MDedge Dermatology

Clinicians should incorporate at least one of three validated instruments to measure signs of atopic dermatitis (AD) in their clinical practice, the authors of a new consensus statement recommended.

These include the Eczema Area and Severity Index (EASI), the Validated Investigator Global Assessment for AD (vIGAAD), and the Investigator’s Global Assessment (IGA) multiplied by or measured concurrently with a body surface area (BSA) assessment.

The recommendations are part of a consensus statement based on an updated systematic review conducted by the Harmonizing Outcome Measures for Eczema Clinical Practice (HOME-CP) initiative, whose goal is to identify validated, feasible outcome instruments designed to measure AD in the clinical setting. In the statement, which was published in JAMA Dermatology on May 22, 2024, corresponding author Eric L. Simpson, MD, MCR, professor of dermatology at Oregon Health & Science University, Portland, and coauthors described HOME-CP as “a ‘pick-and-choose’ list of valid and feasible OMIs [outcome measure instruments] that can be incorporated into the practice setting depending on the particular need of that clinic or health system.”

For the effort, the authors implemented a mixed methods design and incorporated systematic reviews and qualitative consensus methods modeled after the HOME core outcome set initiative, which developed a set of consensus-based core outcome sets for clinical trials and clinical practice. In October of 2022, a daylong in-person consensus exercise was held in Montreal, Canada, where attendees met to reach consensus on recommended instruments to measure AD clinical signs in clinical practice, based on an updated systematic review evaluating the validity of clinical signs instruments.

The review included 22 studies describing 16 instruments that assessed AD clinical signs and an additional 12 variants of instruments. The meeting was attended by 34 individuals from 13 countries, including patient and patient advocate research partners, health care professionals, researchers, methodologists, and industry representatives. Consensus was defined as less than 30% disagreement.

Following their daylong consensus exercise, the stakeholders reached consensus on recommendations to use the EASI, the vIGAAD, and an IGA multiplied or measured alongside a BSA measurement to measure the domain of clinical signs of AD in the clinical practice setting. “The use of multiple IGAs, most with insufficient validation, and the diverse methods used to assess BSA prevented participants from making specific recommendations for the exact IGA/BSA instrument,” the authors wrote. “We recommend that clinicians include at least one of the recommended instruments in their clinical practices and in documentation.” 

They explained that the ideal method of measuring BSA was difficult to assess “because multiple techniques exist for its measurement, including regional percentages, the Rule of Nines, or the handprint method. Most studies did not report which method was performed, and to our knowledge, no studies have been performed in patients with AD that have formally compared them.”

During the consensus exercise, the authors noted, several clinicians “expressed concern whether the EASI was feasible for universal use in clinical practice given its complexity, long completion time, and documentation/calculation requirements.” But clinicians who commonly perform the EASI in clinical practice said that the time it takes to complete this measure “has dropped substantially and now is not a considerable burden,” they wrote, adding that, “studies have shown that with trained investigators, EASI completion times can be as low as nearly 2 minutes.”

The authors acknowledged certain limitations of their recommendations, including the lack of input from primary care clinicians. “It is unknown whether ClinROMs [clinician-reported outcome measures] for AD clinical signs are used in the primary care setting, especially given the large amount of conditions that are managed simultaneously and the ever-increasing number of primary care documentation requirements,” they wrote.

Robert Sidbury, MD, MPH, chief of the division of dermatology at Seattle Children’s Hospital, who was asked to comment on the consensus statement, said that with the advent of new, improved, and more expensive medications for AD, “it is ever more important that [the clinical] assessment is reliable and reproducible.”

Insurers “are understandably less willing to rubber-stamp approval of more expensive medications without a reliable standard by which to justify such decisions,” he added. “This is even more important in a disease state like atopic dermatitis that lacks a reliable biomarker. Therefore, one or several practical, reliable, validated severity metrics will help standardize and improve AD care.”

Dr. Sidbury, who cochaired the 2023 American Academy of Dermatology guidelines of care for the management of AD in adults with phototherapy and systemic therapies, added that the instruments evaluated in the review “can be challenging for anyone,” not just primary care providers. “The EASI isn’t that easy, and while there is a learning curve and it ultimately does, like anything, become more efficient in the gathering, it is unclear if non-AD researchers will be willing to invest the time” to routinely use it, he said.

Dr. Simpson and several coauthors reported receiving grants and personal fees from multiple pharmaceutical companies. Dr. Sidbury reported that he serves as an investigator for Regeneron, Galderma, UCB, Castle, and Pfizer; is a consultant for LEO, Lilly, Arcutis, Dermavant, and Pierre Fabre; and a speaker for Beiersdorf.

A version of this article appeared on Medscape.com .

Clinicians should incorporate at least one of three validated instruments to measure signs of atopic dermatitis (AD) in their clinical practice, the authors of a new consensus statement recommended.

These include the Eczema Area and Severity Index (EASI), the Validated Investigator Global Assessment for AD (vIGAAD), and the Investigator’s Global Assessment (IGA) multiplied by or measured concurrently with a body surface area (BSA) assessment.

The recommendations are part of a consensus statement based on an updated systematic review conducted by the Harmonizing Outcome Measures for Eczema Clinical Practice (HOME-CP) initiative, whose goal is to identify validated, feasible outcome instruments designed to measure AD in the clinical setting. In the statement, which was published in JAMA Dermatology on May 22, 2024, corresponding author Eric L. Simpson, MD, MCR, professor of dermatology at Oregon Health & Science University, Portland, and coauthors described HOME-CP as “a ‘pick-and-choose’ list of valid and feasible OMIs [outcome measure instruments] that can be incorporated into the practice setting depending on the particular need of that clinic or health system.”

For the effort, the authors implemented a mixed methods design and incorporated systematic reviews and qualitative consensus methods modeled after the HOME core outcome set initiative, which developed a set of consensus-based core outcome sets for clinical trials and clinical practice. In October of 2022, a daylong in-person consensus exercise was held in Montreal, Canada, where attendees met to reach consensus on recommended instruments to measure AD clinical signs in clinical practice, based on an updated systematic review evaluating the validity of clinical signs instruments.

The review included 22 studies describing 16 instruments that assessed AD clinical signs and an additional 12 variants of instruments. The meeting was attended by 34 individuals from 13 countries, including patient and patient advocate research partners, health care professionals, researchers, methodologists, and industry representatives. Consensus was defined as less than 30% disagreement.

Following their daylong consensus exercise, the stakeholders reached consensus on recommendations to use the EASI, the vIGAAD, and an IGA multiplied or measured alongside a BSA measurement to measure the domain of clinical signs of AD in the clinical practice setting. “The use of multiple IGAs, most with insufficient validation, and the diverse methods used to assess BSA prevented participants from making specific recommendations for the exact IGA/BSA instrument,” the authors wrote. “We recommend that clinicians include at least one of the recommended instruments in their clinical practices and in documentation.” 

They explained that the ideal method of measuring BSA was difficult to assess “because multiple techniques exist for its measurement, including regional percentages, the Rule of Nines, or the handprint method. Most studies did not report which method was performed, and to our knowledge, no studies have been performed in patients with AD that have formally compared them.”

During the consensus exercise, the authors noted, several clinicians “expressed concern whether the EASI was feasible for universal use in clinical practice given its complexity, long completion time, and documentation/calculation requirements.” But clinicians who commonly perform the EASI in clinical practice said that the time it takes to complete this measure “has dropped substantially and now is not a considerable burden,” they wrote, adding that, “studies have shown that with trained investigators, EASI completion times can be as low as nearly 2 minutes.”

The authors acknowledged certain limitations of their recommendations, including the lack of input from primary care clinicians. “It is unknown whether ClinROMs [clinician-reported outcome measures] for AD clinical signs are used in the primary care setting, especially given the large amount of conditions that are managed simultaneously and the ever-increasing number of primary care documentation requirements,” they wrote.

Robert Sidbury, MD, MPH, chief of the division of dermatology at Seattle Children’s Hospital, who was asked to comment on the consensus statement, said that with the advent of new, improved, and more expensive medications for AD, “it is ever more important that [the clinical] assessment is reliable and reproducible.”

Insurers “are understandably less willing to rubber-stamp approval of more expensive medications without a reliable standard by which to justify such decisions,” he added. “This is even more important in a disease state like atopic dermatitis that lacks a reliable biomarker. Therefore, one or several practical, reliable, validated severity metrics will help standardize and improve AD care.”

Dr. Sidbury, who cochaired the 2023 American Academy of Dermatology guidelines of care for the management of AD in adults with phototherapy and systemic therapies, added that the instruments evaluated in the review “can be challenging for anyone,” not just primary care providers. “The EASI isn’t that easy, and while there is a learning curve and it ultimately does, like anything, become more efficient in the gathering, it is unclear if non-AD researchers will be willing to invest the time” to routinely use it, he said.

Dr. Simpson and several coauthors reported receiving grants and personal fees from multiple pharmaceutical companies. Dr. Sidbury reported that he serves as an investigator for Regeneron, Galderma, UCB, Castle, and Pfizer; is a consultant for LEO, Lilly, Arcutis, Dermavant, and Pierre Fabre; and a speaker for Beiersdorf.

A version of this article appeared on Medscape.com .

Clinicians should incorporate at least one of three validated instruments to measure signs of atopic dermatitis (AD) in their clinical practice, the authors of a new consensus statement recommended.

These include the Eczema Area and Severity Index (EASI), the Validated Investigator Global Assessment for AD (vIGAAD), and the Investigator’s Global Assessment (IGA) multiplied by or measured concurrently with a body surface area (BSA) assessment.

The recommendations are part of a consensus statement based on an updated systematic review conducted by the Harmonizing Outcome Measures for Eczema Clinical Practice (HOME-CP) initiative, whose goal is to identify validated, feasible outcome instruments designed to measure AD in the clinical setting. In the statement, which was published in JAMA Dermatology on May 22, 2024, corresponding author Eric L. Simpson, MD, MCR, professor of dermatology at Oregon Health & Science University, Portland, and coauthors described HOME-CP as “a ‘pick-and-choose’ list of valid and feasible OMIs [outcome measure instruments] that can be incorporated into the practice setting depending on the particular need of that clinic or health system.”

For the effort, the authors implemented a mixed methods design and incorporated systematic reviews and qualitative consensus methods modeled after the HOME core outcome set initiative, which developed a set of consensus-based core outcome sets for clinical trials and clinical practice. In October of 2022, a daylong in-person consensus exercise was held in Montreal, Canada, where attendees met to reach consensus on recommended instruments to measure AD clinical signs in clinical practice, based on an updated systematic review evaluating the validity of clinical signs instruments.

The review included 22 studies describing 16 instruments that assessed AD clinical signs and an additional 12 variants of instruments. The meeting was attended by 34 individuals from 13 countries, including patient and patient advocate research partners, health care professionals, researchers, methodologists, and industry representatives. Consensus was defined as less than 30% disagreement.

Following their daylong consensus exercise, the stakeholders reached consensus on recommendations to use the EASI, the vIGAAD, and an IGA multiplied or measured alongside a BSA measurement to measure the domain of clinical signs of AD in the clinical practice setting. “The use of multiple IGAs, most with insufficient validation, and the diverse methods used to assess BSA prevented participants from making specific recommendations for the exact IGA/BSA instrument,” the authors wrote. “We recommend that clinicians include at least one of the recommended instruments in their clinical practices and in documentation.” 

They explained that the ideal method of measuring BSA was difficult to assess “because multiple techniques exist for its measurement, including regional percentages, the Rule of Nines, or the handprint method. Most studies did not report which method was performed, and to our knowledge, no studies have been performed in patients with AD that have formally compared them.”

During the consensus exercise, the authors noted, several clinicians “expressed concern whether the EASI was feasible for universal use in clinical practice given its complexity, long completion time, and documentation/calculation requirements.” But clinicians who commonly perform the EASI in clinical practice said that the time it takes to complete this measure “has dropped substantially and now is not a considerable burden,” they wrote, adding that, “studies have shown that with trained investigators, EASI completion times can be as low as nearly 2 minutes.”

The authors acknowledged certain limitations of their recommendations, including the lack of input from primary care clinicians. “It is unknown whether ClinROMs [clinician-reported outcome measures] for AD clinical signs are used in the primary care setting, especially given the large amount of conditions that are managed simultaneously and the ever-increasing number of primary care documentation requirements,” they wrote.

Robert Sidbury, MD, MPH, chief of the division of dermatology at Seattle Children’s Hospital, who was asked to comment on the consensus statement, said that with the advent of new, improved, and more expensive medications for AD, “it is ever more important that [the clinical] assessment is reliable and reproducible.”

Insurers “are understandably less willing to rubber-stamp approval of more expensive medications without a reliable standard by which to justify such decisions,” he added. “This is even more important in a disease state like atopic dermatitis that lacks a reliable biomarker. Therefore, one or several practical, reliable, validated severity metrics will help standardize and improve AD care.”

Dr. Sidbury, who cochaired the 2023 American Academy of Dermatology guidelines of care for the management of AD in adults with phototherapy and systemic therapies, added that the instruments evaluated in the review “can be challenging for anyone,” not just primary care providers. “The EASI isn’t that easy, and while there is a learning curve and it ultimately does, like anything, become more efficient in the gathering, it is unclear if non-AD researchers will be willing to invest the time” to routinely use it, he said.

Dr. Simpson and several coauthors reported receiving grants and personal fees from multiple pharmaceutical companies. Dr. Sidbury reported that he serves as an investigator for Regeneron, Galderma, UCB, Castle, and Pfizer; is a consultant for LEO, Lilly, Arcutis, Dermavant, and Pierre Fabre; and a speaker for Beiersdorf.

A version of this article appeared on Medscape.com .

A new clinical practice guideline by the American Society for Radiation Oncology (ASTRO) steers use of external beam radiation therapy (EBRT) for the palliation of symptomatic bone metastases, including recommendations concerning pain management and quality of life.

The guideline was needed to update previous recommendations and incorporate new high-quality evidence for the management of symptomatic bone metastases, Sara Alcorn, MD, PhD, of the University of Minnesota, Minneapolis, and colleagues wrote in Practical Radiation Oncology.

The focus was on the efficacy of EBRT in reducing pain, improving skeletal function, and enhancing quality of life, they wrote in the clinical practice guideline.

In developing their recommendations, the ASTRO task force reviewed evidence from 53 randomized controlled trials (RCTs) and 31 nonrandomized studies, and considered clinical experience.
 

Indications for Palliative Radiation

EBRT is strongly recommended for reducing pain from osseous metastasis and improving ambulatory status, sphincter function, and reducing pain in patients with spinal metastases causing compression of the spinal cord or cauda equina.

For patients with symptomatic bone metastases and an anticipated life expectancy of at least 4 weeks, EBRT is conditionally recommended to improve quality of life.

Implementation of other Treatments Alongside Palliative Radiation

Instead of RT alone, surgery with postoperative RT is conditionally recommended for patients with compression of the spinal cord or cauda equina.

Postoperative RT is strongly recommended for patients who have undergone surgery for non-spine bone metastases or spine metastases without involving spinal cord or cauda equina compression.

For patients with spinal bone metastases compressing the spinal cord or cauda equina, combining RT with dexamethasone is strongly recommended over RT alone.

Techniques, Dose-Fractionation, and Dose-Constraints for Initial Palliative Radiation

For patients with symptomatic bone metastases undergoing conventional palliative RT, strongly recommended doses are 800 cGy in 1 fraction, 2000 cGy in 5 fractions, 2400 cGy in 6 fractions, or 3000 cGy in 10 fractions.

For patients with spinal bone metastases causing compression of the spinal cord or cauda equina who are not candidates for initial surgical decompression and are treated with conventional palliative RT, strongly recommended doses are 800 cGy in 1 fraction, 1600 cGy in 2 fractions, 2000 cGy in 5 fractions, or 3000 cGy in 10 fractions.

When selecting dose-fractionation, consider patient and disease factors such as prognosis and radiosensitivity, the authors wrote.

Highly conformal planning and delivery techniques, such as intensity-modulated radiation therapy, are conditionally recommended for patients with spinal bone metastases compressing the spinal cord or cauda equina who are receiving dose-escalated palliative RT.

The strongly recommended stereotactic body radiotherapy (SBRT) doses for patients with symptomatic bone metastases are 1200 to 1600 cGy in 1 fraction for non-spine metastases and 2400 cGy in 2 fractions for spine metastases. Other established SBRT dose and fractionation regimens with similar biologically effective doses may be considered based on patient tumor characteristics, normal tissue factors, and physician experience.

For patients with symptomatic bone metastases who have an ECOG PS of 0-2, are not undergoing surgical intervention, and have no neurological symptoms, SBRT is conditionally recommended over conventional palliative RT. Other factors to consider include life expectancy, tumor radiosensitivity, and metastatic disease burden, the guideline says.
 

Techniques, Dose-Fractionation, and Dose-Constraints for Palliative Reirradiation

For patients with spinal bone metastases requiring reirradiation to the same site, the strongly recommended conventional palliative RT regimens are 800 cGy in 1 fraction, 2000 cGy in 5 fractions, 2400 cGy in 6 fractions, or 2000 cGy in 8 fractions. When determining the RT dose-fractionation, consider the prior RT dose, time interval, and total spinal cord tolerance, the guideline says.

Treatment with SBRT is conditionally recommended for patients with spinal bone metastases needing reirradiation at the same site. When determining if SBRT is appropriate, consider patient factors such as urgency of treatment, prognosis, and radio-resistance. In addition, consider the prior RT dose, time interval, and total spinal cord tolerance when determining the RT dose-fractionation, the authors say.

The strongly recommended options for patients with symptomatic non-spine bone metastases needing reirradiation at the same site are single-fraction RT (800 cGy in 1 fraction) or multifraction conventional palliative RT (2000 cGy in 5 fractions or 2400 cGy in 6 fractions).
 

Impact of Techniques and Dose-fractionation on Quality of Life and Toxicity

For patients with bone metastases undergoing palliative radiation, it is strongly recommended to use a shared decision-making approach to determine the dose, fractionation, and supportive measures to optimize quality of life.

“Based on published data, the ASTRO task force’s recommendations inform best clinical practices on palliative RT for symptomatic bone metastases,” the guideline panelists said.

Limitations

While the guideline provides comprehensive recommendations, the panelists underscored the importance of individualized treatment approaches. Future research is needed to address gaps in evidence, particularly regarding advanced RT techniques and reirradiation strategies.

Guideline development was funded by ASTRO, with the systematic evidence review funded by the Patient-Centered Outcomes Research Institute. The panelists disclosed relationships with AstraZeneca, Elekta, Teladoc, and others.

A new clinical practice guideline by the American Society for Radiation Oncology (ASTRO) steers use of external beam radiation therapy (EBRT) for the palliation of symptomatic bone metastases, including recommendations concerning pain management and quality of life.

The guideline was needed to update previous recommendations and incorporate new high-quality evidence for the management of symptomatic bone metastases, Sara Alcorn, MD, PhD, of the University of Minnesota, Minneapolis, and colleagues wrote in Practical Radiation Oncology.

The focus was on the efficacy of EBRT in reducing pain, improving skeletal function, and enhancing quality of life, they wrote in the clinical practice guideline.

In developing their recommendations, the ASTRO task force reviewed evidence from 53 randomized controlled trials (RCTs) and 31 nonrandomized studies, and considered clinical experience.
 

Indications for Palliative Radiation

EBRT is strongly recommended for reducing pain from osseous metastasis and improving ambulatory status, sphincter function, and reducing pain in patients with spinal metastases causing compression of the spinal cord or cauda equina.

For patients with symptomatic bone metastases and an anticipated life expectancy of at least 4 weeks, EBRT is conditionally recommended to improve quality of life.

Implementation of other Treatments Alongside Palliative Radiation

Instead of RT alone, surgery with postoperative RT is conditionally recommended for patients with compression of the spinal cord or cauda equina.

Postoperative RT is strongly recommended for patients who have undergone surgery for non-spine bone metastases or spine metastases without involving spinal cord or cauda equina compression.

For patients with spinal bone metastases compressing the spinal cord or cauda equina, combining RT with dexamethasone is strongly recommended over RT alone.

Techniques, Dose-Fractionation, and Dose-Constraints for Initial Palliative Radiation

For patients with symptomatic bone metastases undergoing conventional palliative RT, strongly recommended doses are 800 cGy in 1 fraction, 2000 cGy in 5 fractions, 2400 cGy in 6 fractions, or 3000 cGy in 10 fractions.

For patients with spinal bone metastases causing compression of the spinal cord or cauda equina who are not candidates for initial surgical decompression and are treated with conventional palliative RT, strongly recommended doses are 800 cGy in 1 fraction, 1600 cGy in 2 fractions, 2000 cGy in 5 fractions, or 3000 cGy in 10 fractions.

When selecting dose-fractionation, consider patient and disease factors such as prognosis and radiosensitivity, the authors wrote.

Highly conformal planning and delivery techniques, such as intensity-modulated radiation therapy, are conditionally recommended for patients with spinal bone metastases compressing the spinal cord or cauda equina who are receiving dose-escalated palliative RT.

The strongly recommended stereotactic body radiotherapy (SBRT) doses for patients with symptomatic bone metastases are 1200 to 1600 cGy in 1 fraction for non-spine metastases and 2400 cGy in 2 fractions for spine metastases. Other established SBRT dose and fractionation regimens with similar biologically effective doses may be considered based on patient tumor characteristics, normal tissue factors, and physician experience.

For patients with symptomatic bone metastases who have an ECOG PS of 0-2, are not undergoing surgical intervention, and have no neurological symptoms, SBRT is conditionally recommended over conventional palliative RT. Other factors to consider include life expectancy, tumor radiosensitivity, and metastatic disease burden, the guideline says.
 

Techniques, Dose-Fractionation, and Dose-Constraints for Palliative Reirradiation

For patients with spinal bone metastases requiring reirradiation to the same site, the strongly recommended conventional palliative RT regimens are 800 cGy in 1 fraction, 2000 cGy in 5 fractions, 2400 cGy in 6 fractions, or 2000 cGy in 8 fractions. When determining the RT dose-fractionation, consider the prior RT dose, time interval, and total spinal cord tolerance, the guideline says.

Treatment with SBRT is conditionally recommended for patients with spinal bone metastases needing reirradiation at the same site. When determining if SBRT is appropriate, consider patient factors such as urgency of treatment, prognosis, and radio-resistance. In addition, consider the prior RT dose, time interval, and total spinal cord tolerance when determining the RT dose-fractionation, the authors say.

The strongly recommended options for patients with symptomatic non-spine bone metastases needing reirradiation at the same site are single-fraction RT (800 cGy in 1 fraction) or multifraction conventional palliative RT (2000 cGy in 5 fractions or 2400 cGy in 6 fractions).
 

Impact of Techniques and Dose-fractionation on Quality of Life and Toxicity

For patients with bone metastases undergoing palliative radiation, it is strongly recommended to use a shared decision-making approach to determine the dose, fractionation, and supportive measures to optimize quality of life.

“Based on published data, the ASTRO task force’s recommendations inform best clinical practices on palliative RT for symptomatic bone metastases,” the guideline panelists said.

Limitations

While the guideline provides comprehensive recommendations, the panelists underscored the importance of individualized treatment approaches. Future research is needed to address gaps in evidence, particularly regarding advanced RT techniques and reirradiation strategies.

Guideline development was funded by ASTRO, with the systematic evidence review funded by the Patient-Centered Outcomes Research Institute. The panelists disclosed relationships with AstraZeneca, Elekta, Teladoc, and others.

A new clinical practice guideline by the American Society for Radiation Oncology (ASTRO) steers use of external beam radiation therapy (EBRT) for the palliation of symptomatic bone metastases, including recommendations concerning pain management and quality of life.

The guideline was needed to update previous recommendations and incorporate new high-quality evidence for the management of symptomatic bone metastases, Sara Alcorn, MD, PhD, of the University of Minnesota, Minneapolis, and colleagues wrote in Practical Radiation Oncology.

The focus was on the efficacy of EBRT in reducing pain, improving skeletal function, and enhancing quality of life, they wrote in the clinical practice guideline.

In developing their recommendations, the ASTRO task force reviewed evidence from 53 randomized controlled trials (RCTs) and 31 nonrandomized studies, and considered clinical experience.
 

Indications for Palliative Radiation

EBRT is strongly recommended for reducing pain from osseous metastasis and improving ambulatory status, sphincter function, and reducing pain in patients with spinal metastases causing compression of the spinal cord or cauda equina.

For patients with symptomatic bone metastases and an anticipated life expectancy of at least 4 weeks, EBRT is conditionally recommended to improve quality of life.

Implementation of other Treatments Alongside Palliative Radiation

Instead of RT alone, surgery with postoperative RT is conditionally recommended for patients with compression of the spinal cord or cauda equina.

Postoperative RT is strongly recommended for patients who have undergone surgery for non-spine bone metastases or spine metastases without involving spinal cord or cauda equina compression.

For patients with spinal bone metastases compressing the spinal cord or cauda equina, combining RT with dexamethasone is strongly recommended over RT alone.

Techniques, Dose-Fractionation, and Dose-Constraints for Initial Palliative Radiation

For patients with symptomatic bone metastases undergoing conventional palliative RT, strongly recommended doses are 800 cGy in 1 fraction, 2000 cGy in 5 fractions, 2400 cGy in 6 fractions, or 3000 cGy in 10 fractions.

For patients with spinal bone metastases causing compression of the spinal cord or cauda equina who are not candidates for initial surgical decompression and are treated with conventional palliative RT, strongly recommended doses are 800 cGy in 1 fraction, 1600 cGy in 2 fractions, 2000 cGy in 5 fractions, or 3000 cGy in 10 fractions.

When selecting dose-fractionation, consider patient and disease factors such as prognosis and radiosensitivity, the authors wrote.

Highly conformal planning and delivery techniques, such as intensity-modulated radiation therapy, are conditionally recommended for patients with spinal bone metastases compressing the spinal cord or cauda equina who are receiving dose-escalated palliative RT.

The strongly recommended stereotactic body radiotherapy (SBRT) doses for patients with symptomatic bone metastases are 1200 to 1600 cGy in 1 fraction for non-spine metastases and 2400 cGy in 2 fractions for spine metastases. Other established SBRT dose and fractionation regimens with similar biologically effective doses may be considered based on patient tumor characteristics, normal tissue factors, and physician experience.

For patients with symptomatic bone metastases who have an ECOG PS of 0-2, are not undergoing surgical intervention, and have no neurological symptoms, SBRT is conditionally recommended over conventional palliative RT. Other factors to consider include life expectancy, tumor radiosensitivity, and metastatic disease burden, the guideline says.
 

Techniques, Dose-Fractionation, and Dose-Constraints for Palliative Reirradiation

For patients with spinal bone metastases requiring reirradiation to the same site, the strongly recommended conventional palliative RT regimens are 800 cGy in 1 fraction, 2000 cGy in 5 fractions, 2400 cGy in 6 fractions, or 2000 cGy in 8 fractions. When determining the RT dose-fractionation, consider the prior RT dose, time interval, and total spinal cord tolerance, the guideline says.

Treatment with SBRT is conditionally recommended for patients with spinal bone metastases needing reirradiation at the same site. When determining if SBRT is appropriate, consider patient factors such as urgency of treatment, prognosis, and radio-resistance. In addition, consider the prior RT dose, time interval, and total spinal cord tolerance when determining the RT dose-fractionation, the authors say.

The strongly recommended options for patients with symptomatic non-spine bone metastases needing reirradiation at the same site are single-fraction RT (800 cGy in 1 fraction) or multifraction conventional palliative RT (2000 cGy in 5 fractions or 2400 cGy in 6 fractions).
 

Impact of Techniques and Dose-fractionation on Quality of Life and Toxicity

For patients with bone metastases undergoing palliative radiation, it is strongly recommended to use a shared decision-making approach to determine the dose, fractionation, and supportive measures to optimize quality of life.

“Based on published data, the ASTRO task force’s recommendations inform best clinical practices on palliative RT for symptomatic bone metastases,” the guideline panelists said.

Limitations

While the guideline provides comprehensive recommendations, the panelists underscored the importance of individualized treatment approaches. Future research is needed to address gaps in evidence, particularly regarding advanced RT techniques and reirradiation strategies.

Guideline development was funded by ASTRO, with the systematic evidence review funded by the Patient-Centered Outcomes Research Institute. The panelists disclosed relationships with AstraZeneca, Elekta, Teladoc, and others.

According to the Centers for Disease Control and Prevention (CDC), over 684,000 Americans are diagnosed with an “obesity-associated” cancer each year.

The incidence of many of these cancers has been rising in recent years, particularly among younger people — a trend that sits in contrast with the overall decline in cancers with no established relationship to excess weight, such as lung and skin cancers. 

Is obesity the new smoking? Not exactly.

Tracing a direct line between excess fat and cancer is much less clear-cut than it is with tobacco. While about 42% of cancers — including common ones such as colorectal and postmenopausal breast cancers — are considered obesity-related, only about 8% of incident cancers are attributed to excess body weight. People often develop those diseases regardless of weight.

Although plenty of evidence points to excess body fat as a cancer risk factor, it’s unclear at what point excess weight has an effect. Is gaining weight later in life, for instance, better or worse for cancer risk than being overweight or obese from a young age?

There’s another glaring knowledge gap: Does losing weight at some point in adulthood change the picture? In other words, how many of those 684,000 diagnoses might have been prevented if people shed excess pounds?

When it comes to weight and cancer risk, “there’s a lot we don’t know,” said Jennifer W. Bea, PhD, associate professor, health promotion sciences, University of Arizona, Tucson.

A Consistent but Complicated Relationship

Given the growing incidence of obesity — which currently affects about 42% of US adults and 20% of children and teenagers — it’s no surprise that many studies have delved into the potential effects of excess weight on cancer rates.

Although virtually all the evidence comes from large cohort studies, leaving the cause-effect question open, certain associations keep showing up.

“What we know is that, consistently, a higher body mass index [BMI] — particularly in the obese category — leads to a higher risk of multiple cancers,” said Jeffrey A. Meyerhardt, MD, MPH, codirector, Colon and Rectal Cancer Center, Dana-Farber Cancer Institute, Boston.

In a widely cited report published in The New England Journal of Medicine in 2016, the International Agency for Research on Cancer (IARC) analyzed over 1000 epidemiologic studies on body fat and cancer. The agency pointed to over a dozen cancers, including some of the most common and deadly, linked to excess body weight.

That list includes esophageal adenocarcinoma and endometrial cancer — associated with the highest risk — along with kidney, liver, stomach (gastric cardia), pancreatic, colorectal, postmenopausal breast, gallbladder, ovarian, and thyroid cancers, plus multiple myeloma and meningioma. There’s also “limited” evidence linking excess weight to additional cancer types, including aggressive prostate cancer and certain head and neck cancers.

At the same time, Dr. Meyerhardt said, many of those same cancers are also associated with issues that lead to, or coexist with, overweight and obesity, including poor diet, lack of exercise, and metabolic conditions such as diabetes. 

It’s a complicated web, and it’s likely, Dr. Meyerhardt said, that high BMI both directly affects cancer risk and is part of a “causal pathway” of other factors that do.

Regarding direct effects, preclinical research has pointed to multiple ways in which excess body fat could contribute to cancer, said Karen M. Basen-Engquist, PhD, MPH, professor, Division of Cancer Prevention and Population Services, The University of Texas MD Anderson Cancer Center, Houston.

One broad mechanism to help explain the obesity-cancer link is chronic systemic inflammation because excess fat tissue can raise levels of substances in the body, such as tumor necrosis factor alpha and interleukin 6, which fuel inflammation. Excess fat also contributes to hyperinsulinemia — too much insulin in the blood — which can help promote the growth and spread of tumor cells. 

But the underlying reasons also appear to vary by cancer type, Dr. Basen-Engquist said. With hormonally driven cancer types, such as breast and endometrial, excess body fat may alter hormone levels in ways that spur tumor growth. Extra fat tissue may, for example, convert androgens into estrogens, which could help feed estrogen-dependent tumors.

That, Dr. Basen-Engquist noted, could be why excess weight is associated with postmenopausal, not premenopausal, breast cancer: Before menopause, body fat is a relatively minor contributor to estrogen levels but becomes more important after menopause.

How Big Is the Effect?

While more than a dozen cancers have been consistently linked to excess weight, the strength of those associations varies considerably. 

Endometrial and esophageal cancers are two that stand out. In the 2016 IARC analysis, people with severe obesity had a seven-times greater risk for endometrial cancer and 4.8-times greater risk for esophageal adenocarcinoma vs people with a normal BMI.

With other cancers, the risk increases for those with severe obesity compared with a normal BMI were far more modest: 10% for ovarian cancer, 30% for colorectal cancer, and 80% for kidney and stomach cancers, for example. For postmenopausal breast cancer, every five-unit increase in BMI was associated with a 10% relative risk increase.

A 2018 study from the American Cancer Society, which attempted to estimate the proportion of cancers in the United States attributable to modifiable risk factors — including alcohol consumption, ultraviolet rays exposure, and physical inactivity — found that smoking accounted for the highest proportion of cancer cases by a wide margin (19%), but excess weight came in second (7.8%).

Again, weight appeared to play a bigger role in certain cancers than others: An estimated 60% of endometrial cancers were linked to excess weight, as were roughly one third of esophageal, kidney, and liver cancers. At the other end of the spectrum, just over 11% of breast, 5% of colorectal, and 4% of ovarian cancers were attributable to excess weight.

Even at the lower end, those rates could make a big difference on the population level, especially for groups with higher rates of obesity.

CDC data show that obesity-related cancers are rising among women younger than 50 years, most rapidly among Hispanic women, and some less common obesity-related cancers, such as stomach, thyroid and pancreatic, are also rising among Black individuals and Hispanic Americans.

Obesity may be one reason for growing cancer disparities, said Leah Ferrucci, PhD, MPH, assistant professor, epidemiology, Yale School of Public Health, New Haven, Connecticut. But, she added, the evidence is limited because Black individuals and Hispanic Americans are understudied.

When Do Extra Pounds Matter?

When it comes to cancer risk, at what point in life does excess weight, or weight gain, matter? Is the standard weight gain in middle age, for instance, as hazardous as being overweight or obese from a young age?

Some evidence suggests there’s no “safe” time for putting on excess pounds.

A recent meta-analysis concluded that weight gain at any point after age 18 years is associated with incremental increases in the risk for postmenopausal breast cancer. A 2023 study in JAMA Network Open found a similar pattern with colorectal and other gastrointestinal cancers: People who had sustained overweight or obesity from age 20 years through middle age faced an increased risk of developing those cancers after age 55 years. 

The timing of weight gain didn’t seem to matter either. The same elevated risk held among people who were normal weight in their younger years but became overweight after age 55 years.

Those studies focused on later-onset disease. But, in recent years, experts have tracked a troubling rise in early-onset cancers — those diagnosed before age 50 years — particularly gastrointestinal cancers. 

An obvious question, Dr. Meyerhardt said, is whether the growing prevalence of obesity among young people is partly to blame.

There’s some data to support that, he said. An analysis from the Nurses’ Health Study II found that women with obesity had double the risk for early-onset colorectal cancer as those with a normal BMI. And every 5-kg increase in weight after age 18 years was associated with a 9% increase in colorectal cancer risk.

But while obesity trends probably partly explain the rise in early-onset cancers, there is likely more to the story, Dr. Meyerhardt said.

“I think all of us who see an increasing number of patients under 50 with colorectal cancer know there’s a fair number who do not fit that [high BMI] profile,” he said. “There’s a fair number over 50 who don’t either.”

Does Weight Loss Help?

With all the evidence pointing to high BMI as a cancer risk factor, a logical conclusion is that weight loss should reduce that excess risk. However, Dr. Bea said, there’s actually little data to support that, and what exists comes from observational studies.

Some research has focused on people who had substantial weight loss after bariatric surgery, with encouraging results. A study published in JAMA found that among 5053 people who underwent bariatric surgery, 2.9% developed an obesity-related cancer over 10 years compared with 4.9% in the nonsurgery group.

Most people, however, aim for less dramatic weight loss, with the help of diet and exercise or sometimes medication. Some evidence shows that a modest degree of weight loss may lower the risks for postmenopausal breast and endometrial cancers. 

A 2020 pooled analysis found, for instance, that among women aged ≥ 50 years, those who lost as little as 2.0-4.5 kg, or 4.4-10.0 pounds, and kept it off for 10 years had a lower risk for breast cancer than women whose weight remained stable. And losing more weight — 9 kg, or about 20 pounds, or more — was even better for lowering cancer risk.

But other research suggests the opposite. A recent analysis found that people who lost weight within the past 2 years through diet and exercise had a higher risk for a range of cancers compared with those who did not lose weight. Overall, though, the increased risk was quite low.

Whatever the research does, or doesn’t, show about weight and cancer risk, Dr. Basen-Engquist said, it’s important that risk factors, obesity and otherwise, aren’t “used as blame tools.”

“With obesity, behavior certainly plays into it,” she said. “But there are so many influences on our behavior that are socially determined.”

Both Dr. Basen-Engquist and Dr. Meyerhardt said it’s important for clinicians to consider the individual in front of them and for everyone to set realistic expectations. 

People with obesity should not feel they have to become thin to be healthier, and no one has to leap from being sedentary to exercising several hours a week. 

“We don’t want patients to feel that if they don’t get to a stated goal in a guideline, it’s all for naught,” Dr. Meyerhardt said.

A version of this article appeared on Medscape.com.

According to the Centers for Disease Control and Prevention (CDC), over 684,000 Americans are diagnosed with an “obesity-associated” cancer each year.

The incidence of many of these cancers has been rising in recent years, particularly among younger people — a trend that sits in contrast with the overall decline in cancers with no established relationship to excess weight, such as lung and skin cancers. 

Is obesity the new smoking? Not exactly.

Tracing a direct line between excess fat and cancer is much less clear-cut than it is with tobacco. While about 42% of cancers — including common ones such as colorectal and postmenopausal breast cancers — are considered obesity-related, only about 8% of incident cancers are attributed to excess body weight. People often develop those diseases regardless of weight.

Although plenty of evidence points to excess body fat as a cancer risk factor, it’s unclear at what point excess weight has an effect. Is gaining weight later in life, for instance, better or worse for cancer risk than being overweight or obese from a young age?

There’s another glaring knowledge gap: Does losing weight at some point in adulthood change the picture? In other words, how many of those 684,000 diagnoses might have been prevented if people shed excess pounds?

When it comes to weight and cancer risk, “there’s a lot we don’t know,” said Jennifer W. Bea, PhD, associate professor, health promotion sciences, University of Arizona, Tucson.

A Consistent but Complicated Relationship

Given the growing incidence of obesity — which currently affects about 42% of US adults and 20% of children and teenagers — it’s no surprise that many studies have delved into the potential effects of excess weight on cancer rates.

Although virtually all the evidence comes from large cohort studies, leaving the cause-effect question open, certain associations keep showing up.

“What we know is that, consistently, a higher body mass index [BMI] — particularly in the obese category — leads to a higher risk of multiple cancers,” said Jeffrey A. Meyerhardt, MD, MPH, codirector, Colon and Rectal Cancer Center, Dana-Farber Cancer Institute, Boston.

In a widely cited report published in The New England Journal of Medicine in 2016, the International Agency for Research on Cancer (IARC) analyzed over 1000 epidemiologic studies on body fat and cancer. The agency pointed to over a dozen cancers, including some of the most common and deadly, linked to excess body weight.

That list includes esophageal adenocarcinoma and endometrial cancer — associated with the highest risk — along with kidney, liver, stomach (gastric cardia), pancreatic, colorectal, postmenopausal breast, gallbladder, ovarian, and thyroid cancers, plus multiple myeloma and meningioma. There’s also “limited” evidence linking excess weight to additional cancer types, including aggressive prostate cancer and certain head and neck cancers.

At the same time, Dr. Meyerhardt said, many of those same cancers are also associated with issues that lead to, or coexist with, overweight and obesity, including poor diet, lack of exercise, and metabolic conditions such as diabetes. 

It’s a complicated web, and it’s likely, Dr. Meyerhardt said, that high BMI both directly affects cancer risk and is part of a “causal pathway” of other factors that do.

Regarding direct effects, preclinical research has pointed to multiple ways in which excess body fat could contribute to cancer, said Karen M. Basen-Engquist, PhD, MPH, professor, Division of Cancer Prevention and Population Services, The University of Texas MD Anderson Cancer Center, Houston.

One broad mechanism to help explain the obesity-cancer link is chronic systemic inflammation because excess fat tissue can raise levels of substances in the body, such as tumor necrosis factor alpha and interleukin 6, which fuel inflammation. Excess fat also contributes to hyperinsulinemia — too much insulin in the blood — which can help promote the growth and spread of tumor cells. 

But the underlying reasons also appear to vary by cancer type, Dr. Basen-Engquist said. With hormonally driven cancer types, such as breast and endometrial, excess body fat may alter hormone levels in ways that spur tumor growth. Extra fat tissue may, for example, convert androgens into estrogens, which could help feed estrogen-dependent tumors.

That, Dr. Basen-Engquist noted, could be why excess weight is associated with postmenopausal, not premenopausal, breast cancer: Before menopause, body fat is a relatively minor contributor to estrogen levels but becomes more important after menopause.

How Big Is the Effect?

While more than a dozen cancers have been consistently linked to excess weight, the strength of those associations varies considerably. 

Endometrial and esophageal cancers are two that stand out. In the 2016 IARC analysis, people with severe obesity had a seven-times greater risk for endometrial cancer and 4.8-times greater risk for esophageal adenocarcinoma vs people with a normal BMI.

With other cancers, the risk increases for those with severe obesity compared with a normal BMI were far more modest: 10% for ovarian cancer, 30% for colorectal cancer, and 80% for kidney and stomach cancers, for example. For postmenopausal breast cancer, every five-unit increase in BMI was associated with a 10% relative risk increase.

A 2018 study from the American Cancer Society, which attempted to estimate the proportion of cancers in the United States attributable to modifiable risk factors — including alcohol consumption, ultraviolet rays exposure, and physical inactivity — found that smoking accounted for the highest proportion of cancer cases by a wide margin (19%), but excess weight came in second (7.8%).

Again, weight appeared to play a bigger role in certain cancers than others: An estimated 60% of endometrial cancers were linked to excess weight, as were roughly one third of esophageal, kidney, and liver cancers. At the other end of the spectrum, just over 11% of breast, 5% of colorectal, and 4% of ovarian cancers were attributable to excess weight.

Even at the lower end, those rates could make a big difference on the population level, especially for groups with higher rates of obesity.

CDC data show that obesity-related cancers are rising among women younger than 50 years, most rapidly among Hispanic women, and some less common obesity-related cancers, such as stomach, thyroid and pancreatic, are also rising among Black individuals and Hispanic Americans.

Obesity may be one reason for growing cancer disparities, said Leah Ferrucci, PhD, MPH, assistant professor, epidemiology, Yale School of Public Health, New Haven, Connecticut. But, she added, the evidence is limited because Black individuals and Hispanic Americans are understudied.

When Do Extra Pounds Matter?

When it comes to cancer risk, at what point in life does excess weight, or weight gain, matter? Is the standard weight gain in middle age, for instance, as hazardous as being overweight or obese from a young age?

Some evidence suggests there’s no “safe” time for putting on excess pounds.

A recent meta-analysis concluded that weight gain at any point after age 18 years is associated with incremental increases in the risk for postmenopausal breast cancer. A 2023 study in JAMA Network Open found a similar pattern with colorectal and other gastrointestinal cancers: People who had sustained overweight or obesity from age 20 years through middle age faced an increased risk of developing those cancers after age 55 years. 

The timing of weight gain didn’t seem to matter either. The same elevated risk held among people who were normal weight in their younger years but became overweight after age 55 years.

Those studies focused on later-onset disease. But, in recent years, experts have tracked a troubling rise in early-onset cancers — those diagnosed before age 50 years — particularly gastrointestinal cancers. 

An obvious question, Dr. Meyerhardt said, is whether the growing prevalence of obesity among young people is partly to blame.

There’s some data to support that, he said. An analysis from the Nurses’ Health Study II found that women with obesity had double the risk for early-onset colorectal cancer as those with a normal BMI. And every 5-kg increase in weight after age 18 years was associated with a 9% increase in colorectal cancer risk.

But while obesity trends probably partly explain the rise in early-onset cancers, there is likely more to the story, Dr. Meyerhardt said.

“I think all of us who see an increasing number of patients under 50 with colorectal cancer know there’s a fair number who do not fit that [high BMI] profile,” he said. “There’s a fair number over 50 who don’t either.”

Does Weight Loss Help?

With all the evidence pointing to high BMI as a cancer risk factor, a logical conclusion is that weight loss should reduce that excess risk. However, Dr. Bea said, there’s actually little data to support that, and what exists comes from observational studies.

Some research has focused on people who had substantial weight loss after bariatric surgery, with encouraging results. A study published in JAMA found that among 5053 people who underwent bariatric surgery, 2.9% developed an obesity-related cancer over 10 years compared with 4.9% in the nonsurgery group.

Most people, however, aim for less dramatic weight loss, with the help of diet and exercise or sometimes medication. Some evidence shows that a modest degree of weight loss may lower the risks for postmenopausal breast and endometrial cancers. 

A 2020 pooled analysis found, for instance, that among women aged ≥ 50 years, those who lost as little as 2.0-4.5 kg, or 4.4-10.0 pounds, and kept it off for 10 years had a lower risk for breast cancer than women whose weight remained stable. And losing more weight — 9 kg, or about 20 pounds, or more — was even better for lowering cancer risk.

But other research suggests the opposite. A recent analysis found that people who lost weight within the past 2 years through diet and exercise had a higher risk for a range of cancers compared with those who did not lose weight. Overall, though, the increased risk was quite low.

Whatever the research does, or doesn’t, show about weight and cancer risk, Dr. Basen-Engquist said, it’s important that risk factors, obesity and otherwise, aren’t “used as blame tools.”

“With obesity, behavior certainly plays into it,” she said. “But there are so many influences on our behavior that are socially determined.”

Both Dr. Basen-Engquist and Dr. Meyerhardt said it’s important for clinicians to consider the individual in front of them and for everyone to set realistic expectations. 

People with obesity should not feel they have to become thin to be healthier, and no one has to leap from being sedentary to exercising several hours a week. 

“We don’t want patients to feel that if they don’t get to a stated goal in a guideline, it’s all for naught,” Dr. Meyerhardt said.

A version of this article appeared on Medscape.com.

According to the Centers for Disease Control and Prevention (CDC), over 684,000 Americans are diagnosed with an “obesity-associated” cancer each year.

The incidence of many of these cancers has been rising in recent years, particularly among younger people — a trend that sits in contrast with the overall decline in cancers with no established relationship to excess weight, such as lung and skin cancers. 

Is obesity the new smoking? Not exactly.

Tracing a direct line between excess fat and cancer is much less clear-cut than it is with tobacco. While about 42% of cancers — including common ones such as colorectal and postmenopausal breast cancers — are considered obesity-related, only about 8% of incident cancers are attributed to excess body weight. People often develop those diseases regardless of weight.

Although plenty of evidence points to excess body fat as a cancer risk factor, it’s unclear at what point excess weight has an effect. Is gaining weight later in life, for instance, better or worse for cancer risk than being overweight or obese from a young age?

There’s another glaring knowledge gap: Does losing weight at some point in adulthood change the picture? In other words, how many of those 684,000 diagnoses might have been prevented if people shed excess pounds?

When it comes to weight and cancer risk, “there’s a lot we don’t know,” said Jennifer W. Bea, PhD, associate professor, health promotion sciences, University of Arizona, Tucson.

A Consistent but Complicated Relationship

Given the growing incidence of obesity — which currently affects about 42% of US adults and 20% of children and teenagers — it’s no surprise that many studies have delved into the potential effects of excess weight on cancer rates.

Although virtually all the evidence comes from large cohort studies, leaving the cause-effect question open, certain associations keep showing up.

“What we know is that, consistently, a higher body mass index [BMI] — particularly in the obese category — leads to a higher risk of multiple cancers,” said Jeffrey A. Meyerhardt, MD, MPH, codirector, Colon and Rectal Cancer Center, Dana-Farber Cancer Institute, Boston.

In a widely cited report published in The New England Journal of Medicine in 2016, the International Agency for Research on Cancer (IARC) analyzed over 1000 epidemiologic studies on body fat and cancer. The agency pointed to over a dozen cancers, including some of the most common and deadly, linked to excess body weight.

That list includes esophageal adenocarcinoma and endometrial cancer — associated with the highest risk — along with kidney, liver, stomach (gastric cardia), pancreatic, colorectal, postmenopausal breast, gallbladder, ovarian, and thyroid cancers, plus multiple myeloma and meningioma. There’s also “limited” evidence linking excess weight to additional cancer types, including aggressive prostate cancer and certain head and neck cancers.

At the same time, Dr. Meyerhardt said, many of those same cancers are also associated with issues that lead to, or coexist with, overweight and obesity, including poor diet, lack of exercise, and metabolic conditions such as diabetes. 

It’s a complicated web, and it’s likely, Dr. Meyerhardt said, that high BMI both directly affects cancer risk and is part of a “causal pathway” of other factors that do.

Regarding direct effects, preclinical research has pointed to multiple ways in which excess body fat could contribute to cancer, said Karen M. Basen-Engquist, PhD, MPH, professor, Division of Cancer Prevention and Population Services, The University of Texas MD Anderson Cancer Center, Houston.

One broad mechanism to help explain the obesity-cancer link is chronic systemic inflammation because excess fat tissue can raise levels of substances in the body, such as tumor necrosis factor alpha and interleukin 6, which fuel inflammation. Excess fat also contributes to hyperinsulinemia — too much insulin in the blood — which can help promote the growth and spread of tumor cells. 

But the underlying reasons also appear to vary by cancer type, Dr. Basen-Engquist said. With hormonally driven cancer types, such as breast and endometrial, excess body fat may alter hormone levels in ways that spur tumor growth. Extra fat tissue may, for example, convert androgens into estrogens, which could help feed estrogen-dependent tumors.

That, Dr. Basen-Engquist noted, could be why excess weight is associated with postmenopausal, not premenopausal, breast cancer: Before menopause, body fat is a relatively minor contributor to estrogen levels but becomes more important after menopause.

How Big Is the Effect?

While more than a dozen cancers have been consistently linked to excess weight, the strength of those associations varies considerably. 

Endometrial and esophageal cancers are two that stand out. In the 2016 IARC analysis, people with severe obesity had a seven-times greater risk for endometrial cancer and 4.8-times greater risk for esophageal adenocarcinoma vs people with a normal BMI.

With other cancers, the risk increases for those with severe obesity compared with a normal BMI were far more modest: 10% for ovarian cancer, 30% for colorectal cancer, and 80% for kidney and stomach cancers, for example. For postmenopausal breast cancer, every five-unit increase in BMI was associated with a 10% relative risk increase.

A 2018 study from the American Cancer Society, which attempted to estimate the proportion of cancers in the United States attributable to modifiable risk factors — including alcohol consumption, ultraviolet rays exposure, and physical inactivity — found that smoking accounted for the highest proportion of cancer cases by a wide margin (19%), but excess weight came in second (7.8%).

Again, weight appeared to play a bigger role in certain cancers than others: An estimated 60% of endometrial cancers were linked to excess weight, as were roughly one third of esophageal, kidney, and liver cancers. At the other end of the spectrum, just over 11% of breast, 5% of colorectal, and 4% of ovarian cancers were attributable to excess weight.

Even at the lower end, those rates could make a big difference on the population level, especially for groups with higher rates of obesity.

CDC data show that obesity-related cancers are rising among women younger than 50 years, most rapidly among Hispanic women, and some less common obesity-related cancers, such as stomach, thyroid and pancreatic, are also rising among Black individuals and Hispanic Americans.

Obesity may be one reason for growing cancer disparities, said Leah Ferrucci, PhD, MPH, assistant professor, epidemiology, Yale School of Public Health, New Haven, Connecticut. But, she added, the evidence is limited because Black individuals and Hispanic Americans are understudied.

When Do Extra Pounds Matter?

When it comes to cancer risk, at what point in life does excess weight, or weight gain, matter? Is the standard weight gain in middle age, for instance, as hazardous as being overweight or obese from a young age?

Some evidence suggests there’s no “safe” time for putting on excess pounds.

A recent meta-analysis concluded that weight gain at any point after age 18 years is associated with incremental increases in the risk for postmenopausal breast cancer. A 2023 study in JAMA Network Open found a similar pattern with colorectal and other gastrointestinal cancers: People who had sustained overweight or obesity from age 20 years through middle age faced an increased risk of developing those cancers after age 55 years. 

The timing of weight gain didn’t seem to matter either. The same elevated risk held among people who were normal weight in their younger years but became overweight after age 55 years.

Those studies focused on later-onset disease. But, in recent years, experts have tracked a troubling rise in early-onset cancers — those diagnosed before age 50 years — particularly gastrointestinal cancers. 

An obvious question, Dr. Meyerhardt said, is whether the growing prevalence of obesity among young people is partly to blame.

There’s some data to support that, he said. An analysis from the Nurses’ Health Study II found that women with obesity had double the risk for early-onset colorectal cancer as those with a normal BMI. And every 5-kg increase in weight after age 18 years was associated with a 9% increase in colorectal cancer risk.

But while obesity trends probably partly explain the rise in early-onset cancers, there is likely more to the story, Dr. Meyerhardt said.

“I think all of us who see an increasing number of patients under 50 with colorectal cancer know there’s a fair number who do not fit that [high BMI] profile,” he said. “There’s a fair number over 50 who don’t either.”

Does Weight Loss Help?

With all the evidence pointing to high BMI as a cancer risk factor, a logical conclusion is that weight loss should reduce that excess risk. However, Dr. Bea said, there’s actually little data to support that, and what exists comes from observational studies.

Some research has focused on people who had substantial weight loss after bariatric surgery, with encouraging results. A study published in JAMA found that among 5053 people who underwent bariatric surgery, 2.9% developed an obesity-related cancer over 10 years compared with 4.9% in the nonsurgery group.

Most people, however, aim for less dramatic weight loss, with the help of diet and exercise or sometimes medication. Some evidence shows that a modest degree of weight loss may lower the risks for postmenopausal breast and endometrial cancers. 

A 2020 pooled analysis found, for instance, that among women aged ≥ 50 years, those who lost as little as 2.0-4.5 kg, or 4.4-10.0 pounds, and kept it off for 10 years had a lower risk for breast cancer than women whose weight remained stable. And losing more weight — 9 kg, or about 20 pounds, or more — was even better for lowering cancer risk.

But other research suggests the opposite. A recent analysis found that people who lost weight within the past 2 years through diet and exercise had a higher risk for a range of cancers compared with those who did not lose weight. Overall, though, the increased risk was quite low.

Whatever the research does, or doesn’t, show about weight and cancer risk, Dr. Basen-Engquist said, it’s important that risk factors, obesity and otherwise, aren’t “used as blame tools.”

“With obesity, behavior certainly plays into it,” she said. “But there are so many influences on our behavior that are socially determined.”

Both Dr. Basen-Engquist and Dr. Meyerhardt said it’s important for clinicians to consider the individual in front of them and for everyone to set realistic expectations. 

People with obesity should not feel they have to become thin to be healthier, and no one has to leap from being sedentary to exercising several hours a week. 

“We don’t want patients to feel that if they don’t get to a stated goal in a guideline, it’s all for naught,” Dr. Meyerhardt said.

A version of this article appeared on Medscape.com.

TOPLINE:

A new study found that use of e-cigarettes by parents was associated with an increased risk for atopic dermatitis (AD) in children.

METHODOLOGY:

• AD is one of the most common inflammatory conditions in children and is linked to environmental risk factors, such as exposure to secondhand smoke and prenatal exposure to tobacco.
• To address the effect of e-cigarettes use on children, researchers conducted a cross-sectional analysis of data from the 2014-2018 National Health Interview Survey, a nationally representative sample of the US population.
• The analysis included 48,637,111 individuals (mean age, 8.4 years), with 6,354,515 (13%) indicating a history of AD (mean age, 8 years).

TAKEAWAY:

• The prevalence of parental e-cigarette use was 18.0% among individuals with AD, compared with 14.4% among those without AD.
• This corresponded to a 24% higher risk for AD associated with parental e-cigarette use (adjusted odds ratio, 1.24; 95% CI, 1.08-1.42).
• The association between e-cigarette use and AD in children held regardless of parent’s sex.

IN PRACTICE:

“Our results suggest that parental e-cigarette use was associated with pediatric AD,” the authors concluded. They noted that the authors of a previous study that associated e-cigarette use with AD in adults postulated that the cause was “the inflammatory state created by” e-cigarettes.

SOURCE:

This study, led by Gun Min Youn, Department of Dermatology, Stanford University School of Medicine, Stanford, California, was published online in JAMA Dermatology.

LIMITATIONS:

The cross-sectional survey design limited the ability to draw causal inferences. Defining e-cigarette use as a single past instance could affect the strength of the findings. Only past-year e-cigarette use was considered. Furthermore, data on pediatric cigarette or e-cigarette use, a potential confounder, were unavailable.

DISCLOSURES:

The study did not disclose funding information. One author reported receiving consultation fees outside the submitted work. No other disclosures were reported.

A version of this article appeared on Medscape.com.

TOPLINE:

A new study found that use of e-cigarettes by parents was associated with an increased risk for atopic dermatitis (AD) in children.

METHODOLOGY:

• AD is one of the most common inflammatory conditions in children and is linked to environmental risk factors, such as exposure to secondhand smoke and prenatal exposure to tobacco.
• To address the effect of e-cigarettes use on children, researchers conducted a cross-sectional analysis of data from the 2014-2018 National Health Interview Survey, a nationally representative sample of the US population.
• The analysis included 48,637,111 individuals (mean age, 8.4 years), with 6,354,515 (13%) indicating a history of AD (mean age, 8 years).

TAKEAWAY:

• The prevalence of parental e-cigarette use was 18.0% among individuals with AD, compared with 14.4% among those without AD.
• This corresponded to a 24% higher risk for AD associated with parental e-cigarette use (adjusted odds ratio, 1.24; 95% CI, 1.08-1.42).
• The association between e-cigarette use and AD in children held regardless of parent’s sex.

IN PRACTICE:

“Our results suggest that parental e-cigarette use was associated with pediatric AD,” the authors concluded. They noted that the authors of a previous study that associated e-cigarette use with AD in adults postulated that the cause was “the inflammatory state created by” e-cigarettes.

SOURCE:

This study, led by Gun Min Youn, Department of Dermatology, Stanford University School of Medicine, Stanford, California, was published online in JAMA Dermatology.

LIMITATIONS:

The cross-sectional survey design limited the ability to draw causal inferences. Defining e-cigarette use as a single past instance could affect the strength of the findings. Only past-year e-cigarette use was considered. Furthermore, data on pediatric cigarette or e-cigarette use, a potential confounder, were unavailable.

DISCLOSURES:

The study did not disclose funding information. One author reported receiving consultation fees outside the submitted work. No other disclosures were reported.

A version of this article appeared on Medscape.com.

TOPLINE:

A new study found that use of e-cigarettes by parents was associated with an increased risk for atopic dermatitis (AD) in children.

METHODOLOGY:

• AD is one of the most common inflammatory conditions in children and is linked to environmental risk factors, such as exposure to secondhand smoke and prenatal exposure to tobacco.
• To address the effect of e-cigarettes use on children, researchers conducted a cross-sectional analysis of data from the 2014-2018 National Health Interview Survey, a nationally representative sample of the US population.
• The analysis included 48,637,111 individuals (mean age, 8.4 years), with 6,354,515 (13%) indicating a history of AD (mean age, 8 years).

TAKEAWAY:

• The prevalence of parental e-cigarette use was 18.0% among individuals with AD, compared with 14.4% among those without AD.
• This corresponded to a 24% higher risk for AD associated with parental e-cigarette use (adjusted odds ratio, 1.24; 95% CI, 1.08-1.42).
• The association between e-cigarette use and AD in children held regardless of parent’s sex.

IN PRACTICE:

“Our results suggest that parental e-cigarette use was associated with pediatric AD,” the authors concluded. They noted that the authors of a previous study that associated e-cigarette use with AD in adults postulated that the cause was “the inflammatory state created by” e-cigarettes.

SOURCE:

This study, led by Gun Min Youn, Department of Dermatology, Stanford University School of Medicine, Stanford, California, was published online in JAMA Dermatology.

LIMITATIONS:

The cross-sectional survey design limited the ability to draw causal inferences. Defining e-cigarette use as a single past instance could affect the strength of the findings. Only past-year e-cigarette use was considered. Furthermore, data on pediatric cigarette or e-cigarette use, a potential confounder, were unavailable.

DISCLOSURES:

The study did not disclose funding information. One author reported receiving consultation fees outside the submitted work. No other disclosures were reported.

A version of this article appeared on Medscape.com.

TOPLINE:

An early serum cortisol concentration of > 237 nmol/L (> 8.6 μg/dL) has been validated as a safe and useful screening test with 100% specificity for predicting recovery of the hypothalamic-pituitary-adrenal (HPA) axis in patients on tapering regimes from long‐term chronic glucocorticoid therapy (CGT).

METHODOLOGY:

• A retrospective review of 250-µg Synacthen test (SST) results performed in patients on tapering CGT doses from a single-center rheumatology department over 12 months.
• A total of 60 SSTs were performed in 58 patients, all in the morning (7-12 AM) after withholding CGT for 48 hours.
• Peripheral blood was sampled for cortisol at baseline, 30 minutes, and 60 minutes.
• Adrenal insufficiency (AI) was defined as a peak serum cortisol concentration.

TAKEAWAY:

• The mean duration of CGT (all prednisolone) was 63 months, prescribed primarily for giant cell arteritis/polymyalgia rheumatica (48%) and inflammatory arthritis (18%), with a mean daily dose of 3.4 mg at the time of SST.
• With the investigators’ previously reported basal serum cortisol concentration of > 237 nmol/L (> 8.6 μg/dL) used to confirm an intact HPA axis, no patient with AI would have been missed, but 37 of 51 (73%) unnecessary SSTs in euadrenal patients would have been avoided.
• A basal serum cortisol concentration of > 227 nmol/L had a specificity of 100% for predicting passing the SST, while a basal serum cortisol concentration of ≤ 55 nmol/L had a 100% sensitivity for predicting failure.
• A mean daily prednisolone dosing at the time of SST in patients with AI was significantly higher than that with normal SSTs (5.7 vs 2.9 mg, respectively; P = .01).

IN PRACTICE:

“This offers a more rapid, convenient, and cost‐effective screening method for patients requiring biochemical assessment of the HPA axis with the potential for significant resource savings without any adverse impact on patient safety,” the authors wrote.

SOURCE:

The study was conducted by Ella Sharma, of the Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK, and colleagues and published online on May 19, 2024, as a letter in Clinical Endocrinology.

LIMITATIONS:

Not provided.

DISCLOSURES: 

Not provided.
 

A version of this article appeared on Medscape.com.

TOPLINE:

An early serum cortisol concentration of > 237 nmol/L (> 8.6 μg/dL) has been validated as a safe and useful screening test with 100% specificity for predicting recovery of the hypothalamic-pituitary-adrenal (HPA) axis in patients on tapering regimes from long‐term chronic glucocorticoid therapy (CGT).

METHODOLOGY:

• A retrospective review of 250-µg Synacthen test (SST) results performed in patients on tapering CGT doses from a single-center rheumatology department over 12 months.
• A total of 60 SSTs were performed in 58 patients, all in the morning (7-12 AM) after withholding CGT for 48 hours.
• Peripheral blood was sampled for cortisol at baseline, 30 minutes, and 60 minutes.
• Adrenal insufficiency (AI) was defined as a peak serum cortisol concentration.

TAKEAWAY:

• The mean duration of CGT (all prednisolone) was 63 months, prescribed primarily for giant cell arteritis/polymyalgia rheumatica (48%) and inflammatory arthritis (18%), with a mean daily dose of 3.4 mg at the time of SST.
• With the investigators’ previously reported basal serum cortisol concentration of > 237 nmol/L (> 8.6 μg/dL) used to confirm an intact HPA axis, no patient with AI would have been missed, but 37 of 51 (73%) unnecessary SSTs in euadrenal patients would have been avoided.
• A basal serum cortisol concentration of > 227 nmol/L had a specificity of 100% for predicting passing the SST, while a basal serum cortisol concentration of ≤ 55 nmol/L had a 100% sensitivity for predicting failure.
• A mean daily prednisolone dosing at the time of SST in patients with AI was significantly higher than that with normal SSTs (5.7 vs 2.9 mg, respectively; P = .01).

IN PRACTICE:

“This offers a more rapid, convenient, and cost‐effective screening method for patients requiring biochemical assessment of the HPA axis with the potential for significant resource savings without any adverse impact on patient safety,” the authors wrote.

SOURCE:

The study was conducted by Ella Sharma, of the Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK, and colleagues and published online on May 19, 2024, as a letter in Clinical Endocrinology.

LIMITATIONS:

Not provided.

DISCLOSURES: 

Not provided.
 

A version of this article appeared on Medscape.com.

TOPLINE:

An early serum cortisol concentration of > 237 nmol/L (> 8.6 μg/dL) has been validated as a safe and useful screening test with 100% specificity for predicting recovery of the hypothalamic-pituitary-adrenal (HPA) axis in patients on tapering regimes from long‐term chronic glucocorticoid therapy (CGT).

METHODOLOGY:

• A retrospective review of 250-µg Synacthen test (SST) results performed in patients on tapering CGT doses from a single-center rheumatology department over 12 months.
• A total of 60 SSTs were performed in 58 patients, all in the morning (7-12 AM) after withholding CGT for 48 hours.
• Peripheral blood was sampled for cortisol at baseline, 30 minutes, and 60 minutes.
• Adrenal insufficiency (AI) was defined as a peak serum cortisol concentration.

TAKEAWAY:

• The mean duration of CGT (all prednisolone) was 63 months, prescribed primarily for giant cell arteritis/polymyalgia rheumatica (48%) and inflammatory arthritis (18%), with a mean daily dose of 3.4 mg at the time of SST.
• With the investigators’ previously reported basal serum cortisol concentration of > 237 nmol/L (> 8.6 μg/dL) used to confirm an intact HPA axis, no patient with AI would have been missed, but 37 of 51 (73%) unnecessary SSTs in euadrenal patients would have been avoided.
• A basal serum cortisol concentration of > 227 nmol/L had a specificity of 100% for predicting passing the SST, while a basal serum cortisol concentration of ≤ 55 nmol/L had a 100% sensitivity for predicting failure.
• A mean daily prednisolone dosing at the time of SST in patients with AI was significantly higher than that with normal SSTs (5.7 vs 2.9 mg, respectively; P = .01).

IN PRACTICE:

“This offers a more rapid, convenient, and cost‐effective screening method for patients requiring biochemical assessment of the HPA axis with the potential for significant resource savings without any adverse impact on patient safety,” the authors wrote.

SOURCE:

The study was conducted by Ella Sharma, of the Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK, and colleagues and published online on May 19, 2024, as a letter in Clinical Endocrinology.

LIMITATIONS:

Not provided.

DISCLOSURES: 

Not provided.
 

A version of this article appeared on Medscape.com.

Attendees of the 2024 American Academy of Dermatology annual meeting in San Diego, California, were eager to delve into the latest trends and advancements in dermatology and dermatologic surgery. This article provides a few key takeaways for residents from a range of engaging sessions, with an emphasis on procedural dermatology and physician health and well-being.

Practical Applications of Surgical Enhancements

In an informative session dedicated to dermatologic surgeons and their patients, “Simple Tricks and Practical Tips to Optimize the Surgical Experience for You and Your Patients,” attendees learned practical tips for enhancing the surgical experience. The discussion spanned various aspects of surgery, from managing preoperative anxiety with anxiolytics such as midazolam to the strategic use of skin hooks for delicate tissue manipulation. Midazolam is fast acting and its use is tailored to patient factors such as weight, hepatic function, and prior use. An innovative anxiety management algorithm combining “talkesethesia” with other methods such as anodynes and benzodiazepines underscored the importance of a calm patient in successful surgical outcomes. Talkesthesia involves engaging patients in soothing and distracting conversation throughout the procedure. This technique can include discussing nonmedical topics of interest with the patient—such as their hobbies, family, or favorite movies—to divert their attention from the surgical process and reduce anxiety. By creating a friendly and reassuring atmosphere, talkesthesia helps to establish trust between the patient and the medical team, ultimately contributing to a more relaxed and cooperative patient.¹

The utility of skin hooks also was discussed, with an emphasis on their role in ensuring gentle tissue handling. The modified buried vertical mattress technique was discussed for its added benefits in wound approximation and strength. Emphasis was placed on the importance of maintaining a clear surgical field by electrocautery to ensure optimal visibility.

Focusing on the treatment of skin cancer, curettage alone was touted as a viable alternative to electrodesiccation and curettage, especially in reducing postoperative hypopigmentation while maintaining high cure rates. This method was shown to be effective in treating basal cell carcinoma and well-differentiated squamous cell carcinoma.^2,3

Suturing techniques such as pulley, purse-string, and buried sutures offer efficiencies in time, cost, and improved healing in high-tension areas. These methods can contribute to postsurgical aesthetic and functional outcomes. Additionally, Dr. Desiree Ratner shared her tips for painless local anesthesia techniques, emphasizing the importance of patient comfort through methods such as slow injection and buffering of lidocaine. The next time you give a local anesthetic, try this technique to minimize pain: using a 30-gauge needle, hold the syringe with the bevel up, insert only the bevel into the skin (needle tip goes into the papillary dermis), and numb superficially around the periphery using as little volume as possible. Keep pressure slow and steady without moving the needle, then insert the needle only in previously anesthetized areas, numbing deeply only after the entire periphery has been anesthetized.

The session concluded with the recommendation to provide patients with a goody bag containing postoperative supplies. This thoughtful gesture not only enhances patient satisfaction but also addresses the practical aspect of postsurgery care, offering an inexpensive yet impactful way to ensure patients have the necessary supplies for their recovery.

Take-Home Point—This session distilled essential surgical enhancements into practical applications, emphasizing the importance of anxiety management, delicate tissue handling, innovative suturing techniques, and thoughtful patient care postsurgery. The overarching message highlighted the synergy between technical skill and patient-centric approaches in optimizing surgical outcomes, underscoring the significance of attention to detail in every aspect of patient care, from preoperative preparation to postoperative recovery.

Optimizing Safety and Ergonomics in Surgical Practices

Understanding the dynamics of surgical plume is crucial to safety in the operating room. The carcinogenic risk associated with surgical smoke is not trivial: exposure to the plume generated by monopolar electrocautery in a single day can be equivalent to smoking approximately 30 cigarettes, and a surgeon’s lifetime cancer risk from polycyclic aromatic hydrocarbons exposure is alarmingly high.⁴ To mitigate these risks, several strategies were recommended, including using lower-energy settings, choosing indirect or bipolar cautery, and ensuring efficient room ventilation with HEPA (high-efficiency particulate absorbing) filters to turn over air frequently. Additionally, employing the use of smoke evacuators and suction devices with proper filters can reduce particulate matter in the operating room.

The importance of the surgeon’s posture during procedures also was emphasized for ergonomic benefits and to minimize fatigue. Maintaining a neutral stance with the core and glutes engaged, standing on the balls of the feet, and aligning the table height to keep the hands at the lower chest level were recommended; this not only helps in reducing strain but also in maintaining precision during surgical tasks.

The surgeons on the panel also highlighted the novel use of hydrocolloid dressings with tattoo lasers, electrodesiccation and curettage for treating rhinophyma, and purse-string closure for chest defects as evolving practices to enhance outcomes and safety.

The session offered valuable insights into suturing techniques, advocating for the use of deep sutures—­ideally Monocryl (Ethicon US, LLC)—for superficial closures and fast-absorbing gut sutures for patients who are not expected to return for suture removal. Keith LeBlanc Jr, MD, shared one of his favorite tricks for suturing fragile, sun-damaged skin on the forearm in elderly patients: apply adhesive skin closures aligned parallel to the suture line, then suture through them for extra support. This can help ensure a more secure closure.

In situations when no deep sutures are required, such as on the hair-bearing scalp, large bites through the galea using monofilament nonabsorbable sutures for up to 14 days or staples can offer favorable closures and enhanced hemostasis. Tranexamic acid has emerged as a versatile hemostatic agent—available in multiple forms ranging from direct injection to topical applications—and is cost-effective, enhancing its accessibility in various surgical settings.

A high proportion of patients are taken aback by the length of the scar following removal of what they perceive as a small skin cancer. Leslie Storey, MD, cleverly recommended using the back of a glove to mark surgical ­planning, giving the patient a visual guide for anticipating the size of the excision. This is a simple yet effective approach to enhance patient understanding and informed consent. 

Lastly, the notion that “patients remember you if you don’t cause them pain” resonated deeply, underlining the importance of gentle techniques such as pinching the suture rather than pushing the wound edges together and asking assistants to maintain tension without obstructing the field. In the words of Seth Matarasso, MD: “If you pain ‘em, you won’t retain ‘em!”

Take-Home Point—The take-home message from the session was a comprehensive approach to surgical excellence that aligns technical proficiency with a strong emphasis on safety, patient comfort, and operative efficiency. Surgeons were advised to adopt practices that reduce the risks associated with surgical plume, maintain ergonomic discipline, and apply innovative suturing techniques to enhance patient outcomes. Compassionate patient care, innovative use of materials and methods, and a commitment to continual learning and adaptation of new evidence-based practices are paramount for the modern surgeon.

Approaches for Facial Reconstruction

The intricacies of multisubunit facial reconstruction were explored in a session that blended the pursuit of aesthetic harmony with functional restoration, “Simplifying the Complex: Reconstructing Multisubunit Defects.” The session began with an introduction to flap design principles, emphasizing the importance of thorough defect analysis and the strategic design of flaps. A key objective within this framework is the integration of the flap within existing cosmetic subunits to avoid unwanted effects such as unintended eyebrow elevation.

The concept of tissue reservoirs was discussed,focusing on regions such as the glabella as potential sources for skin recruitment. This then transitioned into a nuanced discussion on incision planning, underscoring the significance of aligning incision lines with relaxed skin tension lines to enhance healing and minimize scarring.

The topic of delayed reconstruction also was introduced as a deliberate tactic for high-risk tumor management. This approach allows for an in-depth pathologic examination and provides patients with more time for psychological adjustment, which may be particularly important for those with complex medical histories or those who require staged surgical interventions.

In a thorough examination of flap design techniques, the session highlighted the bilobed transposition flap as a versatile choice for nasal reconstruction, particularly apt for the distal third of the nose due to its design that harnesses skin from nonadjacent areas. Accompanying this was an exploration of Zitelli modifications, which enhance the bilobed flap by reducing issues such as pincushioning through a moderated rotation angle and the strategic incorporation of a Burow triangle.

Finally, the interpolated paranasal flap was discussed. This technique is designed to reduce the risk for cheek asymmetry and is suitable for patients with generous donor sites; however, this method requires diligent evaluation to avoid complications such as external nasal valve collapse.

Take-Home Point—This session highlighted approaches in facial reconstruction, emphasizing the necessity of strategic flap design and meticulous incision planning to maintain aesthetic harmony and functional integrity.

Strategies for Improving Physician Well-Being

Evidence-based recommendations to support physicians’ well-being are crucial as the health care system becomes increasingly demanding. Instead of focusing on aspects of the health care system that frequently are outside of physicians’ control, the session “A Realistic and Evidence-Based Roadmap for Thriving in Life and Career” discussed many practical, self-empowering tools and strategies to lead a happier and healthier life—both personally and professionally.

The speakers cautioned against the concept of an “unlimited ceiling” for achieving a certain goal, where an unlimited amount of time and energy is allowed to be dedicated to a given task over a period of time. They highlighted the potential consequences of this approach, such as stress, dissatisfaction, and ultimately burnout. The speakers explored the concept of well-being as a continuous journey rather than a destination, emphasizing that it is not the opposite of burnout. To promote well-being, the speakers advocated for utilizing concepts rooted in positive psychology to empower the individual rather than longing for a different environment. They hypothesized that changing one’s life can be accomplished by changing one’s mind, independent of the environment.

The roadmap for physician well-being, as presented by clinical psychologist Amy MacDonald, PsyD, commenced with urging the audience to introspect on situations and experiences, categorizing them into “feel good” and “feel bad” buckets. For every feel-good event, Dr. MacDonald proposed 5 mental exercises for optimized well-being: (1) control/increase: evaluate whether one can control or increase the frequency of the event; (2) consider: reflect on why this event feels good and explore other aspects to gain any additional joy from the event; (3) share: recognize that some feel goods are more joyous when shared; (4) value: connect the feel-good experiences with personal core values, as research shows value affirmations can buffer neuroendocrine and psychological stress responses; and (5) savor: deliberately relish each small or notable feel-good moment.

Similarly, after labeling an event as a feel-bad experience, Dr. MacDonald encouraged the audience to go through mental exercises to strengthen their well-being journey; however, before proceeding, she highlighted the importance of arming ourselves with self-compassion. The 5 mental exercises to address feel bads include (1) solve: assess whether we have control over the situation and attempt to make changes if possible; (2) reframe: explore new perspectives and assess assumptions without minimizing the situation; (3) connect: embrace the positive impact of safe human connections on our stress response; (4) reflect: search curiously using a compassionate lens for any existing patterns of reactions; and (5) accept and pivot: allow thoughts and feelings to exist and pivot to values-based engagement without waiting for the environment to change. Consistently seeking and appreciating feel goods while addressing rather than suppressing the feel bads can lead to joyful satisfaction and overall well-being.

Additional pearls for optimizing physician well-being included accurately labeling emotions rather than lumping them into an overarching theme (eg, stressed), avoiding comparisons with others, choosing courage over comfort, celebrating vulnerability, and embracing the ability to say no to prioritize engagements aligned with one’s purpose and values. Additional resources were shared for further reading, including Emotional Agility by Susan David, Daring Greatly and Rising Strong by Brené Brown, and Self-Compassion by Kristin Neff.

Take-Home Point—This lecture highlighted key strategies for physicians to improve their well-being, emphasizing self-empowerment and practical tools over external circumstances. It distinguished between productive and destructive influences on satisfaction, and emphasized decision-making aligned with personal values. The concept of well-being as a journey, not a destination, was central, encouraging positive psychology and self-reflection to enhance fulfillment. By focusing on amplifying feel-good experiences and addressing feel-bad experiences with resilience, the lecture advocated for internal over external change, offering a pathway to a balanced and satisfying professional and personal life for physicians.

Final Thoughts

The recent American Academy of Dermatology meeting offered valuable insights and practical pearls to enhance surgical practices and promote physician well-being, in addition to a wide range of topics beyond what is mentioned in this article. From optimizing surgical techniques to prioritizing patient care and safety, the sessions underscored the importance of continuous learning and adaptation in the ever-evolving field of dermatology. As we reflect on the lessons learned and the camaraderie shared during this gathering, let us carry forward these teachings to improve patient outcomes, foster innovation, and cultivate resilience in our pursuit of excellence. Together, we can continue to push the boundaries of dermatologic care while nurturing our own well-being and that of our colleagues, ensuring a brighter future for both patients and practitioners alike.



Acknowledgments—Sultan H. Qiblawi, MD, MBA; Eva Shelton, MD; and Christy T. Behnam, MD (all from Madison, Wisconsin), shared their insights and key takeaways from American Academy of Dermatology lecturers, which enriched the content of this article.

Attendees of the 2024 American Academy of Dermatology annual meeting in San Diego, California, were eager to delve into the latest trends and advancements in dermatology and dermatologic surgery. This article provides a few key takeaways for residents from a range of engaging sessions, with an emphasis on procedural dermatology and physician health and well-being.

Practical Applications of Surgical Enhancements

In an informative session dedicated to dermatologic surgeons and their patients, “Simple Tricks and Practical Tips to Optimize the Surgical Experience for You and Your Patients,” attendees learned practical tips for enhancing the surgical experience. The discussion spanned various aspects of surgery, from managing preoperative anxiety with anxiolytics such as midazolam to the strategic use of skin hooks for delicate tissue manipulation. Midazolam is fast acting and its use is tailored to patient factors such as weight, hepatic function, and prior use. An innovative anxiety management algorithm combining “talkesethesia” with other methods such as anodynes and benzodiazepines underscored the importance of a calm patient in successful surgical outcomes. Talkesthesia involves engaging patients in soothing and distracting conversation throughout the procedure. This technique can include discussing nonmedical topics of interest with the patient—such as their hobbies, family, or favorite movies—to divert their attention from the surgical process and reduce anxiety. By creating a friendly and reassuring atmosphere, talkesthesia helps to establish trust between the patient and the medical team, ultimately contributing to a more relaxed and cooperative patient.¹

The utility of skin hooks also was discussed, with an emphasis on their role in ensuring gentle tissue handling. The modified buried vertical mattress technique was discussed for its added benefits in wound approximation and strength. Emphasis was placed on the importance of maintaining a clear surgical field by electrocautery to ensure optimal visibility.

Focusing on the treatment of skin cancer, curettage alone was touted as a viable alternative to electrodesiccation and curettage, especially in reducing postoperative hypopigmentation while maintaining high cure rates. This method was shown to be effective in treating basal cell carcinoma and well-differentiated squamous cell carcinoma.^2,3

Suturing techniques such as pulley, purse-string, and buried sutures offer efficiencies in time, cost, and improved healing in high-tension areas. These methods can contribute to postsurgical aesthetic and functional outcomes. Additionally, Dr. Desiree Ratner shared her tips for painless local anesthesia techniques, emphasizing the importance of patient comfort through methods such as slow injection and buffering of lidocaine. The next time you give a local anesthetic, try this technique to minimize pain: using a 30-gauge needle, hold the syringe with the bevel up, insert only the bevel into the skin (needle tip goes into the papillary dermis), and numb superficially around the periphery using as little volume as possible. Keep pressure slow and steady without moving the needle, then insert the needle only in previously anesthetized areas, numbing deeply only after the entire periphery has been anesthetized.

The session concluded with the recommendation to provide patients with a goody bag containing postoperative supplies. This thoughtful gesture not only enhances patient satisfaction but also addresses the practical aspect of postsurgery care, offering an inexpensive yet impactful way to ensure patients have the necessary supplies for their recovery.

Take-Home Point—This session distilled essential surgical enhancements into practical applications, emphasizing the importance of anxiety management, delicate tissue handling, innovative suturing techniques, and thoughtful patient care postsurgery. The overarching message highlighted the synergy between technical skill and patient-centric approaches in optimizing surgical outcomes, underscoring the significance of attention to detail in every aspect of patient care, from preoperative preparation to postoperative recovery.

Optimizing Safety and Ergonomics in Surgical Practices

Understanding the dynamics of surgical plume is crucial to safety in the operating room. The carcinogenic risk associated with surgical smoke is not trivial: exposure to the plume generated by monopolar electrocautery in a single day can be equivalent to smoking approximately 30 cigarettes, and a surgeon’s lifetime cancer risk from polycyclic aromatic hydrocarbons exposure is alarmingly high.⁴ To mitigate these risks, several strategies were recommended, including using lower-energy settings, choosing indirect or bipolar cautery, and ensuring efficient room ventilation with HEPA (high-efficiency particulate absorbing) filters to turn over air frequently. Additionally, employing the use of smoke evacuators and suction devices with proper filters can reduce particulate matter in the operating room.

The importance of the surgeon’s posture during procedures also was emphasized for ergonomic benefits and to minimize fatigue. Maintaining a neutral stance with the core and glutes engaged, standing on the balls of the feet, and aligning the table height to keep the hands at the lower chest level were recommended; this not only helps in reducing strain but also in maintaining precision during surgical tasks.

The surgeons on the panel also highlighted the novel use of hydrocolloid dressings with tattoo lasers, electrodesiccation and curettage for treating rhinophyma, and purse-string closure for chest defects as evolving practices to enhance outcomes and safety.

The session offered valuable insights into suturing techniques, advocating for the use of deep sutures—­ideally Monocryl (Ethicon US, LLC)—for superficial closures and fast-absorbing gut sutures for patients who are not expected to return for suture removal. Keith LeBlanc Jr, MD, shared one of his favorite tricks for suturing fragile, sun-damaged skin on the forearm in elderly patients: apply adhesive skin closures aligned parallel to the suture line, then suture through them for extra support. This can help ensure a more secure closure.

In situations when no deep sutures are required, such as on the hair-bearing scalp, large bites through the galea using monofilament nonabsorbable sutures for up to 14 days or staples can offer favorable closures and enhanced hemostasis. Tranexamic acid has emerged as a versatile hemostatic agent—available in multiple forms ranging from direct injection to topical applications—and is cost-effective, enhancing its accessibility in various surgical settings.

A high proportion of patients are taken aback by the length of the scar following removal of what they perceive as a small skin cancer. Leslie Storey, MD, cleverly recommended using the back of a glove to mark surgical ­planning, giving the patient a visual guide for anticipating the size of the excision. This is a simple yet effective approach to enhance patient understanding and informed consent. 

Lastly, the notion that “patients remember you if you don’t cause them pain” resonated deeply, underlining the importance of gentle techniques such as pinching the suture rather than pushing the wound edges together and asking assistants to maintain tension without obstructing the field. In the words of Seth Matarasso, MD: “If you pain ‘em, you won’t retain ‘em!”

Take-Home Point—The take-home message from the session was a comprehensive approach to surgical excellence that aligns technical proficiency with a strong emphasis on safety, patient comfort, and operative efficiency. Surgeons were advised to adopt practices that reduce the risks associated with surgical plume, maintain ergonomic discipline, and apply innovative suturing techniques to enhance patient outcomes. Compassionate patient care, innovative use of materials and methods, and a commitment to continual learning and adaptation of new evidence-based practices are paramount for the modern surgeon.

Approaches for Facial Reconstruction

The intricacies of multisubunit facial reconstruction were explored in a session that blended the pursuit of aesthetic harmony with functional restoration, “Simplifying the Complex: Reconstructing Multisubunit Defects.” The session began with an introduction to flap design principles, emphasizing the importance of thorough defect analysis and the strategic design of flaps. A key objective within this framework is the integration of the flap within existing cosmetic subunits to avoid unwanted effects such as unintended eyebrow elevation.

The concept of tissue reservoirs was discussed,focusing on regions such as the glabella as potential sources for skin recruitment. This then transitioned into a nuanced discussion on incision planning, underscoring the significance of aligning incision lines with relaxed skin tension lines to enhance healing and minimize scarring.

The topic of delayed reconstruction also was introduced as a deliberate tactic for high-risk tumor management. This approach allows for an in-depth pathologic examination and provides patients with more time for psychological adjustment, which may be particularly important for those with complex medical histories or those who require staged surgical interventions.

