and MMS care purchased.

The 19 sites that provided MMS were evenly divided by volume: high (> 500 cases/y), medium (200-500 cases/y), and low (< 200 cases/y). Case volume correlated with the numbers of surgeons, nurses, and support staff at each site. Number of patient rooms dedicated to MMS at each site was not correlated with case volume; however, not ascertaining the number of days per week MMS was performed may have contributed to the lack of observed correlation.The majority of Mohs surgeons (25; 89.3%) within the VHA were affiliated with academic programs, which may partly explain the uneven geographic distribution of VHA sites that provide MMS (dermatology residency programs typically are in larger cities). The majority of Mohs surgeons were fellowship-trained through the ACMS or the ACGME. As the ACGME first began accrediting fellowship programs in 2003, younger surgeons were more likely to have completed this fellowship. According to respondents from sites that did not provide MMS, noncompetitive VHA salaries might be a barrier to Mohs surgeon recruitment. If a shift to providing more MMS care within the VHA were desired, an effective strategy could be to raise surgeon salaries. Higher salaries would bring in more Mohs surgeons and thereby yield higher MMS case volumes at VHA sites.

However, whether MMS is best provided for veterans within the VHA or at outside sites through referrals warrants further study. More than 60% of sites provided access to MMS through purchased care, either by fee-basis/non-VA medical care referrals or by the patient-elected Veterans Choice program. According to 84.2% of respondents at MMS sites and 66.7% of respondents at non-MMS sites, patients received care within a reasonable amount of time. In addition, respondents at MMS sites estimated longer patient travel distance for surgery. Respondents reported being concerned about coordination of care and follow-up for patients who received MMS outside the VHA. Other than referrals to outside sites for MMS, current triage practices include referral to other surgical specialties within the VHA, predominantly ear, nose, and throat and plastic surgery, for WLE. Given that access to on-site MMS varies significantly by geographic location, on-site MMS may be preferable in some locations, and external referrals in others. Based on this study's findings, on-site MMS seems superior to external referrals in all respects except patient travel distance. More research is needed to determine the most cost-effective triage practices. One option would be to have each VISN develop a skin cancer care center of excellence that would assist providers in appropriate triage and management.

Limitations

A decade has passed since Karen and colleagues conducted their study on MMS within the VHA.¹¹ Data from this study suggest some progress has been made in improving veterans’ access to MMS. However, VHA sites that provide MMS are still predominantly located in large cities. In cases in which VHA providers refer patients to outside facilities, care coordination and follow-up are challenging. The present findings provide a basis for continuing VHA efforts to optimize resource allocation and improve longitudinal care for veterans who require MMS for skin cancer. Another area of interest is the comparative cost-effectiveness of MMS care provided within the VHA rather than at outside sites through purchased care. The answer may depend on geographic location, as MMS demand may be higher in some regions than that of others. For patients who receive MMS care outside the VHA, efforts should be made to improve communication and follow-up between VHA and external providers.

This study was limited in that it surveyed only those VHA sites with dermatology services or sections. It is possible, though unlikely, that MMS also was provided through nondermatology services. This study’s 70.3% response rate (52/74 dermatology chiefs) matched that of Karen and colleagues.¹¹ Nevertheless, given that 30% of the surveyed chiefs did not respond and that analysis was performed separately for 2 small subgroups, (19 VHA sites that provided on-site MMS and 33 VHA sites that did not), the present findings may not be representative of the VHA as a whole.

Another limitation was that the survey captured respondent estimates of surgical caseloads and resources. Confirmation of these estimates would require a review of internal medical records and workforce analyses, which was beyond the scope of this study.

Conclusion

Although some progress has been made over the past 10 years, access to MMS within the VHA remains limited. About one-third of VHA sites provide on-site MMS; the other two-thirds refer patients with skin cancer to MMS sites outside the VHA. According to their dermatology chiefs, VHA sites that provide MMS have adequate resources and staffing and acceptable wait times for surgery; the challenge is in patients’ long travel distances. At sites that do not provide MMS, patients have access to MMS as well, and acceptable wait times and travel distances; the challenge is in follow-up, especially with activation of the Veterans Choice program. Studies should focus on standardizing veterans’ care and improving their access to MMS.

Click here to read the digital edition.

Skin cancer is one of the most prevalent conditions among VHA patients.¹ One of the largest U.S. health care systems, the VHA serves more than 9 million veterans.² In 2012, 4% of VHA patients had a diagnosis of keratinocyte carcinoma or actinic keratosis; 49,229 cases of basal cell carcinoma and 26,310 cases of squamous cell carcinoma were diagnosed.¹ With an aging veteran population and the incidence of skin cancers expected to increase, the development of cost-effective ways to provide easily accessible skin cancer treatments has become a priority for the VHA.

National Comprehensive Cancer Network (NCCN) guidelines recommend 3 types of surgical treatment for localized keratinocyte carcinoma: local destruction, wide local excision (WLE), and Mohs micrographic surgery (MMS). Tumors at low risk for recurrence may be treated with local destruction or WLE, and tumors at high risk may be treated with WLE or MMS.³

Mohs micrographic surgery involves staged narrow-margin excision with intraoperative tumor mapping and complete circumferential peripheral and deep margin assessment (CCPDMA). With the Mohs surgeon acting as both surgeon and dermatopathologist, it is possible to provide intraoperative correlation with the tissue bed and immediate additional margin resection precisely where needed. Relative to WLE, MMS yields improved histopathologic clearance rates and lower 5-year recurrence rates. It also provides improved preservation of normal tissue, optimized aesthetic outcomes, and high patient satisfaction.^4-7 All this is achieved in an outpatient setting with the patient under local anesthesia; therefore the cost of ambulatory surgical centers or hospital operating rooms are avoided.^5,8,9

The NCCN recommends WLE for high-risk tumors only if CCPDMA can be achieved. However, CCPDMA requires specialized surgical technique, tissue orientation, and pathology and is not equivalent to standard WLE with routine surgical pathology. Even with intraoperative bread-loafed frozen section analysis, WLE does not achieve the 100% margin assessment obtained with MMS.

In 2012, the American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery, and the American Society for Mohs Surgery developed the Mohs Appropriate Use Criteria,which are now widely used as part of the standard of care to determine which cases of skin cancer should be treated with MMS over other modalities.¹⁰ These criteria, which are based on both evidence and expert consensus, take into account tumor size, histology, location, and patient factors, such as immunosuppression.

Despite its established benefits, MMS has not been uniformly accessible to veterans seeking VHA care. In 2007, Karen and colleagues surveyed dermatology chiefs and staff dermatologists from 101 VHA hospitals to characterize veterans’ access to MMS and found MMS available at only 11 VHA sites in 9 states.¹¹ Further, access within the VHA was not evenly distributed across the U.S.

The VHA often makes payments, under “non-VA medical care” or “fee-basis care,” to providers in the community for services that the VHA is otherwise unable to provide. In 2014, Congress passed the Veterans Access, Choice, and Accountability Act and established the Veterans Choice program.^2,12 This program allows veterans to obtain medical services from providers outside the VHA, based on veteran wait time and place of residence.¹² The goal is to improve access. The present authors distinguish between 2 types of care: there are fee-based referrals managed and tracked by the VHA physician and the Veterans Choice for care without the diagnosing physician involvement or knowledge. In addition to expanding treatment options, the act called for reform within the VHA to improve resources and infrastructure needed to provide the best care for the veteran patient population.²

The authors conducted a study to identify current availability of MMS within the VHA and to provide a 10-year update to the survey findings of Karen and colleagues.¹¹ VHA facilities that offer MMS were surveyed to determine available resources and what is needed to provide MMS within the VHA. Also surveyed were VHA facilities that do not offer MMS to determine how VHA patients with skin cancer receive surgical care from non-VA providers or from other surgical specialties.

Related: Nivolumab Linked to Nephritis in Melanoma

Methods

This study, deemed exempt from review by the University of California San Francisco Institutional Review Board, was a survey of dermatology section and service chiefs across the VHA. Subjects were identified through conference calls with VHA dermatologists, searches of individual VHA websites, and requests on dermatology e-mail listservs and were invited by email to participate in the survey.

The Research Electronic Data Capture platform (REDCap; Vanderbilt University Medical Center) was used for survey creation, implementation, dissemination, and data storage. The survey had 6 sections: site information; MMS availability; Mohs surgeon, Mohs laboratory, and support staff; MMS care; patient referral; and Mohs surgeon recruitment.

Data were collected between June 20 and August 1, 2016. Collected VHA site information included name, location, description, and MMS availability. If MMS was available, data were collected on surgeon training and background, number of MMS cases in 2015, and facility and support staff. In addition, subjects rated statements about various aspects of care provided (eg, patient wait time, patient distance traveled) on a 6-point Likert scale: strongly disagree, moderately disagree, slightly disagree, slightly agree, moderately agree, or strongly agree. This section included both positive and negative statements.

