PD01-SURGERY

P100The use of Mohs micrographic surgery for the treatment of nonmelanomaskin cancers in the Medicare population

KateViola,MD,MHS,YaleUniversityCollegeofMedicine,NewHaven,CT,UnitedStates;Cary Gross, MD, MPH, Yale University School of Medicine, New Haven, CT, UnitedStates; Ryan Turner, MD, Albert Einstein College of Medicine, Bronx, NY, United States;Whitney Tolpinrud, Yale University School of Medicine, New Haven, CT, United States

Background: Mohs micrographic surgery (MMS) is associated with low recurrencerates and optimal preservation of normal tissue. The American Academy ofDermatology has set forth guidelines for the use of MMS in patients with skincancer where adequate excision and negative margins is essential. However, little isknown about current physician practices for Medicare patients with nonmelanomaskin cancers (NMSC) undergoing surgical resection.

Objective: To identify Medicare utilization rates of surgical care with MMS and othersurgical intervention for the treatment of NMSC over time. To identify patient andtumor characteristics and geographic variation in treatment.

Methods: We performed a retrospective review of patients receiving surgicalintervention for the treatment of NMSC from 2001 through 2006 using a 5% randomsample of Medicare claims data from the Surveillance, Epidemiology and End Results(SEER) database, representing 26% of the US population. Data were summarizedusing descriptive characteristics including age, gender, race, tumor anatomy, marginsize, and geographic region.

Results: There were 26,931 persons surgically treated for NMSC, of which 9,802(36%) received MMS and 17,129 (64%) had other surgical intervention. The totalproportion of MMS increased from 12% to 20% yearly. Fifty-seven percent (5603) ofpatients receiving MMS were male with the median age range from 75 to 79 years;78% (8216) of all MMS were completed on the head or neck. The majority of all MMSwere performed in the West (52%) with areas in California having a high percentageof MMS when compared to other surgical excision type (Los Angeles, 42%; SanJose/Monterey, 36%; greater California, 38%); cities including Atlanta (45%) andDetroit (41%) also had comparable MMS utilization rates. Areas with lower patientpercentages treated with MMS included Louisiana (11%), Hawaii (19%), and NewMexico (23%). In our bivariate analysis, age, race, region country and lesion locationwere associated with MMS for skin cancer treatment (all P\.001).

Conclusion: Our research is the first to our knowledge to examine population-basedpatterns of MMS treatment in Medicare patients. Although our study demonstrates asteady increase in the utilization of MMS for NMSC, we have identified disparities inutilization associated with patient and physician demographics with this treatmenttype, particularly in geographic variation throughout the country.

FEBRUARY

cial support: None identified.

Commer

P101Association between Mohs surgery wait times and surgical defect size inpatients with squamous cell or basal cell carcinoma of the skin

Joseph Diehl, Division of Dermatology, David Geffen School of Medicine atUCLA, Los Angeles, CA, United States; Li-Jung Liang, PhD, West Los AngelesVeterans Administration Medical Center, Los Angeles, CA, United States; LisaAquino, MD, MS, Kaiser Permanente Los Angeles Medical Center, Los Angeles,CA, United States; Melvin Chiu, MD, MPH, Division of Dermatology, David GeffenSchool of Medicine at UCLA, Los Angeles, CA, United States

Background: Nonmelanoma skin cancers (NMSCs) can have high morbidity but arerarely fatal. Lack of impact on quality of life and lack of availability of surgeons maylead to delays in seeking or obtaining treatment for NMSC. However, data areextremely limited on effects of treatment delay on NMSC outcomes.

Objective: Using post-Mohsmicrographic surgery (MMS) defect size as a proxy for finaltumor size, we sought to determine if increasing time from biopsy toMMS led to largertumor sizes.Wealsoanalyzed risk factors thatmayhave led tomore rapid tumorgrowth.

Methods: Patients who underwent MMS for biopsy-proven NMSC between 2004 and2007 were retrospectively identified. Those lacking measurements of the diameterof the presenting lesion or final MMS defect were excluded. Delay and diameterincrease were calculated from presentation to MMS defect. Risk factors examinedwere tumor location, size, histologic type, if treating a recurrence, and if the patientwas a diabetic, smoker, or alcoholic. Linear regression was used to analyze change indiameter over time, and 2-sample t tests were used for risk factors.

Results: From 531 MMS excisions, 259 lesions qualified. The mean age was 69.9years, with 99% of the lesions being fromwhite males. Mean wait timewas 142 days,mean diameter at presentation was 0.9 cm (37% $ 1 cm), and the mean MMS defectwas 1.8 cm. Tumorswere 59 SCC, 200 BCC, and 22 recurrences. Thirty-nine patientswere diabetics, 43 smoked, and 25 were alcoholics. There was no statisticaldifference in increase of tumor size related to time delays of up to 1 year, nor wereany factors associated with increased or decreased growth rates.

