Variation in Care for Recurrent Non-Melanoma Skin Cancer in a University-Based vs. VA Practice
For most non-melanoma skin cancers (NMSC), many therapies can prevent recurrence. However, treatment for recurrent NMSC is more difficult, with a higher rate of subsequent recurrence than primary tumors in addition to more frequent metastasis. Formal recommendations for treatment of recurrent NMSC include both surgical excision and Mohs surgery as first-line therapy, although some data suggest that Mohs should be the treatment of choice. Previous studies have shown a largely unexplained variation in care in treatment of primary tumors between university-based and VA clinical sites that shared practitioners. This study sought to determine if treatment of recurrent non-melanoma skin cancer varied in two different practice settings – a university-based dermatology practice and the dermatology clinic at its affiliated VAMC. Conventional therapies for NMSC were available at both sites, and over the two-year study period there were 91 recurrent tumors in 81 veterans who were diagnosed at the VA site compared to 119 recurrent tumors in 110 patients who were diagnosed at the university site.
Findings show that treatment choices differed significantly between the two sites: the proportion of tumors treated with excisional surgery in the VA and university sites were 60% and 14%, respectively; the proportion of tumors treated with Mohs surgery were 24% and 61%, respectively. After adjusting for patient, tumor and clinician characteristics that may have affected treatment choice, tumors treated at the university-based site remained significantly more likely to be treated with Mohs surgery. There was no evidence that the quality of care varied at the two sites.
Clark F, Sahay A, Bertenthal D, Maddock L, Lindquist K, Grekin R, and Chren M. Variation in Care for Recurrent Non-Melanoma Skin Cancer in a University-Based Practice and a Veterans Affairs Clinic. Archives of Dermatology September 2008;144(9):1148-52.
This study was funded by HSR&D. Mr. Bertenthal, Ms. Maddock, Ms. Lindquist, and Dr. Chren are part of HSR&D’s Research Enhancement Award Program in San Francisco.