If MMS was not available at the VHA site, data were collected on patient referrals, including location within or outside the VHA and patient use of the Veterans Choice program. Subjects also rated positive and negative statements about referral experiences on a Likert scale (eg, patient wait time, patient distance traveled).

Categorical data were summarized, means and standard deviations were calculated for nominal data, and data analysis was performed with Microsoft Excel (Redmond, WA).

Results

The authors identified and surveyed 74 dermatology service and section chiefs across the VHA. Of these chiefs, 52 (70.3%) completed the survey. Completed surveys represented 49 hospital sites and 3 community-based outpatient clinics (CBOCs), including an integrated community-based clinic-hospital.

Sites That Provided MMS

Of the 52 sites with a completed survey, 19 provided MMS. These 19 sites were in 13 states and the District of Columbia, and the majority were in major cities along the coasts. All 19 sites were hospital medical centers, not community-based outpatient clinics, and all provided MMS through the dermatology department. In 2015, an estimated 6,686 MMS cases were performed, or an average of 371 per site (range, 40-1,000 cases/site) or 4.9 MMS cases per day (range, 3-8). These 19 sites were divided by yearly volume: high (> 500 cases/y), medium (200-500 cases/y), and low (< 200 cases/y).

Physical Space. On average, each site used 2.89 patient rooms (SD, 1.1; range, 1-6) for MMS. The Table lists numbers of patient rooms based on case volume.

The MMS laboratory was adjacent to the surgical suite at 18 of the MMS sites and in the same building as the surgical suite, but not next to it, at 1 site. For their samples, 11 sites used an automated staining method, 7 used hand staining, and 2 used other methods (1 site used both automated and hand staining). Fourteen sites used hematoxlyin-eosin only, 1 used toluidine blue only, 3 used both hematoxlyin-eosin and toluidine blue, and 1 used MART-1 (melanoma antigen recognized by T cells 1) with hematoxlyin-eosin.

Related: Systemic Therapy in Metastatic Melanoma

Mohs Micrographic Surgeons. Sites with higher case volumes had more Mohs surgeons and more Mohs surgeons with VA appointments (captured as “eighths” or fraction of 8/8 full-time equivalent [FTE]). Information on fellowships and professional memberships was available for 30 Mohs surgeons: Ten (33.3%) were trained in fellowships accredited by both the American College of Mohs Surgery (ACMS) and the Accreditation Council for Graduate Medical Education (ACGME), 8 (26.7%) were trained in ACMS-recognized fellowships only, 7 (23.3%) were trained at ACGME-accredited fellowships only, 2 (6.7%) were trained elsewhere, and 3 (10.0%) had training listed as “uncertain.”

The majority of Mohs surgeons were members of professional societies, and many were members of more than one. Of the 30 Mohs surgeons, 24 (80.0%) were ACMS members, 5 (16.7%) were members of the American Society of Mohs Surgery, and 22 (73.3%) were members of the American Society of Dermatologic Surgery. Twenty-five (89.3%) were affiliated with an academic program.

Of the 30 surgeons, 19 (63.3%) were VHA employees hired by eighths, with an average eighths of 3.9 (SD, 2.7), or 49% of a FTE. Data on these surgeons’ pay tables and tiers were insufficient (only 3 provided the information). Of the other 11 surgeons, 10 (33.3%) were contracted, and 1 (3.3%) volunteered without compensation.

Support Staff. Of the 19 MMS sites, 17 (89.5%) used 1 histotechnician, and 2 (10.5%) used more than 1. Ten sites (52.6%) hired histotechnicians as contractors, 8 (42.1%) as employees, and 1 (5.3%) on a fee basis. In general, sites with higher case volumes had more nursing and support staff. Thirteen sites (68.4%) participated in the training of dermatology residents, and 5 sites (26.3%) trained Mohs fellows.

Wait Time Estimate. The survey also asked for estimates of the average amount of time patients waited for MMS. Of the 19 sites, 8 (42.1%) reported a wait time of less than 1 month, 10 (52.6%) reported 2 to 6 months, and 1 (5.3%) reported 7 months to 1 year. Seventeen (89.5%) of the 19 sites had a grading or triage system for expediting certain cancer types. At 7 sites, cases were prioritized on the basis of physician assessment; at 3 sites, aggressive or invasive squamous cell carcinoma received priority; other sites gave priority to patients with melanoma, patients with carcinoma near the nose or eye, organ transplant recipients, and other immunosuppressed patients.

Sites That Did Not Provide MMS

Of the 52 sites with a completed survey, 33 (63.5%) did not provide on-site MMS. Of these 33 sites, 28 (84.8%) used purchased care to refer patients to fee-basis non-VA dermatologists. In addition, 30 sites (90.9%) had patients activate Veterans Choice. Three sites referred patients to VA sites in another VISN.