Discussion: Our data gives no evidence that delays of up to 1 year from diagnosis toMMS affect final defect size. In contrast to previous studies, lesions [1 cm indiameter at presentation and recurrent NMSCs did not result in greater sizeincreases. Factors which are associated with altered risks of NMSC also do notappear to affect the kinetics of growth. Our data suggests the possibility of an initialrapid growth of tumors which plateaus and proceeds at a much slower pacethereafter. Further prospective study is needed to examine this hypothesis.Limitations of our study are its retrospective nature, homogenous demographics,and lack of data on 5-year recurrence. Histologic subtypes, considered a risk factor oftumor progression, were not available in most cases.

cial support: None identified.

Commer

2011

P102Safety during dermatologic procedures and surgeries: A survey ofphysician injuries and prevention strategies

Jacqueline Goulart, The Mount Sinai School of Medicine, New York, NY, UnitedStates; Jacob Levitt, MD, The Mount Sinai School of Medicine, New York, NY,United States; Susan Oliveria, MPH, Memorial Sloan-Kettering Cancer Center,New York, NY, United States

Background: Dermatologists perform a high volume of procedures and surgeriesusing sharp instruments, thereby increasing their risk for injury. Few studies havebeen conducted on the prevalence of these injuries in the clinical practice setting.

Objectives: We conducted a survey study of dermatology residents and attendingphysicians to quantify the frequency and type of injuries and to further understandthe reporting of these injuries and safety techniques utilized.

Results: A total of 452 residents and 127 attendings answered the survey (overallresponse rate, 41%). Eighty-five percent (n¼ 494) of respondents reported an injury.The majority had been injured 1 to 5 times. Despite the high rate of injury, 478 (83%)reported that safe technique was adequately emphasized during their training.Physicians who reported never being injured were more likely to be satisfied withtheir safety education compared with physicians who reported more than oneinjury. Of those who had sustained an injury (n ¼ 494), 343 (69%) did not alwaysreport their injuries. The most common injury reported was needlestick (n ¼ 386,78%) followed by splash (n ¼ 213, 43%). Among those with injuries, specificmethods of injury prevention were identified by 482 (96%), and 485 (97%) provideddescriptions of technique adjustments that resulted from an injury.

Conclusion: Injuries are common in the dermatology setting. These data suggestsubstantial underreporting of injuries. Improved prevention and reporting strategiesare needed to increase occupational safety in dermatology practice. Diffusion ofthese data and prevention strategies are important for the ultimate development ofbest practices in dermatology.

cial support: None identified.

Commer

P103Skin assessment by high frequency ultrasound is a useful and reliablemethod to quantify photoaging in skin

Giuseppe Micali, MD, Dermatology Clinic, University of Catania, Catania, Italy;Aurora Tedeschi, MD, PhD, Dermatology Clinic, University of Catania, Catania,Italy; Beatrice Nardone, MD, Department of Dermatology, NorthwesternUniversity, Chicago, IL and Dermatology Clinic, University of Catania, Catania,Italy, Chicago, IL, United States; Francesco Lacarrubba, MD, Dermatology Clinic,University of Catania, Catania, Italy

Background: Objective quantification of skin photoaging by a precise and nonin-vasive method is an unmet need for in vivo studies. Several methods have beenproposed for this purpose, including high frequency ultrasound. In particular, it hasbeen shown in various studies that subepidermal low echogenic band (SLEB)represents a marker of photoaging that seems to be related to dermal elastosis,basophilic degradation of collagen, and the accumulation of glycosaminoglycansand water in the papillary dermis. The aim of this study is to evaluate if SLEB severityis useful to quantify skin photoaging in subjects with none to various degrees ofphotodamage but no evidence of skin cancer.

Methods: Sixty-two subjects (21M/41F) were enrolled in the study (range, 17-91 yrs;mean age, 46 yrs) with Fitzpatrick skin phototypes I to IV in order to determine towhat extent SLEB is present over a wide range of ages. Ultrasound examination wasperformed on both sun-protected and sun-exposed skin, using 22-Mhz, cross-sectional B-mode scans. The presence and severity of clinical signs for skinphotoaging were assessed by a dermatologist. SLEB was graded using a 4-pointscale as follow: 0, no SLEB; 1, mild; 2, moderate; and 3 severe SLEB.

Results: SLEB grade was significantly higher in sun-exposed skin compared to sun-protected skin (P ¼ .0001). SLEB grade positively correlated with severity ofphotoaging clinical signs (r ¼ 0.36; P ¼ .004). Moreover, SLEB grade was higher inskintypes I (n ¼ 7) and II (n ¼ 21) compared to IV (n ¼ 9), and this differencewas significant (P ¼ .04). Finally, a significant correlation was found between SLEBgrade and age in both sun-exposed and sun-protected skin (r ¼ 0.57; P ¼ .0001 andr ¼ 0.48; P\.001, respectively).

Conclusion: A positive correlationwith agewas found in sun-protected skin andmaylikely be related to an overall cumulative and/or chronic solar exposure, notnecessarily to sun-protected skin. Moreover, our findings suggest that SLEB severitycould therefore be used as an objective and reliable method to quantify photoagingskin. Therefore, high frequency ultrasound should continue to expand its use tostudy dermal changes in various skin disorders, including skin photoaging. Inaddition, evaluating SLEB severity might be useful as an objective outcome measurein skin aging procedures and treatments.

cial support: None identified.

Commer

J AM ACAD DERMATOL AB1