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Clinical Question
For patients with stage I invasive melanoma, is Mohs micrographic surgery as effective as surgery with a wide margin excision?
Bottom line
This observational study suggests that for patients with low-grade invasive melanoma, no nodal or extra-nodal spread, and a Breslow thickness of less than 0.8 mm, Mohs micrographic surgery offers similar survival to wide excision surgery. This was not a randomized trial, so residual confounding (ie, the inability to adjust for an important variable that is associated with both Mohs surgery and survival) could be distorting the results. Mohs surgery is less disfiguring, though not necessarily less costly. 1b
Reference
Study design: Cohort (prospective)
Funding: Unknown/not stated
Setting: Outpatient (specialty)
Synopsis
These authors used data from a prospective cohort of cancer patients (the National Cancer Database) who were given a diagnosis of stage I melanoma between 2004 and 2014. More than 80% had a Breslow thickness of less than 0.8 mm. The authors excluded those with in situ disease or nodal or extranodal metastasis and those who underwent radiotherapy or chemotherapy. They used propensity score matching to create 2 groups of patients: one group was treated with Mohs micrographic surgery (MMS) and the other was treated with the more traditional wide margin excision (WME). The groups were matched by age, sex, race, comorbidities, type of insurance, academic versus nonacademic site of treatment, and anatomical location of the lesion. Prior to adjustment there was no difference in survival between MMS and WME. After propensity score adjustment, survival was slightly better and mortality lower for MMS (hazard ratio [HR] 0.82; 95% CI 0.68 - 0.98). The authors also did a multivariate analysis with overall survival as the dependent variable and the factors used in the propensity score matching as the covariates along with type of excision (MMS vs WME). In this analysis, MMS was associated with a significantly lower mortality rate (HR 0.86; 0.76 - 0.97). ERRATUM: The POEM from 12 February 2020 describing a study of ubrogepant for treatment of acute migraine mistakenly identified it as a monoclonal antibody in the Clinical Question and Bottom-Line sections. It is actually a calcitonin gene-related peptide antagonist.
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA