As Mohs surgery becomes an ever more widely accepted and available treatment option for nonmelanoma skin cancer, it is very important to know how to choose the right surgeon.
Technically, any surgeon who can cut the skin and process the tissue using the Mohs method is performing Mohs surgery – there is no specialized quality control requirement for surgeons who decide that they want to do Mohs. Consequently, as the interest in Mohs increases, it becomes especially important for a patient to select a qualified surgeon. What’s at stake? Nothing less than a patient’s chance for being cured and avoiding disfigurement.
Think of it this way. According to the Skin Cancer Foundation, about 13 million people living in the U.S. have had at least one nonmelanoma skin cancer in their lifetime (typically basal cell carcinoma or squamous cell carcinoma), so it’s very common. Each year in the U.S., there are about 700,000 cases of squamous cell carcinoma diagnosed and about 2.8 million cases of basal cell carcinoma diagnosed. Squamous cell carcinoma causes about 2500 deaths in the U.S. each year. And while basal cell carcinoma is not fatal, it can be very disfiguring if it’s allowed to grow.
With nonmelanoma skin cancer, what you see on the skin’s surface can be just the tip of the iceberg… The tumor is sometimes very destructive deep in the skin or even deeper into muscle, cartilage, or bone. Imagine what happens if a person goes to a Mohs surgeon and the surgeon misses a few cancerous cells. The patient leaves with a false sense of confidence while their tumor continues to grow. Because Mohs surgery works with such small margins of tissue, this scenario is more likely to happen without the proper quality controls. In the case of squamous cell carcinoma, the remaining tumor cells can metastasize (spread to another part of the body), and the patient could die. With basal cell carcinoma, the remaining tumor cells can expand deeper into the body. The next time the patient seeks treatment, much more tissue will need to be removed, with a greater potential for physical disfigurement. This is why quality control is absolutely paramount to a well-trained Mohs surgeon and their patient.
The American College of Mohs Surgery (ACMS) is the most reliable source of well-trained Mohs surgeons. I’m a member of the Mohs College and have first-hand experience with the rigorous training and quality control required for members. The ACMS is not an actual physical place. It’s an organization that oversees training, ongoing development, and advancement of Mohs surgery for its members and ultimately provides the best possible patient experience.
Surgeons interested in becoming ACMS members apply to take part in a fellowship. The selection process is highly competitive. Only a limited number of fellowships are available. This is because fellowship requires study under a veteran Mohs College surgeon. Fellowships last 1-2 years. Each participant must perform a minimum of 500 cases each year under their fellowship director. During this time, they are gaining the necessary experience for reading slides, closing defects, and making surgical judgments. Once their fellowship is complete, a surgeon can apply to become an Associate Member. After a surgeon becomes an Associate Member, they can become a Fellow Member once they complete a certain number of cases after a certain number of years. Each member is re-evaluated every 1-5 years by the ACMS to make sure they are upholding the standards.
This training is necessary because a qualified Mohs surgeon needs plenty of experience. Each patient is different, and a Mohs surgeon must know how to handle individual patient issues as well as recognize when someone else is more qualified to perform a specific part of the task. For example, in my practice I have a wide network of professionals. If there is any risk that a tumor could disfigure a lip, nose, or eye, then I won’t hesitate to contact an oculoplastic surgeon or an ear, nose, and throat specialist (ENT). Sometimes I’ll call a plastic surgeon if I feel they can do a better job closing a defect. Because I perform nothing but Mohs surgery, I have a top-rate network. My point is this: my training through the ACMS has given me the experience and insight needed to make the best decisions for my patient and to ensure I have the proper resources.
Another factor that differentiates ACMS members from other Mohs surgeons is the strong emphasis on the quality of slides. A Mohs surgeon is only going to be as accurate as their slides. There is no room for error if you aren’t taking any margin in the skin around a tumor. If your slide is missing a section – even just a few cells – and that section has cancer, the outcome can be tragic. This is why the ACMS also trains a special technician called a histotechnician to make the slides. A histotechnician is trained through the American Society for Mohs Histotechnology. These technicians take part in an initial training as well as continued professional development, and they are subject to periodic diagnostic and quality control evaluations. ACMS members only use specially trained histotechnicians to prepare their slides.
Currently, most doctors performing Mohs surgery are not members of the ACMS. You can find out if your Mohs surgeon is a member by going to mohscollege.org and looking up your surgeon’s name. But be aware. There is also the American Society of Mohs Surgery. The American Society of Mohs Surgery is not the same as the College, and its members are not required to do a fellowship. To be fair, I know there are Society members who are very good. If you’re considering surgery with a Mohs surgeon who is not a member of the College, make sure to ask your dermatologist about the surgeon’s training and expertise. Ask how many cases they perform each year. Most ACMS members perform at least 500 cases per year and often the number is well over 1000.
I place such incredible emphasis and trust in the ACMS because in my opinion, ACMS members are most advanced in their training and have the most reliable quality control measures for their patients. Again, that’s not to say there aren’t non-ACMS members who do an excellent job with Mohs surgery. But for a patient searching for a qualified Mohs surgeon, I believe the best option is to choose a member of the ACMS who specializes in skin cancer treatment. A surgeon who fits this description has experience and a large network – and knows how to use it.