Surgeon Recruitment

Five sites (9.6%) had an unfilled Mohs micrographic surgeon position. The average FTE of these unfilled positions was 0.6. One position had been open for less than 6 months, and the other 4 for more than 1 year. All 5 respondents with unfilled positions strongly agreed with the statement, “The position is unfilled because the salary is not competitive with the local market.”

Assessment of Care Provided

Respondents at sites that provided MMS rated various aspects of care (Figure 1). 

Respondents from sites that purchased MMS care from non-VA medical care rated surgery availability and ease of patient follow-up (Figure 2). 

Related: Getting a Better Picture of Skin Cancer

Discussion

Skin cancer is highly prevalent in the veteran patient population, and each year treatment by the VHA requires considerable spending.¹ The results of this cross-sectional survey characterize veterans’ access to MMS within the VHA and provide a 10-year update to the survey findings of Karen and colleagues.¹¹ Compared with their study, this survey offers a more granular description of practices and facilities as well as comparisons of VHA care with care purchased from outside sources. In outlining the state of MMS care within the VHA, this study highlights progress made and provides the updated data needed for continued efforts to optimize care and resource allocation for patients who require MMS within the VHA.

Although the number of VHA sites that provide MMS has increased over the past 10 years—from 11 sites in 9 states in 2007 to 19 sites in 13 states now—it is important to note that access to MMS care highly depends on geographic location.¹¹ The VHA sites that provide MMS are clustered in major cities along the coasts. Four states (California, Florida, New York, and Texas) had > 1 MMS site, whereas most other states did not have any. In addition, only 1 MMS site served all of the northwest U.S. To ensure the anonymity of survey respondents, the authors did not further characterize the regional distribution of MMS sites.

Despite the increase in MMS sites, the number of MMS cases performed within the VHA seemed to have decreased. An estimated 8,310 cases were performed within the VHA in 2006,which decreased to 6,686 in 2015.¹¹ Although these are estimates, the number of VHA cases likely decreased because of a rise in purchased care. Reviewing VHA electronic health records, Yoon and colleagues found that 19,681 MMS cases were performed either within the VHA or at non-VA medical care sites in 2012.¹ Although the proportions of MMS cases performed within and outside the VHA were not reported, clearly many veterans had MMS performed through the VHA in recent years, and a high percentage of these cases were external referrals. More study is needed to further characterize MMS care within the VHA and MMS care purchased.

The 19 sites that provided MMS were evenly divided by volume: high (> 500 cases/y), medium (200-500 cases/y), and low (< 200 cases/y). Case volume correlated with the numbers of surgeons, nurses, and support staff at each site. Number of patient rooms dedicated to MMS at each site was not correlated with case volume; however, not ascertaining the number of days per week MMS was performed may have contributed to the lack of observed correlation.The majority of Mohs surgeons (25; 89.3%) within the VHA were affiliated with academic programs, which may partly explain the uneven geographic distribution of VHA sites that provide MMS (dermatology residency programs typically are in larger cities). The majority of Mohs surgeons were fellowship-trained through the ACMS or the ACGME. As the ACGME first began accrediting fellowship programs in 2003, younger surgeons were more likely to have completed this fellowship. According to respondents from sites that did not provide MMS, noncompetitive VHA salaries might be a barrier to Mohs surgeon recruitment. If a shift to providing more MMS care within the VHA were desired, an effective strategy could be to raise surgeon salaries. Higher salaries would bring in more Mohs surgeons and thereby yield higher MMS case volumes at VHA sites.

However, whether MMS is best provided for veterans within the VHA or at outside sites through referrals warrants further study. More than 60% of sites provided access to MMS through purchased care, either by fee-basis/non-VA medical care referrals or by the patient-elected Veterans Choice program. According to 84.2% of respondents at MMS sites and 66.7% of respondents at non-MMS sites, patients received care within a reasonable amount of time. In addition, respondents at MMS sites estimated longer patient travel distance for surgery. Respondents reported being concerned about coordination of care and follow-up for patients who received MMS outside the VHA. Other than referrals to outside sites for MMS, current triage practices include referral to other surgical specialties within the VHA, predominantly ear, nose, and throat and plastic surgery, for WLE. Given that access to on-site MMS varies significantly by geographic location, on-site MMS may be preferable in some locations, and external referrals in others. Based on this study's findings, on-site MMS seems superior to external referrals in all respects except patient travel distance. More research is needed to determine the most cost-effective triage practices. One option would be to have each VISN develop a skin cancer care center of excellence that would assist providers in appropriate triage and management.