In a thorough examination of flap design techniques, the session highlighted the bilobed transposition flap as a versatile choice for nasal reconstruction, particularly apt for the distal third of the nose due to its design that harnesses skin from nonadjacent areas. Accompanying this was an exploration of Zitelli modifications, which enhance the bilobed flap by reducing issues such as pincushioning through a moderated rotation angle and the strategic incorporation of a Burow triangle.

Finally, the interpolated paranasal flap was discussed. This technique is designed to reduce the risk for cheek asymmetry and is suitable for patients with generous donor sites; however, this method requires diligent evaluation to avoid complications such as external nasal valve collapse.

Take-Home Point—This session highlighted approaches in facial reconstruction, emphasizing the necessity of strategic flap design and meticulous incision planning to maintain aesthetic harmony and functional integrity.

Strategies for Improving Physician Well-Being

Evidence-based recommendations to support physicians’ well-being are crucial as the health care system becomes increasingly demanding. Instead of focusing on aspects of the health care system that frequently are outside of physicians’ control, the session “A Realistic and Evidence-Based Roadmap for Thriving in Life and Career” discussed many practical, self-empowering tools and strategies to lead a happier and healthier life—both personally and professionally.

The speakers cautioned against the concept of an “unlimited ceiling” for achieving a certain goal, where an unlimited amount of time and energy is allowed to be dedicated to a given task over a period of time. They highlighted the potential consequences of this approach, such as stress, dissatisfaction, and ultimately burnout. The speakers explored the concept of well-being as a continuous journey rather than a destination, emphasizing that it is not the opposite of burnout. To promote well-being, the speakers advocated for utilizing concepts rooted in positive psychology to empower the individual rather than longing for a different environment. They hypothesized that changing one’s life can be accomplished by changing one’s mind, independent of the environment.

The roadmap for physician well-being, as presented by clinical psychologist Amy MacDonald, PsyD, commenced with urging the audience to introspect on situations and experiences, categorizing them into “feel good” and “feel bad” buckets. For every feel-good event, Dr. MacDonald proposed 5 mental exercises for optimized well-being: (1) control/increase: evaluate whether one can control or increase the frequency of the event; (2) consider: reflect on why this event feels good and explore other aspects to gain any additional joy from the event; (3) share: recognize that some feel goods are more joyous when shared; (4) value: connect the feel-good experiences with personal core values, as research shows value affirmations can buffer neuroendocrine and psychological stress responses; and (5) savor: deliberately relish each small or notable feel-good moment.

Similarly, after labeling an event as a feel-bad experience, Dr. MacDonald encouraged the audience to go through mental exercises to strengthen their well-being journey; however, before proceeding, she highlighted the importance of arming ourselves with self-compassion. The 5 mental exercises to address feel bads include (1) solve: assess whether we have control over the situation and attempt to make changes if possible; (2) reframe: explore new perspectives and assess assumptions without minimizing the situation; (3) connect: embrace the positive impact of safe human connections on our stress response; (4) reflect: search curiously using a compassionate lens for any existing patterns of reactions; and (5) accept and pivot: allow thoughts and feelings to exist and pivot to values-based engagement without waiting for the environment to change. Consistently seeking and appreciating feel goods while addressing rather than suppressing the feel bads can lead to joyful satisfaction and overall well-being.

Additional pearls for optimizing physician well-being included accurately labeling emotions rather than lumping them into an overarching theme (eg, stressed), avoiding comparisons with others, choosing courage over comfort, celebrating vulnerability, and embracing the ability to say no to prioritize engagements aligned with one’s purpose and values. Additional resources were shared for further reading, including Emotional Agility by Susan David, Daring Greatly and Rising Strong by Brené Brown, and Self-Compassion by Kristin Neff.

Take-Home Point—This lecture highlighted key strategies for physicians to improve their well-being, emphasizing self-empowerment and practical tools over external circumstances. It distinguished between productive and destructive influences on satisfaction, and emphasized decision-making aligned with personal values. The concept of well-being as a journey, not a destination, was central, encouraging positive psychology and self-reflection to enhance fulfillment. By focusing on amplifying feel-good experiences and addressing feel-bad experiences with resilience, the lecture advocated for internal over external change, offering a pathway to a balanced and satisfying professional and personal life for physicians.

Final Thoughts

The recent American Academy of Dermatology meeting offered valuable insights and practical pearls to enhance surgical practices and promote physician well-being, in addition to a wide range of topics beyond what is mentioned in this article. From optimizing surgical techniques to prioritizing patient care and safety, the sessions underscored the importance of continuous learning and adaptation in the ever-evolving field of dermatology. As we reflect on the lessons learned and the camaraderie shared during this gathering, let us carry forward these teachings to improve patient outcomes, foster innovation, and cultivate resilience in our pursuit of excellence. Together, we can continue to push the boundaries of dermatologic care while nurturing our own well-being and that of our colleagues, ensuring a brighter future for both patients and practitioners alike.



Acknowledgments—Sultan H. Qiblawi, MD, MBA; Eva Shelton, MD; and Christy T. Behnam, MD (all from Madison, Wisconsin), shared their insights and key takeaways from American Academy of Dermatology lecturers, which enriched the content of this article.

Attendees of the 2024 American Academy of Dermatology annual meeting in San Diego, California, were eager to delve into the latest trends and advancements in dermatology and dermatologic surgery. This article provides a few key takeaways for residents from a range of engaging sessions, with an emphasis on procedural dermatology and physician health and well-being.

Practical Applications of Surgical Enhancements

In an informative session dedicated to dermatologic surgeons and their patients, “Simple Tricks and Practical Tips to Optimize the Surgical Experience for You and Your Patients,” attendees learned practical tips for enhancing the surgical experience. The discussion spanned various aspects of surgery, from managing preoperative anxiety with anxiolytics such as midazolam to the strategic use of skin hooks for delicate tissue manipulation. Midazolam is fast acting and its use is tailored to patient factors such as weight, hepatic function, and prior use. An innovative anxiety management algorithm combining “talkesethesia” with other methods such as anodynes and benzodiazepines underscored the importance of a calm patient in successful surgical outcomes. Talkesthesia involves engaging patients in soothing and distracting conversation throughout the procedure. This technique can include discussing nonmedical topics of interest with the patient—such as their hobbies, family, or favorite movies—to divert their attention from the surgical process and reduce anxiety. By creating a friendly and reassuring atmosphere, talkesthesia helps to establish trust between the patient and the medical team, ultimately contributing to a more relaxed and cooperative patient.¹

The utility of skin hooks also was discussed, with an emphasis on their role in ensuring gentle tissue handling. The modified buried vertical mattress technique was discussed for its added benefits in wound approximation and strength. Emphasis was placed on the importance of maintaining a clear surgical field by electrocautery to ensure optimal visibility.

Focusing on the treatment of skin cancer, curettage alone was touted as a viable alternative to electrodesiccation and curettage, especially in reducing postoperative hypopigmentation while maintaining high cure rates. This method was shown to be effective in treating basal cell carcinoma and well-differentiated squamous cell carcinoma.^2,3

Suturing techniques such as pulley, purse-string, and buried sutures offer efficiencies in time, cost, and improved healing in high-tension areas. These methods can contribute to postsurgical aesthetic and functional outcomes. Additionally, Dr. Desiree Ratner shared her tips for painless local anesthesia techniques, emphasizing the importance of patient comfort through methods such as slow injection and buffering of lidocaine. The next time you give a local anesthetic, try this technique to minimize pain: using a 30-gauge needle, hold the syringe with the bevel up, insert only the bevel into the skin (needle tip goes into the papillary dermis), and numb superficially around the periphery using as little volume as possible. Keep pressure slow and steady without moving the needle, then insert the needle only in previously anesthetized areas, numbing deeply only after the entire periphery has been anesthetized.

The session concluded with the recommendation to provide patients with a goody bag containing postoperative supplies. This thoughtful gesture not only enhances patient satisfaction but also addresses the practical aspect of postsurgery care, offering an inexpensive yet impactful way to ensure patients have the necessary supplies for their recovery.

Take-Home Point—This session distilled essential surgical enhancements into practical applications, emphasizing the importance of anxiety management, delicate tissue handling, innovative suturing techniques, and thoughtful patient care postsurgery. The overarching message highlighted the synergy between technical skill and patient-centric approaches in optimizing surgical outcomes, underscoring the significance of attention to detail in every aspect of patient care, from preoperative preparation to postoperative recovery.

Optimizing Safety and Ergonomics in Surgical Practices

Understanding the dynamics of surgical plume is crucial to safety in the operating room. The carcinogenic risk associated with surgical smoke is not trivial: exposure to the plume generated by monopolar electrocautery in a single day can be equivalent to smoking approximately 30 cigarettes, and a surgeon’s lifetime cancer risk from polycyclic aromatic hydrocarbons exposure is alarmingly high.⁴ To mitigate these risks, several strategies were recommended, including using lower-energy settings, choosing indirect or bipolar cautery, and ensuring efficient room ventilation with HEPA (high-efficiency particulate absorbing) filters to turn over air frequently. Additionally, employing the use of smoke evacuators and suction devices with proper filters can reduce particulate matter in the operating room.

The importance of the surgeon’s posture during procedures also was emphasized for ergonomic benefits and to minimize fatigue. Maintaining a neutral stance with the core and glutes engaged, standing on the balls of the feet, and aligning the table height to keep the hands at the lower chest level were recommended; this not only helps in reducing strain but also in maintaining precision during surgical tasks.

The surgeons on the panel also highlighted the novel use of hydrocolloid dressings with tattoo lasers, electrodesiccation and curettage for treating rhinophyma, and purse-string closure for chest defects as evolving practices to enhance outcomes and safety.

The session offered valuable insights into suturing techniques, advocating for the use of deep sutures—­ideally Monocryl (Ethicon US, LLC)—for superficial closures and fast-absorbing gut sutures for patients who are not expected to return for suture removal. Keith LeBlanc Jr, MD, shared one of his favorite tricks for suturing fragile, sun-damaged skin on the forearm in elderly patients: apply adhesive skin closures aligned parallel to the suture line, then suture through them for extra support. This can help ensure a more secure closure.

In situations when no deep sutures are required, such as on the hair-bearing scalp, large bites through the galea using monofilament nonabsorbable sutures for up to 14 days or staples can offer favorable closures and enhanced hemostasis. Tranexamic acid has emerged as a versatile hemostatic agent—available in multiple forms ranging from direct injection to topical applications—and is cost-effective, enhancing its accessibility in various surgical settings.

A high proportion of patients are taken aback by the length of the scar following removal of what they perceive as a small skin cancer. Leslie Storey, MD, cleverly recommended using the back of a glove to mark surgical ­planning, giving the patient a visual guide for anticipating the size of the excision. This is a simple yet effective approach to enhance patient understanding and informed consent. 

Lastly, the notion that “patients remember you if you don’t cause them pain” resonated deeply, underlining the importance of gentle techniques such as pinching the suture rather than pushing the wound edges together and asking assistants to maintain tension without obstructing the field. In the words of Seth Matarasso, MD: “If you pain ‘em, you won’t retain ‘em!”

Take-Home Point—The take-home message from the session was a comprehensive approach to surgical excellence that aligns technical proficiency with a strong emphasis on safety, patient comfort, and operative efficiency. Surgeons were advised to adopt practices that reduce the risks associated with surgical plume, maintain ergonomic discipline, and apply innovative suturing techniques to enhance patient outcomes. Compassionate patient care, innovative use of materials and methods, and a commitment to continual learning and adaptation of new evidence-based practices are paramount for the modern surgeon.

Approaches for Facial Reconstruction

The intricacies of multisubunit facial reconstruction were explored in a session that blended the pursuit of aesthetic harmony with functional restoration, “Simplifying the Complex: Reconstructing Multisubunit Defects.” The session began with an introduction to flap design principles, emphasizing the importance of thorough defect analysis and the strategic design of flaps. A key objective within this framework is the integration of the flap within existing cosmetic subunits to avoid unwanted effects such as unintended eyebrow elevation.

The concept of tissue reservoirs was discussed,focusing on regions such as the glabella as potential sources for skin recruitment. This then transitioned into a nuanced discussion on incision planning, underscoring the significance of aligning incision lines with relaxed skin tension lines to enhance healing and minimize scarring.

The topic of delayed reconstruction also was introduced as a deliberate tactic for high-risk tumor management. This approach allows for an in-depth pathologic examination and provides patients with more time for psychological adjustment, which may be particularly important for those with complex medical histories or those who require staged surgical interventions.

In a thorough examination of flap design techniques, the session highlighted the bilobed transposition flap as a versatile choice for nasal reconstruction, particularly apt for the distal third of the nose due to its design that harnesses skin from nonadjacent areas. Accompanying this was an exploration of Zitelli modifications, which enhance the bilobed flap by reducing issues such as pincushioning through a moderated rotation angle and the strategic incorporation of a Burow triangle.

Finally, the interpolated paranasal flap was discussed. This technique is designed to reduce the risk for cheek asymmetry and is suitable for patients with generous donor sites; however, this method requires diligent evaluation to avoid complications such as external nasal valve collapse.

Take-Home Point—This session highlighted approaches in facial reconstruction, emphasizing the necessity of strategic flap design and meticulous incision planning to maintain aesthetic harmony and functional integrity.

Strategies for Improving Physician Well-Being

Evidence-based recommendations to support physicians’ well-being are crucial as the health care system becomes increasingly demanding. Instead of focusing on aspects of the health care system that frequently are outside of physicians’ control, the session “A Realistic and Evidence-Based Roadmap for Thriving in Life and Career” discussed many practical, self-empowering tools and strategies to lead a happier and healthier life—both personally and professionally.

The speakers cautioned against the concept of an “unlimited ceiling” for achieving a certain goal, where an unlimited amount of time and energy is allowed to be dedicated to a given task over a period of time. They highlighted the potential consequences of this approach, such as stress, dissatisfaction, and ultimately burnout. The speakers explored the concept of well-being as a continuous journey rather than a destination, emphasizing that it is not the opposite of burnout. To promote well-being, the speakers advocated for utilizing concepts rooted in positive psychology to empower the individual rather than longing for a different environment. They hypothesized that changing one’s life can be accomplished by changing one’s mind, independent of the environment.

The roadmap for physician well-being, as presented by clinical psychologist Amy MacDonald, PsyD, commenced with urging the audience to introspect on situations and experiences, categorizing them into “feel good” and “feel bad” buckets. For every feel-good event, Dr. MacDonald proposed 5 mental exercises for optimized well-being: (1) control/increase: evaluate whether one can control or increase the frequency of the event; (2) consider: reflect on why this event feels good and explore other aspects to gain any additional joy from the event; (3) share: recognize that some feel goods are more joyous when shared; (4) value: connect the feel-good experiences with personal core values, as research shows value affirmations can buffer neuroendocrine and psychological stress responses; and (5) savor: deliberately relish each small or notable feel-good moment.

Similarly, after labeling an event as a feel-bad experience, Dr. MacDonald encouraged the audience to go through mental exercises to strengthen their well-being journey; however, before proceeding, she highlighted the importance of arming ourselves with self-compassion. The 5 mental exercises to address feel bads include (1) solve: assess whether we have control over the situation and attempt to make changes if possible; (2) reframe: explore new perspectives and assess assumptions without minimizing the situation; (3) connect: embrace the positive impact of safe human connections on our stress response; (4) reflect: search curiously using a compassionate lens for any existing patterns of reactions; and (5) accept and pivot: allow thoughts and feelings to exist and pivot to values-based engagement without waiting for the environment to change. Consistently seeking and appreciating feel goods while addressing rather than suppressing the feel bads can lead to joyful satisfaction and overall well-being.

Additional pearls for optimizing physician well-being included accurately labeling emotions rather than lumping them into an overarching theme (eg, stressed), avoiding comparisons with others, choosing courage over comfort, celebrating vulnerability, and embracing the ability to say no to prioritize engagements aligned with one’s purpose and values. Additional resources were shared for further reading, including Emotional Agility by Susan David, Daring Greatly and Rising Strong by Brené Brown, and Self-Compassion by Kristin Neff.

Take-Home Point—This lecture highlighted key strategies for physicians to improve their well-being, emphasizing self-empowerment and practical tools over external circumstances. It distinguished between productive and destructive influences on satisfaction, and emphasized decision-making aligned with personal values. The concept of well-being as a journey, not a destination, was central, encouraging positive psychology and self-reflection to enhance fulfillment. By focusing on amplifying feel-good experiences and addressing feel-bad experiences with resilience, the lecture advocated for internal over external change, offering a pathway to a balanced and satisfying professional and personal life for physicians.

Final Thoughts

The recent American Academy of Dermatology meeting offered valuable insights and practical pearls to enhance surgical practices and promote physician well-being, in addition to a wide range of topics beyond what is mentioned in this article. From optimizing surgical techniques to prioritizing patient care and safety, the sessions underscored the importance of continuous learning and adaptation in the ever-evolving field of dermatology. As we reflect on the lessons learned and the camaraderie shared during this gathering, let us carry forward these teachings to improve patient outcomes, foster innovation, and cultivate resilience in our pursuit of excellence. Together, we can continue to push the boundaries of dermatologic care while nurturing our own well-being and that of our colleagues, ensuring a brighter future for both patients and practitioners alike.



Acknowledgments—Sultan H. Qiblawi, MD, MBA; Eva Shelton, MD; and Christy T. Behnam, MD (all from Madison, Wisconsin), shared their insights and key takeaways from American Academy of Dermatology lecturers, which enriched the content of this article.

