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Study Letter
90 (
2
); 233-235
doi:
10.25259/IJDVL_991_2022
pmid:
37436022

Factors associated with Mohs micrographic surgery in dermatofibrosarcoma protuberans of the head and neck: A cohort study

Department of Dermatology, Rutgers New Jersey Medical School, Newark, NJ
Department of Dermatology, Brigham and Women’s Hospital, Boston, MA
Department of Dermatology, Columbia University Irving Medical Center, NY
Corresponding author: Prof. Faramarz H. Samie, Department of Dermatology, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, United States. fs2614@cumc.columbia.edu
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Desai AD, Behbahani S, Soliman Y. Samie FH. Factors associated with Mohs micrographic surgery in dermatofibrosarcoma protuberans of the head and neck: A cohort study. Indian J Dermatol Venereol Leprol. 2024;90:233–5. doi: 10.25259/IJDVL_991_2022

Dear Editor,

Dermatofibrosarcoma protruberans (DFSP) of the head and neck is a rare, locally infiltrative, low-grade sarcoma with the incidence in African-American patients being almost twice the rate among Caucasian patients. Prior studies have shown that tumours treated with Mohs micrographic surgery (MMS), when compared with other surgical modalities, have a significantly lower recurrence rate and better aesthetic outcomes in cosmetically sensitive areas, such as the head and neck.1 However, given the high costs and prior authorization often associated with MMS, it remains unclear which patients are typically eligible to receive MMS for DFSP despite its suggested therapeutic success.

We aimed to study predictors of MMS to determine which factors led to this chosen treatment modality. We queried the National Cancer Database (NCDB) from 2004 to 2016 for all cases of DFSP lesions of the head and neck. The NCDB is the largest cancer database within the United States and gathers information from more than 1500 accredited cancer facilities in the United States and Puerto Rico, collecting roughly 70% of all cancer diagnoses in the United States annually.2 We restricted our study to histologically confirmed cases of DFSP using ICD-O-3 histology codes. Only cases with lesions of the head and neck, including the lip, eyelid, external ear, scalp, neck and other unspecified parts of the face were included. After completion of the database review, univariable and multivariable analyses were performed using Microsoft Excel (Microsoft, Seattle, WA) and SAS Software (SAS Studio Release 3.8, Cary, North Carolina). Clinical and demographic characteristics were compared among patients receiving each type of surgery using t-tests, chi-squared and Fisher’s exact tests. Multivariable logistic regression was then performed to assess predictors of receipt of MMS based on analysed variables with less than 50% missing data.

A total of 778 patients underwent surgical procedures. Of the included patients, 434 (56.0%) of the patients were male and 344 (44.2%) of the patients were female. The average age of the included patients was 42.2 ± 15.7 years. Patients were divided into surgical treatment groups and 101 (12.9%) were treated with MMS, 371 (47.7%) with wide local excision (WLE) and 306 (39.3%) with other surgeries.

When comparing MMS independently to all other treatments [Table 1], the incidence of MMS in academic centres remained significantly greater than in community or integrated network programmes (p = 0.0049). Furthermore, for individuals with higher incomes (≥$63,000), there was a higher incidence of MMS (p = 0.0176, Table 1). On multivariable logistic regression analysis [Table 2] assessing predictors of MMS including all variables in Table 1, higher incomes independently predicted treatment with MMS compared to those with lower incomes (≤$38,000) when controlling for confounders (Odds ratio: 2.8, 95% confidence interval: 1.3, 6.1, p = 0.0047).

Table 1: Demographic characteristics of MMS and non-MMS modalities
Othera (n = 677) (87.0%) Mohs (n = 101) (13.0%) p-value
Age 0.8322
 <30 149 (22.0) 22 (21.8)
 30–39 155 (22.9) 29 (28.7)
 40–49 159 (23.5) 22 (21.8)
 50–59 123 (18.2) 15 (14.9)
 60–69 58 (8.6) 10 (9.9)
 70–79 20 (3.0) 2 (2.0)
 80+ 13 (1.9) 1 (1.0)
Sex 0.3511
 Male 382 (56.4) 52 (51.5)
 Female 295 (43.6) 49 (48.5)
Race 0.185
 Caucasian 517 (78.0) 86 (86.0)
 African-American 105 (15.8) 10 (10.0)
 Other 41 (6.2) 4 (4.0)
Insurance Status 0.6852
 Not Insured 60 (9.3) 7 (6.9)
 Private Insurance/Managed Care 451 (69.6) 74 (73.3)
 Medicaid 69 (10.7) 8 (7.9)
 Medicare or other government 68 (10.5) 12 (11.9)
Income Statusb 0.0176
 <$38,000 134 (19.9) 10 (9.9)
 $38,000–$47,999 151 (22.5) 21 (20.8)
 $48,000–$62,999 163 (24.3) 22 (21.8)
 >=$63,000 224 (33.3) 48 (47.5)
Facility Type 0.0049
 Academic/Research Program 197 (52.8) 38 (76.0)
 Community Program 131 (35.1) 11 (22.0)
 Integrated Network Program 45 (12.1) 1 (2.0)
CDCSc 0.2177
 0 or 1 672 (99.3) 99 (98.0)
 2 or 3 5 (0.7) 2 (2.0)
Tumour Size 0.661
 <15 mm 61 (16.3) 10 (17.2)
 15–30 mm 118 (31.6) 20 (34.5)
 30–45 mm 106 (28.3) 12 (20.7)
 45–60 mm 34 (9.1) 8 (13.8)
 60+ mm 55 (14.7) 8 (13.8)
Chemotherapy 0.409
 No 613 (94.9) 92 (96.8)
 Yes 33 (5.1) 3 (3.2)
Radiation Therapy 0.4294
 No 567 (85.0) 88 (88.0)
 Yes 100 (15.0) 12 (12.0)