Limitations

A decade has passed since Karen and colleagues conducted their study on MMS within the VHA.¹¹ Data from this study suggest some progress has been made in improving veterans’ access to MMS. However, VHA sites that provide MMS are still predominantly located in large cities. In cases in which VHA providers refer patients to outside facilities, care coordination and follow-up are challenging. The present findings provide a basis for continuing VHA efforts to optimize resource allocation and improve longitudinal care for veterans who require MMS for skin cancer. Another area of interest is the comparative cost-effectiveness of MMS care provided within the VHA rather than at outside sites through purchased care. The answer may depend on geographic location, as MMS demand may be higher in some regions than that of others. For patients who receive MMS care outside the VHA, efforts should be made to improve communication and follow-up between VHA and external providers.

This study was limited in that it surveyed only those VHA sites with dermatology services or sections. It is possible, though unlikely, that MMS also was provided through nondermatology services. This study’s 70.3% response rate (52/74 dermatology chiefs) matched that of Karen and colleagues.¹¹ Nevertheless, given that 30% of the surveyed chiefs did not respond and that analysis was performed separately for 2 small subgroups, (19 VHA sites that provided on-site MMS and 33 VHA sites that did not), the present findings may not be representative of the VHA as a whole.

Another limitation was that the survey captured respondent estimates of surgical caseloads and resources. Confirmation of these estimates would require a review of internal medical records and workforce analyses, which was beyond the scope of this study.

Conclusion

Although some progress has been made over the past 10 years, access to MMS within the VHA remains limited. About one-third of VHA sites provide on-site MMS; the other two-thirds refer patients with skin cancer to MMS sites outside the VHA. According to their dermatology chiefs, VHA sites that provide MMS have adequate resources and staffing and acceptable wait times for surgery; the challenge is in patients’ long travel distances. At sites that do not provide MMS, patients have access to MMS as well, and acceptable wait times and travel distances; the challenge is in follow-up, especially with activation of the Veterans Choice program. Studies should focus on standardizing veterans’ care and improving their access to MMS.

Click here to read the digital edition.

Skin cancer is one of the most prevalent conditions among VHA patients.¹ One of the largest U.S. health care systems, the VHA serves more than 9 million veterans.² In 2012, 4% of VHA patients had a diagnosis of keratinocyte carcinoma or actinic keratosis; 49,229 cases of basal cell carcinoma and 26,310 cases of squamous cell carcinoma were diagnosed.¹ With an aging veteran population and the incidence of skin cancers expected to increase, the development of cost-effective ways to provide easily accessible skin cancer treatments has become a priority for the VHA.

National Comprehensive Cancer Network (NCCN) guidelines recommend 3 types of surgical treatment for localized keratinocyte carcinoma: local destruction, wide local excision (WLE), and Mohs micrographic surgery (MMS). Tumors at low risk for recurrence may be treated with local destruction or WLE, and tumors at high risk may be treated with WLE or MMS.³

Mohs micrographic surgery involves staged narrow-margin excision with intraoperative tumor mapping and complete circumferential peripheral and deep margin assessment (CCPDMA). With the Mohs surgeon acting as both surgeon and dermatopathologist, it is possible to provide intraoperative correlation with the tissue bed and immediate additional margin resection precisely where needed. Relative to WLE, MMS yields improved histopathologic clearance rates and lower 5-year recurrence rates. It also provides improved preservation of normal tissue, optimized aesthetic outcomes, and high patient satisfaction.^4-7 All this is achieved in an outpatient setting with the patient under local anesthesia; therefore the cost of ambulatory surgical centers or hospital operating rooms are avoided.^5,8,9

The NCCN recommends WLE for high-risk tumors only if CCPDMA can be achieved. However, CCPDMA requires specialized surgical technique, tissue orientation, and pathology and is not equivalent to standard WLE with routine surgical pathology. Even with intraoperative bread-loafed frozen section analysis, WLE does not achieve the 100% margin assessment obtained with MMS.

In 2012, the American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery, and the American Society for Mohs Surgery developed the Mohs Appropriate Use Criteria,which are now widely used as part of the standard of care to determine which cases of skin cancer should be treated with MMS over other modalities.¹⁰ These criteria, which are based on both evidence and expert consensus, take into account tumor size, histology, location, and patient factors, such as immunosuppression.

Despite its established benefits, MMS has not been uniformly accessible to veterans seeking VHA care. In 2007, Karen and colleagues surveyed dermatology chiefs and staff dermatologists from 101 VHA hospitals to characterize veterans’ access to MMS and found MMS available at only 11 VHA sites in 9 states.¹¹ Further, access within the VHA was not evenly distributed across the U.S.