PHOENIX — Immunosuppression is an independent risk factor for poorer outcomes in patients with cutaneous squamous cell carcinoma (cSCC), according to new research that was presented at the American College of Mohs Surgery (ACMS) 2024 annual meeting.

Even though immunosuppression is strongly associated with an increased risk for cSCC, studies to date have generally not shown it to be an independent risk factor for metastasis and disease-specific death (DSD), after accounting for primary tumor stage.

“Solid organ transplant puts patients at risk for developing cutaneous squamous cell carcinoma, and it’s more likely to have aggressive features,” said study author Jason Klein, MD, PhD, a dermatology resident at University of Texas Southwestern Medical Center, Dallas. “But it’s still not known if immunosuppression is an independent risk factor.”

Other groups “have tried to tackle this, but they have all primarily been single-institution data,” he noted, adding that “results so far have been tipping the scale towards immunosuppression not being an independent risk factor” for worse outcomes.

Immunosuppressed individuals face a greater risk for cSCC than the general population and often present with more aggressive, multifocal disease. However, Dr. Klein explained that a previous retrospective study comprising a cohort of approximately 7600 tumors from two centers reported that immunosuppression was not an independent risk factor for both tumor metastasis and cancer-specific death after adjusting for tumor characteristics.

Tipped the Scale

Therefore, the goal of the current study was to repeat this analysis but in a much larger retrospective cohort. Dr. Klein and his colleagues pooled cSCC data from 12 dermatology centers (11 academic and one private) that were located in the United States, Spain, and Brazil. The cohort included 4392 patients (3769 immunocompetent patients and 623 immunosuppressed patients) with 19,237 tumors (15,191 immunocompetent and 4046 immunosuppressed). Study endpoints included local recurrence, metastasis (nodal, satellite/in-transit, and distant), DSD, and “major poor outcomes” (defined as metastasis and DSD combined).

About 30% of the immunosuppressed patients were organ transplant recipients (OTR) and 10% had chronic lymphocytic leukemia (CLL). Half of the immunocompetent patients (50.3%) underwent Mohs surgery as the primary treatment, as did 58.2% of the immunosuppressed patients.

On multivariable analysis, significant predictors of “major poor outcomes” included immunosuppression (subdistribution hazard ratio [SHR], 1.3; P = .04), Brigham and Women’s Hospital tumor stage (SHR 6.7 for T2a, 18.1 for T2b, and 37.2 for T3; P < .001 for all), location on the head/neck (SHR, 2.1; P < .001), and adjuvant radiation (SHR, 1.6; P < .001).

But when metastasis and DSD were evaluated separately, immunosuppression was only predictive of DSD (SHR, 1.7; P = .008) but not metastasis (SHR, 1.2; P = .21). Dr. Klein explained that they also conducted a separate subanalysis limited to OTR and patients with CLL, which demonstrated that immunosuppression was no longer a significant predictor of “major poor outcomes” (SHR, 0.9; P = .66 for OTR; SHR, 1.4; P = .25 for CLL).

“Organ transplant status and CLL were not independent risk factors for major poor outcomes,” he said. “But in summary, we may be tipping the scale to immunosuppression being a risk factor.”

Asked to comment on the findings, Naissan O. Wesley, MD, director of Mohs surgery, Skin Care and Laser Physicians of Beverly Hills, Los Angeles, California, stated that “this larger scale study presented at this meeting was important to further confirm what we see in everyday practice, that immunosuppression may lead to poorer outcomes in patients with cutaneous squamous cell carcinoma.”

Also weighing in on the data, Jesse M. Lewin, MD, chief of Mohs micrographic and dermatologic surgery, at the Icahn School of Medicine at Mount Sinai, New York City, noted that the treatment of cSCC in high-risk patients has been challenging because of the historical lack of data and large studies to guide management.

“The authors provide a large cohort to help stratify which patients are most at risk for poor outcomes, which can inform our decision to refer for neoadjuvant or adjuvant treatment and multi-disciplinary management,” he said. “This is the first step in being able to optimize cure in these patients.”

The study was independently supported. Dr. Klein, Dr. Lewin, and Dr. Wesley reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

PHOENIX — Immunosuppression is an independent risk factor for poorer outcomes in patients with cutaneous squamous cell carcinoma (cSCC), according to new research that was presented at the American College of Mohs Surgery (ACMS) 2024 annual meeting.

Even though immunosuppression is strongly associated with an increased risk for cSCC, studies to date have generally not shown it to be an independent risk factor for metastasis and disease-specific death (DSD), after accounting for primary tumor stage.

“Solid organ transplant puts patients at risk for developing cutaneous squamous cell carcinoma, and it’s more likely to have aggressive features,” said study author Jason Klein, MD, PhD, a dermatology resident at University of Texas Southwestern Medical Center, Dallas. “But it’s still not known if immunosuppression is an independent risk factor.”

Other groups “have tried to tackle this, but they have all primarily been single-institution data,” he noted, adding that “results so far have been tipping the scale towards immunosuppression not being an independent risk factor” for worse outcomes.

Immunosuppressed individuals face a greater risk for cSCC than the general population and often present with more aggressive, multifocal disease. However, Dr. Klein explained that a previous retrospective study comprising a cohort of approximately 7600 tumors from two centers reported that immunosuppression was not an independent risk factor for both tumor metastasis and cancer-specific death after adjusting for tumor characteristics.

Tipped the Scale

Therefore, the goal of the current study was to repeat this analysis but in a much larger retrospective cohort. Dr. Klein and his colleagues pooled cSCC data from 12 dermatology centers (11 academic and one private) that were located in the United States, Spain, and Brazil. The cohort included 4392 patients (3769 immunocompetent patients and 623 immunosuppressed patients) with 19,237 tumors (15,191 immunocompetent and 4046 immunosuppressed). Study endpoints included local recurrence, metastasis (nodal, satellite/in-transit, and distant), DSD, and “major poor outcomes” (defined as metastasis and DSD combined).

About 30% of the immunosuppressed patients were organ transplant recipients (OTR) and 10% had chronic lymphocytic leukemia (CLL). Half of the immunocompetent patients (50.3%) underwent Mohs surgery as the primary treatment, as did 58.2% of the immunosuppressed patients.

On multivariable analysis, significant predictors of “major poor outcomes” included immunosuppression (subdistribution hazard ratio [SHR], 1.3; P = .04), Brigham and Women’s Hospital tumor stage (SHR 6.7 for T2a, 18.1 for T2b, and 37.2 for T3; P < .001 for all), location on the head/neck (SHR, 2.1; P < .001), and adjuvant radiation (SHR, 1.6; P < .001).

But when metastasis and DSD were evaluated separately, immunosuppression was only predictive of DSD (SHR, 1.7; P = .008) but not metastasis (SHR, 1.2; P = .21). Dr. Klein explained that they also conducted a separate subanalysis limited to OTR and patients with CLL, which demonstrated that immunosuppression was no longer a significant predictor of “major poor outcomes” (SHR, 0.9; P = .66 for OTR; SHR, 1.4; P = .25 for CLL).

“Organ transplant status and CLL were not independent risk factors for major poor outcomes,” he said. “But in summary, we may be tipping the scale to immunosuppression being a risk factor.”

Asked to comment on the findings, Naissan O. Wesley, MD, director of Mohs surgery, Skin Care and Laser Physicians of Beverly Hills, Los Angeles, California, stated that “this larger scale study presented at this meeting was important to further confirm what we see in everyday practice, that immunosuppression may lead to poorer outcomes in patients with cutaneous squamous cell carcinoma.”

Also weighing in on the data, Jesse M. Lewin, MD, chief of Mohs micrographic and dermatologic surgery, at the Icahn School of Medicine at Mount Sinai, New York City, noted that the treatment of cSCC in high-risk patients has been challenging because of the historical lack of data and large studies to guide management.

“The authors provide a large cohort to help stratify which patients are most at risk for poor outcomes, which can inform our decision to refer for neoadjuvant or adjuvant treatment and multi-disciplinary management,” he said. “This is the first step in being able to optimize cure in these patients.”

The study was independently supported. Dr. Klein, Dr. Lewin, and Dr. Wesley reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

PHOENIX — Immunosuppression is an independent risk factor for poorer outcomes in patients with cutaneous squamous cell carcinoma (cSCC), according to new research that was presented at the American College of Mohs Surgery (ACMS) 2024 annual meeting.

Even though immunosuppression is strongly associated with an increased risk for cSCC, studies to date have generally not shown it to be an independent risk factor for metastasis and disease-specific death (DSD), after accounting for primary tumor stage.

“Solid organ transplant puts patients at risk for developing cutaneous squamous cell carcinoma, and it’s more likely to have aggressive features,” said study author Jason Klein, MD, PhD, a dermatology resident at University of Texas Southwestern Medical Center, Dallas. “But it’s still not known if immunosuppression is an independent risk factor.”

Other groups “have tried to tackle this, but they have all primarily been single-institution data,” he noted, adding that “results so far have been tipping the scale towards immunosuppression not being an independent risk factor” for worse outcomes.

Immunosuppressed individuals face a greater risk for cSCC than the general population and often present with more aggressive, multifocal disease. However, Dr. Klein explained that a previous retrospective study comprising a cohort of approximately 7600 tumors from two centers reported that immunosuppression was not an independent risk factor for both tumor metastasis and cancer-specific death after adjusting for tumor characteristics.

Tipped the Scale

Therefore, the goal of the current study was to repeat this analysis but in a much larger retrospective cohort. Dr. Klein and his colleagues pooled cSCC data from 12 dermatology centers (11 academic and one private) that were located in the United States, Spain, and Brazil. The cohort included 4392 patients (3769 immunocompetent patients and 623 immunosuppressed patients) with 19,237 tumors (15,191 immunocompetent and 4046 immunosuppressed). Study endpoints included local recurrence, metastasis (nodal, satellite/in-transit, and distant), DSD, and “major poor outcomes” (defined as metastasis and DSD combined).

About 30% of the immunosuppressed patients were organ transplant recipients (OTR) and 10% had chronic lymphocytic leukemia (CLL). Half of the immunocompetent patients (50.3%) underwent Mohs surgery as the primary treatment, as did 58.2% of the immunosuppressed patients.

On multivariable analysis, significant predictors of “major poor outcomes” included immunosuppression (subdistribution hazard ratio [SHR], 1.3; P = .04), Brigham and Women’s Hospital tumor stage (SHR 6.7 for T2a, 18.1 for T2b, and 37.2 for T3; P < .001 for all), location on the head/neck (SHR, 2.1; P < .001), and adjuvant radiation (SHR, 1.6; P < .001).

But when metastasis and DSD were evaluated separately, immunosuppression was only predictive of DSD (SHR, 1.7; P = .008) but not metastasis (SHR, 1.2; P = .21). Dr. Klein explained that they also conducted a separate subanalysis limited to OTR and patients with CLL, which demonstrated that immunosuppression was no longer a significant predictor of “major poor outcomes” (SHR, 0.9; P = .66 for OTR; SHR, 1.4; P = .25 for CLL).

“Organ transplant status and CLL were not independent risk factors for major poor outcomes,” he said. “But in summary, we may be tipping the scale to immunosuppression being a risk factor.”

Asked to comment on the findings, Naissan O. Wesley, MD, director of Mohs surgery, Skin Care and Laser Physicians of Beverly Hills, Los Angeles, California, stated that “this larger scale study presented at this meeting was important to further confirm what we see in everyday practice, that immunosuppression may lead to poorer outcomes in patients with cutaneous squamous cell carcinoma.”

Also weighing in on the data, Jesse M. Lewin, MD, chief of Mohs micrographic and dermatologic surgery, at the Icahn School of Medicine at Mount Sinai, New York City, noted that the treatment of cSCC in high-risk patients has been challenging because of the historical lack of data and large studies to guide management.

“The authors provide a large cohort to help stratify which patients are most at risk for poor outcomes, which can inform our decision to refer for neoadjuvant or adjuvant treatment and multi-disciplinary management,” he said. “This is the first step in being able to optimize cure in these patients.”

The study was independently supported. Dr. Klein, Dr. Lewin, and Dr. Wesley reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

PHOENIX — There is a high prevalence of emotional and physical burden associated with being a Mohs surgeon, particularly among women and younger surgeons, according to new findings. In addition, most surgeons did not feel prepared to manage or prevent these symptoms.

“Our study highlights the need to implement ergonomic training and emotion-focused coping skills, as part of fellowship training and the continuing medical education curriculum, to alleviate and prevent emotional burnout,” said lead author Eduardo A. Michelen-Gómez, MD, a dermatology resident at the University of Puerto Rico School of Medicine, San Juano. “This interaction also must be designed to cater to generation and sex specific needs.”

Dr. Michelen-Gómez presented the findings at the annual meeting of the American College of Mohs Surgery.

Mohs is a demanding procedure that involves repetitive motion, strict attention to detail, and high practice efficiency, all of which must be balanced with the need to prioritize patient safety and well-being. “All of these factors predispose Mohs surgeons to be at an increased risk of physical and emotional stress,” he said.

Despite these concerns, however, the literature is limited concerning work-associated stressors among Mohs surgeons. To further explore this issue, Dr. Michelen-Gómez and colleagues conducted a survey study of ACMS members to investigate not only the prevalence of emotional and physical stressors associated with being a Mohs surgeon but also what specific actions physicians were taking to prevent and/or treat these stressors.

They designed a 21-question cross-sectional electronic survey that was sent to all active ACMS members in 2023. Outcomes evaluated were gender, years of practice, concern for and prevalence of occupational musculoskeletal disorders, emotional stress and burnout, and surgeon’s knowledge and training to manage these symptoms. A total of 473 Mohs surgeons responded.
 

High Prevalence of Injury and Burnout

“Almost 90% of respondents reported moderate to severe concern for occupational musculoskeletal injuries,” said Dr. Michelen-Gómez. “The prevalence of these injuries was 68%, with neck injuries being the most common complaint. Of the entire cohort, 67% have adopted ergonomic practices patterns.”

Female surgeons had a higher prevalence of musculoskeletal injuries than men, and there was no correlation between years of practice and prevalence of these injuries.

Their results also showed that 70% of respondents reported experiencing psychological and emotional stress or burnout associated with being a Mohs surgeon. The cause of emotional stress differed between men and women. “In males, the most common cause was patient care–related anxiety, while in females, it was finding an adequate work-life balance,” he said.

Surgeons with fewer years of experience were more likely to experience emotional stress (P = .01), and female surgeons had a higher prevalence of burnout and musculoskeletal disorders (71.0% and 71.4%, respectively) than male surgeons (67.7% and 65.2%, respectively).

To prevent or manage musculoskeletal injury, respondents reported using interventions such as physical therapy, yoga/stretching/Pilates, massage therapy, cupping, and using a physical trainer. Specific actions for preventing or managing emotional stress and burnout included engaging with a therapist, working with a life coach, practicing meditation or mindfulness, journaling, relying on religion or spirituality, and exercise.

However, among those who reported musculoskeletal disorders or emotional stress, only 40.56% and 46.67%, respectively, felt they had sufficient knowledge and the resources to manage them appropriately.

“In addition, we found a positive correlation between the development of psychological stress and physical issues,” said Dr. Michelen-Gómez. Future studies can include determining the most effective methods to address the emotional and physical stressors of practicing Mohs Surgery.”

Asked to comment on the study findings, Jesse M. Lewin, MD, chief of Mohs micrographic and dermatologic surgery and vice chair of surgical operations at the Icahn School of Medicine at Mount Sinai, New York City, said that the real-world take-home messages from this study are twofold.

“It is important to focus on physician wellness and prevention of burnout and physical injury to protect our physician workforce, and two, we should equip physicians-in-training with tools to protect their physical and emotional health,” he said.

Dr. Michelen-Gómez and Dr. Lewin, who was not involved with the study, had no relevant disclosures.
 

A version of this article appeared on Medscape.com.

PHOENIX — There is a high prevalence of emotional and physical burden associated with being a Mohs surgeon, particularly among women and younger surgeons, according to new findings. In addition, most surgeons did not feel prepared to manage or prevent these symptoms.

“Our study highlights the need to implement ergonomic training and emotion-focused coping skills, as part of fellowship training and the continuing medical education curriculum, to alleviate and prevent emotional burnout,” said lead author Eduardo A. Michelen-Gómez, MD, a dermatology resident at the University of Puerto Rico School of Medicine, San Juano. “This interaction also must be designed to cater to generation and sex specific needs.”

Dr. Michelen-Gómez presented the findings at the annual meeting of the American College of Mohs Surgery.

Mohs is a demanding procedure that involves repetitive motion, strict attention to detail, and high practice efficiency, all of which must be balanced with the need to prioritize patient safety and well-being. “All of these factors predispose Mohs surgeons to be at an increased risk of physical and emotional stress,” he said.

Despite these concerns, however, the literature is limited concerning work-associated stressors among Mohs surgeons. To further explore this issue, Dr. Michelen-Gómez and colleagues conducted a survey study of ACMS members to investigate not only the prevalence of emotional and physical stressors associated with being a Mohs surgeon but also what specific actions physicians were taking to prevent and/or treat these stressors.

They designed a 21-question cross-sectional electronic survey that was sent to all active ACMS members in 2023. Outcomes evaluated were gender, years of practice, concern for and prevalence of occupational musculoskeletal disorders, emotional stress and burnout, and surgeon’s knowledge and training to manage these symptoms. A total of 473 Mohs surgeons responded.
 

High Prevalence of Injury and Burnout

“Almost 90% of respondents reported moderate to severe concern for occupational musculoskeletal injuries,” said Dr. Michelen-Gómez. “The prevalence of these injuries was 68%, with neck injuries being the most common complaint. Of the entire cohort, 67% have adopted ergonomic practices patterns.”