aOther: includes wide local excision, local tumour excision with electrocautery or laser excision, biopsy (shave/punch) followed by gross excision, or surgery not otherwise specified/major amputation

bBased on NCDB pre-defined income quartiles (i.e. <$38,000 is the lowest income quartile)

cCharlson-Deyo Comorbidity Score

Table 2 Multivariable logistic regression analysis for predictors of MMS
Variable Estimate OR 95% CI p-value
Intercept –1.95 0.0008
Age
 <30 REF
 30–39 0.64 1.48 0.76 2.86 0.0378
 40–49 0.40 1.16 0.58 2.34 0.2132
 50–59 0.23 0.98 0.46 2.09 0.5000
 60–69 0.32 1.08 0.43 2.68 0.3772
 70–79 –0.71 0.38 0.38 0.07 0.3245
 >80 –1.13 0.25 0.02 2.73 0.2575
Sex
 Male REF
 Female 0.18 1.20 0.76 1.87 0.4344
Race
 Caucasian REF
 African-American –0.04 0.73 0.36 1.50 0.9041
 Other –0.24 0.59 0.20 1.74 0.5184
Insurance Status
 Not Insured REF
 Medicaid –0.13 1.09 0.34 3.52 0.71
 Medicare or other Government insurance 0.35 1.74 0.60 5.09 0.2335
 Private Insurance –0.01 1.22 0.50 3.00 0.9597
Income
 <$38,000 REF
 $38,000–47,999 0.08 1.81 0.78 4.19 0.7242
 $48,000–$62,999 –0.07 1.56 0.67 3.63 0.7353
 >=$63,000 0.51 2.79 1.28 6.10 0.0047
CDCS*
 0 or 1 REF
 2 or 3 0.50 2.74 0.50 15.07 0.2463
Radiation
 No REF
 Yes –0.12 0.89 0.46 1.73 0.7318
Chemotherapy
 No REF
 Yes –0.53 0.59 0.17 1.99 0.3931
Charlson-Deyo Comorbidity Score

On chi-square analysis comparing Caucasians to all other racial groups (African-Americans and others), 86 of 603 (14.3%) Caucasians and 15 of 175 (8.6%) patients of other races received MMS (p = 0.0486).

Our analysis shows that MMS was performed more often at an academic centre. The treatment of cutaneous malignancies of the head and neck often requires multidisciplinary care, especially for rarer tumours like DFSP which is more feasible at academic centres due to an increased number of resources and expertise available. Furthermore, higher annual incomes were also independently predictive of MMS. This sheds light on healthcare disparities which occur with regard to accessing MMS. Surveys have shown that providers have asked for advanced deposits and given financial disclosures prior to MMS, possibly disadvantaging low-income patients. MMS has been perceived to be an expensive modality of treatment; however, previous studies have demonstrated its cost-effectiveness, especially when compared to other surgical procedures.1 For example, in typical surgical excision, 32–39% of cases require a follow-up procedure following initial surgical resection to ensure clear margins.3 These follow-up surgeries also lead to a greater volume of tissue removed and significant cosmetic consequence.1,4 In addition, our study showed a lower percentage of African-American patients with DFSP of the head and neck (8.7%) treated with MMS compared to Caucasian patients (14.3%), similar to previous studies showing greater MMS utilization in Caucasian patients as compared to non-Caucasian patients,1 exacerbating higher incidence of DFSP and worse survival in African-American patients.5 To fully explore impact of racism on surgery received, future studies should be performed in single-ethnic nations. Limitations include the self-reported nature of NCDB and lack of specific information as to which centres MMS was available.

In summary, ensuring equitable access to MMS for treatment of DFSP is essential to disease outcome and patient quality of life. We underscore income status as a significant independent predictor of MMS receipt when controlling for insurance status, race, age, sex and other confounders.

Declaration of patient consent

Patient’s consent not required as patients’ identity is not disclosed or compromised.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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