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Discussion
The RRVAMC approach of direct patient referral to the in-house plastic surgeon often spared the patient 2 additional clinical visits or procedures, which might otherwise have been required. Often, the primary care provider referred the patient to a dermatologist who would perform a shave or punch biopsy, awaiting a pathologist’s diagnosis before scheduling definitive (eg, Mohs) surgery with a separate provider. After that, the patient might be scheduled for reconstructive surgery, if necessary, by a plastic surgeon. With the RRVAMC approach, not only were the number of visits/procedures reduced, but the total time was shortened by several weeks, sparing the patient discomfort and uncertainty.
The RRVAMC cost analysis data show an average realistic cost at this setting (considering already available resources) of far less than $2,000 ($1,000-$1,500). This is substantially below the $2,000 to $10,000 cost per case (or lesion in patients with multiple lesions) that would have been required for a private sector referral, based on CMS reimbursement rates for Mohs procedures (CPT codes 17311-17315).
An important element in the cost-effectiveness, quality assurance, and time use in this approach is the flexibility of the key operators (surgery and pathology staff) and the sampling technique. For the latter, the pathologist can use the most efficient technique, depending on specimen source and size: The classic Mohs technique for very small (head and neck area) specimens, but serial cross-sectioning or limited sampling of peripheral and deep margins in other situations. All 3 sectioning approaches in the RRVAMC practice proved reliable in assessing the margins, as they were always verified either on permanent sections and/or through retroactive peer review. Furthermore, in a mostly elderly patient population, there is rarely a need for extremely conservative resection of the margins, as the skin often shows wrinkling or redundancy that allows for a more generous healthy rim around the lesion. In such cases, it may be indeed superfluous to apply the protracted and expensive Mohs procedural variant.
The quality assurance aspect of the RRVAMC approach is also important. Examining permanent sections as well as retroactive peer review can uncover diagnostic or processing errors even in the best of laboratories. That error rate in the surgical pathology community may reach more than 1% to 2%.12 In the RRVAMC practice, the major discrepancy rate is usually below 0.2%. There is a reason for concern in any FS laboratory where such monitoring is not done, considering that even BCC can be occasionally confused on FS with other small blue cell malignancies, such as lymphoma or Merkel cell carcinoma.
Conclusion
The authors offer the RRVAMC pathologist-plastic surgeon team approach to definitive skin cancer surgery as a reliable and less expensive in-house alternative to contractual outsourcing for those VA (or non-VA) medical centers that have a plastic surgeon (or trained equivalent) and a surgical pathologist on staff.
Acknowledgements
This material is the result of work supported with resources and the use of facilities at the Robley Rex VAMC in Louisville, Kentucky.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
