DS06: Contending with COVID‐19 in a Mohs micrographic surgery service

Abstract

DS05 Two-thirds of patients may not require review after Mohs micrographic surgery R. Lapsley, S. Fenwick and T. Oliphant Royal Victoria Infirmary, Newcastle upon Tyne, UK One of the many challenges facing the department during the COVID-19 pandemic was how to provide follow-up safely for Mohs surgical patients. With the need to practice social distancing and avoid unnecessary face-to-face (F2F) follow-up, we felt the system could be improved to ensure patient and staff safety. We created, reviewed and adapted a new system to follow-up on patients. We designed a questionnaire that was sent out to patients 3 months postprocedure. This included questions on aesthetic and functional outcomes, and postoperative complications, including bleeding and infection. Recording these outcomes is a requirement for all Mohs surgical patients, outlined by the British Society for Dermatological Surgery. Information collected via the questionnaire allowed us to identify those who required further follow-up and those who could be discharged. A patient was felt to be suitable for discharge if they reported no postoperative complications, their scar bothered them ‘a little’ at most and they had no functional complications besides paraesthesia. Otherwise, patients were invited for medical photography and an appointment was arranged for them, either by telephone, or if necessary, F2F. Patients were given the option to request a consultation even if they did not meet the criteria for one. Data were collected for 131 patients who had Mohs micrographic surgery between April 2020 and July 2020. Sixty-six per cent did not require follow-up as defined by the criteria. Eighty-nine per cent of patients found the questionnaire ‘acceptable’ or ‘somewhat acceptable’. Feedback from staff has been positive and the questionnaire continues to be our first step in follow-up. Patients are informed of this new format at the time of surgery. Our next step is to identify factors that predict the requirement for review so these patients can have a suitable appointment scheduled. We intend to review the process after the pandemic, as while this approach is considered acceptable in the current climate, we understand that it may be less so once the pandemic is over. We have demonstrated a novel approach to the follow-up of Mohs surgical patients during the COVID-19 pandemic. Our data suggest that two-thirds of postoperative reviews may not be required and propose a sustainable method to identify these cases. This is significant, not only in relation to the pandemic, but in the long term. Appointments should be reserved for a clinical need to ensure efficient use of clinicians’ time. DS06 Contending with COVID-19 in a Mohs micrographic surgery service D. Jackson, E. Edmiston, S. Butt, M. O’Reilly, A. Khalid and C. Fleming NHS Tayside and University of Dundee, Dundee, UK The COVID-19 pandemic has placed significant pressure on healthcare services worldwide. We sought to better understand its impact on our Mohs micrographic surgery (MMS) by comparing outcomes from 2019 and 2020 for basal cell carcinoma (BCC) Mohs excisions. Additionally, we outline the systems and changes to patient pathways we undertook to minimize delay to treatment while running a reduced service, and discuss the benefits and consequences of such changes. We retrospectively reviewed the Mohs dataset and electronic records of patients referred for MMS between June and September in 2019 and 2020. Owing to the COVID-19 pandemic in the spring of 2020, MMS was stopped, with select cases retriaged for standard excision and a reduced MMS service recommenced in June 2020. Additionally, we analysed the outcomes of histological clearance in these 14 patients (16 lesions). Seventy-nine MMS procedures were performed between June and September 2019 vs. 74 over the same period in 2020. The mean waiting time for surgery increased from 164 days to 203. The average number of Mohs stages increased from 1 44 to 1 54. In 2019, 60% of cases were histologically clear after stage 1, 38% after stage 2, 1% after stage 3 and 1% after stage 4. In 2020, 55% of cases were histologically clear after stage 1, 37% after stage 2, 7% after stage 3 and 1% after stage 4. There was an increase in the average postoperative defect from 941 mm in 2019 to 1043 mm in 2020. While rates of BCC growth are generally considered slow, rapid growth in periocular lesions has been noted (Tan E, Lin FP, Sheck LH et al. Growth of periocular basal cell carcinomas. Br J Dermatol 2015; 172: 1002–7). There was a reduction in the use of secondary intention healing, falling from 28% in 2019 to 14% in 2020. Of the 16 lesions that did not receive MMS, 12 specimens achieved complete clearance on conventional histology, one a narrow clearance and three were incompletely excised. The unusual circumstances of the COVID-19 pandemic have provided insights into managing skin cancer without access to MMS. Our data suggest that prolonged halting of MMS for BCC does affect outcomes, with a trend towards more Mohs stages, a larger postoperative defect and more complex reconstruction. Retriage to standard excision demonstrated mixed clearance results on conventional histology. While prioritizing urgent care is essential in extremis, preserving MMS where possible may reduce the overall burden of disease in the long term. For patients with high-risk features or recurrent BCC, MMS remains the gold standard.