The VHA often makes payments, under “non-VA medical care” or “fee-basis care,” to providers in the community for services that the VHA is otherwise unable to provide. In 2014, Congress passed the Veterans Access, Choice, and Accountability Act and established the Veterans Choice program.^2,12 This program allows veterans to obtain medical services from providers outside the VHA, based on veteran wait time and place of residence.¹² The goal is to improve access. The present authors distinguish between 2 types of care: there are fee-based referrals managed and tracked by the VHA physician and the Veterans Choice for care without the diagnosing physician involvement or knowledge. In addition to expanding treatment options, the act called for reform within the VHA to improve resources and infrastructure needed to provide the best care for the veteran patient population.²

The authors conducted a study to identify current availability of MMS within the VHA and to provide a 10-year update to the survey findings of Karen and colleagues.¹¹ VHA facilities that offer MMS were surveyed to determine available resources and what is needed to provide MMS within the VHA. Also surveyed were VHA facilities that do not offer MMS to determine how VHA patients with skin cancer receive surgical care from non-VA providers or from other surgical specialties.

Related: Nivolumab Linked to Nephritis in Melanoma

Methods

This study, deemed exempt from review by the University of California San Francisco Institutional Review Board, was a survey of dermatology section and service chiefs across the VHA. Subjects were identified through conference calls with VHA dermatologists, searches of individual VHA websites, and requests on dermatology e-mail listservs and were invited by email to participate in the survey.

The Research Electronic Data Capture platform (REDCap; Vanderbilt University Medical Center) was used for survey creation, implementation, dissemination, and data storage. The survey had 6 sections: site information; MMS availability; Mohs surgeon, Mohs laboratory, and support staff; MMS care; patient referral; and Mohs surgeon recruitment.

Data were collected between June 20 and August 1, 2016. Collected VHA site information included name, location, description, and MMS availability. If MMS was available, data were collected on surgeon training and background, number of MMS cases in 2015, and facility and support staff. In addition, subjects rated statements about various aspects of care provided (eg, patient wait time, patient distance traveled) on a 6-point Likert scale: strongly disagree, moderately disagree, slightly disagree, slightly agree, moderately agree, or strongly agree. This section included both positive and negative statements.

If MMS was not available at the VHA site, data were collected on patient referrals, including location within or outside the VHA and patient use of the Veterans Choice program. Subjects also rated positive and negative statements about referral experiences on a Likert scale (eg, patient wait time, patient distance traveled).

Categorical data were summarized, means and standard deviations were calculated for nominal data, and data analysis was performed with Microsoft Excel (Redmond, WA).

Results

The authors identified and surveyed 74 dermatology service and section chiefs across the VHA. Of these chiefs, 52 (70.3%) completed the survey. Completed surveys represented 49 hospital sites and 3 community-based outpatient clinics (CBOCs), including an integrated community-based clinic-hospital.

Sites That Provided MMS

Of the 52 sites with a completed survey, 19 provided MMS. These 19 sites were in 13 states and the District of Columbia, and the majority were in major cities along the coasts. All 19 sites were hospital medical centers, not community-based outpatient clinics, and all provided MMS through the dermatology department. In 2015, an estimated 6,686 MMS cases were performed, or an average of 371 per site (range, 40-1,000 cases/site) or 4.9 MMS cases per day (range, 3-8). These 19 sites were divided by yearly volume: high (> 500 cases/y), medium (200-500 cases/y), and low (< 200 cases/y).

Physical Space. On average, each site used 2.89 patient rooms (SD, 1.1; range, 1-6) for MMS. The Table lists numbers of patient rooms based on case volume.

The MMS laboratory was adjacent to the surgical suite at 18 of the MMS sites and in the same building as the surgical suite, but not next to it, at 1 site. For their samples, 11 sites used an automated staining method, 7 used hand staining, and 2 used other methods (1 site used both automated and hand staining). Fourteen sites used hematoxlyin-eosin only, 1 used toluidine blue only, 3 used both hematoxlyin-eosin and toluidine blue, and 1 used MART-1 (melanoma antigen recognized by T cells 1) with hematoxlyin-eosin.

Related: Systemic Therapy in Metastatic Melanoma

Mohs Micrographic Surgeons. Sites with higher case volumes had more Mohs surgeons and more Mohs surgeons with VA appointments (captured as “eighths” or fraction of 8/8 full-time equivalent [FTE]). Information on fellowships and professional memberships was available for 30 Mohs surgeons: Ten (33.3%) were trained in fellowships accredited by both the American College of Mohs Surgery (ACMS) and the Accreditation Council for Graduate Medical Education (ACGME), 8 (26.7%) were trained in ACMS-recognized fellowships only, 7 (23.3%) were trained at ACGME-accredited fellowships only, 2 (6.7%) were trained elsewhere, and 3 (10.0%) had training listed as “uncertain.”

The majority of Mohs surgeons were members of professional societies, and many were members of more than one. Of the 30 Mohs surgeons, 24 (80.0%) were ACMS members, 5 (16.7%) were members of the American Society of Mohs Surgery, and 22 (73.3%) were members of the American Society of Dermatologic Surgery. Twenty-five (89.3%) were affiliated with an academic program.

Of the 30 surgeons, 19 (63.3%) were VHA employees hired by eighths, with an average eighths of 3.9 (SD, 2.7), or 49% of a FTE. Data on these surgeons’ pay tables and tiers were insufficient (only 3 provided the information). Of the other 11 surgeons, 10 (33.3%) were contracted, and 1 (3.3%) volunteered without compensation.

Support Staff. Of the 19 MMS sites, 17 (89.5%) used 1 histotechnician, and 2 (10.5%) used more than 1. Ten sites (52.6%) hired histotechnicians as contractors, 8 (42.1%) as employees, and 1 (5.3%) on a fee basis. In general, sites with higher case volumes had more nursing and support staff. Thirteen sites (68.4%) participated in the training of dermatology residents, and 5 sites (26.3%) trained Mohs fellows.

Wait Time Estimate. The survey also asked for estimates of the average amount of time patients waited for MMS. Of the 19 sites, 8 (42.1%) reported a wait time of less than 1 month, 10 (52.6%) reported 2 to 6 months, and 1 (5.3%) reported 7 months to 1 year. Seventeen (89.5%) of the 19 sites had a grading or triage system for expediting certain cancer types. At 7 sites, cases were prioritized on the basis of physician assessment; at 3 sites, aggressive or invasive squamous cell carcinoma received priority; other sites gave priority to patients with melanoma, patients with carcinoma near the nose or eye, organ transplant recipients, and other immunosuppressed patients.

Sites That Did Not Provide MMS

Of the 52 sites with a completed survey, 33 (63.5%) did not provide on-site MMS. Of these 33 sites, 28 (84.8%) used purchased care to refer patients to fee-basis non-VA dermatologists. In addition, 30 sites (90.9%) had patients activate Veterans Choice. Three sites referred patients to VA sites in another VISN.

Surgeon Recruitment

Five sites (9.6%) had an unfilled Mohs micrographic surgeon position. The average FTE of these unfilled positions was 0.6. One position had been open for less than 6 months, and the other 4 for more than 1 year. All 5 respondents with unfilled positions strongly agreed with the statement, “The position is unfilled because the salary is not competitive with the local market.”

Assessment of Care Provided

Respondents at sites that provided MMS rated various aspects of care (Figure 1). 

Respondents from sites that purchased MMS care from non-VA medical care rated surgery availability and ease of patient follow-up (Figure 2). 

Related: Getting a Better Picture of Skin Cancer

Discussion

Skin cancer is highly prevalent in the veteran patient population, and each year treatment by the VHA requires considerable spending.¹ The results of this cross-sectional survey characterize veterans’ access to MMS within the VHA and provide a 10-year update to the survey findings of Karen and colleagues.¹¹ Compared with their study, this survey offers a more granular description of practices and facilities as well as comparisons of VHA care with care purchased from outside sources. In outlining the state of MMS care within the VHA, this study highlights progress made and provides the updated data needed for continued efforts to optimize care and resource allocation for patients who require MMS within the VHA.

Although the number of VHA sites that provide MMS has increased over the past 10 years—from 11 sites in 9 states in 2007 to 19 sites in 13 states now—it is important to note that access to MMS care highly depends on geographic location.¹¹ The VHA sites that provide MMS are clustered in major cities along the coasts. Four states (California, Florida, New York, and Texas) had > 1 MMS site, whereas most other states did not have any. In addition, only 1 MMS site served all of the northwest U.S. To ensure the anonymity of survey respondents, the authors did not further characterize the regional distribution of MMS sites.

Despite the increase in MMS sites, the number of MMS cases performed within the VHA seemed to have decreased. An estimated 8,310 cases were performed within the VHA in 2006,which decreased to 6,686 in 2015.¹¹ Although these are estimates, the number of VHA cases likely decreased because of a rise in purchased care. Reviewing VHA electronic health records, Yoon and colleagues found that 19,681 MMS cases were performed either within the VHA or at non-VA medical care sites in 2012.¹ Although the proportions of MMS cases performed within and outside the VHA were not reported, clearly many veterans had MMS performed through the VHA in recent years, and a high percentage of these cases were external referrals. More study is needed to further characterize MMS care within the VHA and MMS care purchased.

The 19 sites that provided MMS were evenly divided by volume: high (> 500 cases/y), medium (200-500 cases/y), and low (< 200 cases/y). Case volume correlated with the numbers of surgeons, nurses, and support staff at each site. Number of patient rooms dedicated to MMS at each site was not correlated with case volume; however, not ascertaining the number of days per week MMS was performed may have contributed to the lack of observed correlation.The majority of Mohs surgeons (25; 89.3%) within the VHA were affiliated with academic programs, which may partly explain the uneven geographic distribution of VHA sites that provide MMS (dermatology residency programs typically are in larger cities). The majority of Mohs surgeons were fellowship-trained through the ACMS or the ACGME. As the ACGME first began accrediting fellowship programs in 2003, younger surgeons were more likely to have completed this fellowship. According to respondents from sites that did not provide MMS, noncompetitive VHA salaries might be a barrier to Mohs surgeon recruitment. If a shift to providing more MMS care within the VHA were desired, an effective strategy could be to raise surgeon salaries. Higher salaries would bring in more Mohs surgeons and thereby yield higher MMS case volumes at VHA sites.

However, whether MMS is best provided for veterans within the VHA or at outside sites through referrals warrants further study. More than 60% of sites provided access to MMS through purchased care, either by fee-basis/non-VA medical care referrals or by the patient-elected Veterans Choice program. According to 84.2% of respondents at MMS sites and 66.7% of respondents at non-MMS sites, patients received care within a reasonable amount of time. In addition, respondents at MMS sites estimated longer patient travel distance for surgery. Respondents reported being concerned about coordination of care and follow-up for patients who received MMS outside the VHA. Other than referrals to outside sites for MMS, current triage practices include referral to other surgical specialties within the VHA, predominantly ear, nose, and throat and plastic surgery, for WLE. Given that access to on-site MMS varies significantly by geographic location, on-site MMS may be preferable in some locations, and external referrals in others. Based on this study's findings, on-site MMS seems superior to external referrals in all respects except patient travel distance. More research is needed to determine the most cost-effective triage practices. One option would be to have each VISN develop a skin cancer care center of excellence that would assist providers in appropriate triage and management.

Limitations

A decade has passed since Karen and colleagues conducted their study on MMS within the VHA.¹¹ Data from this study suggest some progress has been made in improving veterans’ access to MMS. However, VHA sites that provide MMS are still predominantly located in large cities. In cases in which VHA providers refer patients to outside facilities, care coordination and follow-up are challenging. The present findings provide a basis for continuing VHA efforts to optimize resource allocation and improve longitudinal care for veterans who require MMS for skin cancer. Another area of interest is the comparative cost-effectiveness of MMS care provided within the VHA rather than at outside sites through purchased care. The answer may depend on geographic location, as MMS demand may be higher in some regions than that of others. For patients who receive MMS care outside the VHA, efforts should be made to improve communication and follow-up between VHA and external providers.

This study was limited in that it surveyed only those VHA sites with dermatology services or sections. It is possible, though unlikely, that MMS also was provided through nondermatology services. This study’s 70.3% response rate (52/74 dermatology chiefs) matched that of Karen and colleagues.¹¹ Nevertheless, given that 30% of the surveyed chiefs did not respond and that analysis was performed separately for 2 small subgroups, (19 VHA sites that provided on-site MMS and 33 VHA sites that did not), the present findings may not be representative of the VHA as a whole.

Another limitation was that the survey captured respondent estimates of surgical caseloads and resources. Confirmation of these estimates would require a review of internal medical records and workforce analyses, which was beyond the scope of this study.

Conclusion

Although some progress has been made over the past 10 years, access to MMS within the VHA remains limited. About one-third of VHA sites provide on-site MMS; the other two-thirds refer patients with skin cancer to MMS sites outside the VHA. According to their dermatology chiefs, VHA sites that provide MMS have adequate resources and staffing and acceptable wait times for surgery; the challenge is in patients’ long travel distances. At sites that do not provide MMS, patients have access to MMS as well, and acceptable wait times and travel distances; the challenge is in follow-up, especially with activation of the Veterans Choice program. Studies should focus on standardizing veterans’ care and improving their access to MMS.

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