Female surgeons had a higher prevalence of musculoskeletal injuries than men, and there was no correlation between years of practice and prevalence of these injuries.

Their results also showed that 70% of respondents reported experiencing psychological and emotional stress or burnout associated with being a Mohs surgeon. The cause of emotional stress differed between men and women. “In males, the most common cause was patient care–related anxiety, while in females, it was finding an adequate work-life balance,” he said.

Surgeons with fewer years of experience were more likely to experience emotional stress (P = .01), and female surgeons had a higher prevalence of burnout and musculoskeletal disorders (71.0% and 71.4%, respectively) than male surgeons (67.7% and 65.2%, respectively).

To prevent or manage musculoskeletal injury, respondents reported using interventions such as physical therapy, yoga/stretching/Pilates, massage therapy, cupping, and using a physical trainer. Specific actions for preventing or managing emotional stress and burnout included engaging with a therapist, working with a life coach, practicing meditation or mindfulness, journaling, relying on religion or spirituality, and exercise.

However, among those who reported musculoskeletal disorders or emotional stress, only 40.56% and 46.67%, respectively, felt they had sufficient knowledge and the resources to manage them appropriately.

“In addition, we found a positive correlation between the development of psychological stress and physical issues,” said Dr. Michelen-Gómez. Future studies can include determining the most effective methods to address the emotional and physical stressors of practicing Mohs Surgery.”

Asked to comment on the study findings, Jesse M. Lewin, MD, chief of Mohs micrographic and dermatologic surgery and vice chair of surgical operations at the Icahn School of Medicine at Mount Sinai, New York City, said that the real-world take-home messages from this study are twofold.

“It is important to focus on physician wellness and prevention of burnout and physical injury to protect our physician workforce, and two, we should equip physicians-in-training with tools to protect their physical and emotional health,” he said.

Dr. Michelen-Gómez and Dr. Lewin, who was not involved with the study, had no relevant disclosures.
 

A version of this article appeared on Medscape.com.

PHOENIX — There is a high prevalence of emotional and physical burden associated with being a Mohs surgeon, particularly among women and younger surgeons, according to new findings. In addition, most surgeons did not feel prepared to manage or prevent these symptoms.

“Our study highlights the need to implement ergonomic training and emotion-focused coping skills, as part of fellowship training and the continuing medical education curriculum, to alleviate and prevent emotional burnout,” said lead author Eduardo A. Michelen-Gómez, MD, a dermatology resident at the University of Puerto Rico School of Medicine, San Juano. “This interaction also must be designed to cater to generation and sex specific needs.”

Dr. Michelen-Gómez presented the findings at the annual meeting of the American College of Mohs Surgery.

Mohs is a demanding procedure that involves repetitive motion, strict attention to detail, and high practice efficiency, all of which must be balanced with the need to prioritize patient safety and well-being. “All of these factors predispose Mohs surgeons to be at an increased risk of physical and emotional stress,” he said.

Despite these concerns, however, the literature is limited concerning work-associated stressors among Mohs surgeons. To further explore this issue, Dr. Michelen-Gómez and colleagues conducted a survey study of ACMS members to investigate not only the prevalence of emotional and physical stressors associated with being a Mohs surgeon but also what specific actions physicians were taking to prevent and/or treat these stressors.

They designed a 21-question cross-sectional electronic survey that was sent to all active ACMS members in 2023. Outcomes evaluated were gender, years of practice, concern for and prevalence of occupational musculoskeletal disorders, emotional stress and burnout, and surgeon’s knowledge and training to manage these symptoms. A total of 473 Mohs surgeons responded.
 

High Prevalence of Injury and Burnout

“Almost 90% of respondents reported moderate to severe concern for occupational musculoskeletal injuries,” said Dr. Michelen-Gómez. “The prevalence of these injuries was 68%, with neck injuries being the most common complaint. Of the entire cohort, 67% have adopted ergonomic practices patterns.”

Female surgeons had a higher prevalence of musculoskeletal injuries than men, and there was no correlation between years of practice and prevalence of these injuries.

Their results also showed that 70% of respondents reported experiencing psychological and emotional stress or burnout associated with being a Mohs surgeon. The cause of emotional stress differed between men and women. “In males, the most common cause was patient care–related anxiety, while in females, it was finding an adequate work-life balance,” he said.

Surgeons with fewer years of experience were more likely to experience emotional stress (P = .01), and female surgeons had a higher prevalence of burnout and musculoskeletal disorders (71.0% and 71.4%, respectively) than male surgeons (67.7% and 65.2%, respectively).

To prevent or manage musculoskeletal injury, respondents reported using interventions such as physical therapy, yoga/stretching/Pilates, massage therapy, cupping, and using a physical trainer. Specific actions for preventing or managing emotional stress and burnout included engaging with a therapist, working with a life coach, practicing meditation or mindfulness, journaling, relying on religion or spirituality, and exercise.

However, among those who reported musculoskeletal disorders or emotional stress, only 40.56% and 46.67%, respectively, felt they had sufficient knowledge and the resources to manage them appropriately.

“In addition, we found a positive correlation between the development of psychological stress and physical issues,” said Dr. Michelen-Gómez. Future studies can include determining the most effective methods to address the emotional and physical stressors of practicing Mohs Surgery.”

Asked to comment on the study findings, Jesse M. Lewin, MD, chief of Mohs micrographic and dermatologic surgery and vice chair of surgical operations at the Icahn School of Medicine at Mount Sinai, New York City, said that the real-world take-home messages from this study are twofold.

“It is important to focus on physician wellness and prevention of burnout and physical injury to protect our physician workforce, and two, we should equip physicians-in-training with tools to protect their physical and emotional health,” he said.

Dr. Michelen-Gómez and Dr. Lewin, who was not involved with the study, had no relevant disclosures.
 

A version of this article appeared on Medscape.com.

Each month I set out on an expedition to find a topic for this column. I came across a new book Rebel Health by Susannah Fox that I thought might be a good one. It’s both a treatise on the shortcomings of healthcare and a Baedeker for patients on how to find their way to being better served. Her argument is that many patients’ needs are unmet and their conditions are often invisible to us in mainstream healthcare. We fail to find solutions to help them. Patients would benefit from more open access to their records and more resources to take control of their own health, she argues. A few chapters in, I thought, “Oh, here we go, another diatribe on doctors and how we care most about how to keep patients in their rightful, subordinate place.” The “Rebel” title is provocative and implies patients need to overthrow the status quo. Well, I am part of the establishment. I stopped reading. This book doesn’t apply to me, I thought.

After all, I’m a healthcare progressive, right? My notes and results have been open for years. I encourage shared decision-making and try to empower patients as much as treat them. The idea that I or my colleagues are unwilling to do whatever is necessary to meet our patients’ needs was maddening. We dedicate our lives to it. My young daughter often greets me in the morning by asking if I’ll be working tonight. Most nights, I am — answering patient messages, collaborating with colleagues to help patients, keeping up with medical knowledge. I was angry at what felt like unjust criticism, especially that we’d neglect patients because their problems are not obvious or worse, there is not enough money to be made helping them. Harrumph.

Kaiser Permanente

That’s when I realized the best thing for me was to read the entire book and digest the arguments. I pride myself on being well-read, but I fall into a common trap: the podcasts I listen to, news I consume, and books I read mostly affirm my beliefs. It is a healthy choice to seek dispositive data and contrasting stories rather than always feeding our personal opinions.

Rebel Health was not written by Robespierre. It was penned by a thoughtful, articulate patient advocate with over 20 years experience. She has far more bona fides than I could achieve in two lifetimes. In the book, she reminds us that scientific advances in the last 100 years have made medicine more effective but also disintermediated caregivers, family, and patients. Patients and caregivers can not only help but also offer innovative and customized solutions to their problems. She describes four patient archetypes: seekers, networkers, solvers, and champions, and offers a four-quadrant model to visualize how some patients are unhelped by our current healthcare system. She advocates for frictionless, open access to health data and tries to inspire patients to connect, innovate, and create to fill the voids that exist in healthcare. We have come a long way from the immured system of a decade ago; much of that is the result of patient advocates. But healthcare is still too costly, too fragmented and too many patients unhelped. “Community is a superpower,” she writes. I agree, we should assemble all the heroes in the universe for this challenge.

Fox also tells stories of patients who solved diagnostic dilemmas through their own research and advocacy. I thought of my own contrasting experiences of patients whose DIY care was based on misinformation and how their false confidence led to poorer outcomes for them. I want to share with her readers how physicians feel hurt when patients question our competence or place the opinion of an adversarial Redditor over ours. Physicians are sometimes wrong and often in doubt. Most of us care deeply about our patients regardless of how visible their diagnosis or how easy they are to appease.

We don’t have time to engage back-and-forth on an insignificantly abnormal test they find in their open chart or why B12 and hormone testing would not be helpful for their disease. It’s also not the patients’ fault. Having unfettered access to their data might add work, but it also adds value. They are trying to learn and be active in their care. Physicians are frustrated mostly because we don’t have time to meet these unmet needs. Everyone is trying their best and we all want the same thing: patients to be satisfied and well.

As for learning the skill of being open-minded, an excellent reference is Adam Grant’s Think Again. It’s inspiring and instructive of how we can all be more open, including how to have productive arguments rather than fruitless fights. We live in divisive times. Perhaps if we all put in effort to be open-minded, push down righteous indignation, and advance more honest humility we’d all be a bit better off.

Patients are the primary audience for the Rebel Health book. Yet, as we care about them and we all want to make healthcare better, it is worth reading in its entirety. I told my daughter I don’t have to work tonight because I’ve written my article this month. When she’s a little older, I’ll tell her all about it. To be successful, she’ll have to be as open-minded as she is smart. She can learn both.

I have no conflict of interest in the book.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

Each month I set out on an expedition to find a topic for this column. I came across a new book Rebel Health by Susannah Fox that I thought might be a good one. It’s both a treatise on the shortcomings of healthcare and a Baedeker for patients on how to find their way to being better served. Her argument is that many patients’ needs are unmet and their conditions are often invisible to us in mainstream healthcare. We fail to find solutions to help them. Patients would benefit from more open access to their records and more resources to take control of their own health, she argues. A few chapters in, I thought, “Oh, here we go, another diatribe on doctors and how we care most about how to keep patients in their rightful, subordinate place.” The “Rebel” title is provocative and implies patients need to overthrow the status quo. Well, I am part of the establishment. I stopped reading. This book doesn’t apply to me, I thought.

After all, I’m a healthcare progressive, right? My notes and results have been open for years. I encourage shared decision-making and try to empower patients as much as treat them. The idea that I or my colleagues are unwilling to do whatever is necessary to meet our patients’ needs was maddening. We dedicate our lives to it. My young daughter often greets me in the morning by asking if I’ll be working tonight. Most nights, I am — answering patient messages, collaborating with colleagues to help patients, keeping up with medical knowledge. I was angry at what felt like unjust criticism, especially that we’d neglect patients because their problems are not obvious or worse, there is not enough money to be made helping them. Harrumph.

Kaiser Permanente

That’s when I realized the best thing for me was to read the entire book and digest the arguments. I pride myself on being well-read, but I fall into a common trap: the podcasts I listen to, news I consume, and books I read mostly affirm my beliefs. It is a healthy choice to seek dispositive data and contrasting stories rather than always feeding our personal opinions.

Rebel Health was not written by Robespierre. It was penned by a thoughtful, articulate patient advocate with over 20 years experience. She has far more bona fides than I could achieve in two lifetimes. In the book, she reminds us that scientific advances in the last 100 years have made medicine more effective but also disintermediated caregivers, family, and patients. Patients and caregivers can not only help but also offer innovative and customized solutions to their problems. She describes four patient archetypes: seekers, networkers, solvers, and champions, and offers a four-quadrant model to visualize how some patients are unhelped by our current healthcare system. She advocates for frictionless, open access to health data and tries to inspire patients to connect, innovate, and create to fill the voids that exist in healthcare. We have come a long way from the immured system of a decade ago; much of that is the result of patient advocates. But healthcare is still too costly, too fragmented and too many patients unhelped. “Community is a superpower,” she writes. I agree, we should assemble all the heroes in the universe for this challenge.

Fox also tells stories of patients who solved diagnostic dilemmas through their own research and advocacy. I thought of my own contrasting experiences of patients whose DIY care was based on misinformation and how their false confidence led to poorer outcomes for them. I want to share with her readers how physicians feel hurt when patients question our competence or place the opinion of an adversarial Redditor over ours. Physicians are sometimes wrong and often in doubt. Most of us care deeply about our patients regardless of how visible their diagnosis or how easy they are to appease.

We don’t have time to engage back-and-forth on an insignificantly abnormal test they find in their open chart or why B12 and hormone testing would not be helpful for their disease. It’s also not the patients’ fault. Having unfettered access to their data might add work, but it also adds value. They are trying to learn and be active in their care. Physicians are frustrated mostly because we don’t have time to meet these unmet needs. Everyone is trying their best and we all want the same thing: patients to be satisfied and well.

As for learning the skill of being open-minded, an excellent reference is Adam Grant’s Think Again. It’s inspiring and instructive of how we can all be more open, including how to have productive arguments rather than fruitless fights. We live in divisive times. Perhaps if we all put in effort to be open-minded, push down righteous indignation, and advance more honest humility we’d all be a bit better off.

Patients are the primary audience for the Rebel Health book. Yet, as we care about them and we all want to make healthcare better, it is worth reading in its entirety. I told my daughter I don’t have to work tonight because I’ve written my article this month. When she’s a little older, I’ll tell her all about it. To be successful, she’ll have to be as open-minded as she is smart. She can learn both.

I have no conflict of interest in the book.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

Each month I set out on an expedition to find a topic for this column. I came across a new book Rebel Health by Susannah Fox that I thought might be a good one. It’s both a treatise on the shortcomings of healthcare and a Baedeker for patients on how to find their way to being better served. Her argument is that many patients’ needs are unmet and their conditions are often invisible to us in mainstream healthcare. We fail to find solutions to help them. Patients would benefit from more open access to their records and more resources to take control of their own health, she argues. A few chapters in, I thought, “Oh, here we go, another diatribe on doctors and how we care most about how to keep patients in their rightful, subordinate place.” The “Rebel” title is provocative and implies patients need to overthrow the status quo. Well, I am part of the establishment. I stopped reading. This book doesn’t apply to me, I thought.

After all, I’m a healthcare progressive, right? My notes and results have been open for years. I encourage shared decision-making and try to empower patients as much as treat them. The idea that I or my colleagues are unwilling to do whatever is necessary to meet our patients’ needs was maddening. We dedicate our lives to it. My young daughter often greets me in the morning by asking if I’ll be working tonight. Most nights, I am — answering patient messages, collaborating with colleagues to help patients, keeping up with medical knowledge. I was angry at what felt like unjust criticism, especially that we’d neglect patients because their problems are not obvious or worse, there is not enough money to be made helping them. Harrumph.

Kaiser Permanente

That’s when I realized the best thing for me was to read the entire book and digest the arguments. I pride myself on being well-read, but I fall into a common trap: the podcasts I listen to, news I consume, and books I read mostly affirm my beliefs. It is a healthy choice to seek dispositive data and contrasting stories rather than always feeding our personal opinions.

Rebel Health was not written by Robespierre. It was penned by a thoughtful, articulate patient advocate with over 20 years experience. She has far more bona fides than I could achieve in two lifetimes. In the book, she reminds us that scientific advances in the last 100 years have made medicine more effective but also disintermediated caregivers, family, and patients. Patients and caregivers can not only help but also offer innovative and customized solutions to their problems. She describes four patient archetypes: seekers, networkers, solvers, and champions, and offers a four-quadrant model to visualize how some patients are unhelped by our current healthcare system. She advocates for frictionless, open access to health data and tries to inspire patients to connect, innovate, and create to fill the voids that exist in healthcare. We have come a long way from the immured system of a decade ago; much of that is the result of patient advocates. But healthcare is still too costly, too fragmented and too many patients unhelped. “Community is a superpower,” she writes. I agree, we should assemble all the heroes in the universe for this challenge.

Fox also tells stories of patients who solved diagnostic dilemmas through their own research and advocacy. I thought of my own contrasting experiences of patients whose DIY care was based on misinformation and how their false confidence led to poorer outcomes for them. I want to share with her readers how physicians feel hurt when patients question our competence or place the opinion of an adversarial Redditor over ours. Physicians are sometimes wrong and often in doubt. Most of us care deeply about our patients regardless of how visible their diagnosis or how easy they are to appease.

We don’t have time to engage back-and-forth on an insignificantly abnormal test they find in their open chart or why B12 and hormone testing would not be helpful for their disease. It’s also not the patients’ fault. Having unfettered access to their data might add work, but it also adds value. They are trying to learn and be active in their care. Physicians are frustrated mostly because we don’t have time to meet these unmet needs. Everyone is trying their best and we all want the same thing: patients to be satisfied and well.

As for learning the skill of being open-minded, an excellent reference is Adam Grant’s Think Again. It’s inspiring and instructive of how we can all be more open, including how to have productive arguments rather than fruitless fights. We live in divisive times. Perhaps if we all put in effort to be open-minded, push down righteous indignation, and advance more honest humility we’d all be a bit better off.

Patients are the primary audience for the Rebel Health book. Yet, as we care about them and we all want to make healthcare better, it is worth reading in its entirety. I told my daughter I don’t have to work tonight because I’ve written my article this month. When she’s a little older, I’ll tell her all about it. To be successful, she’ll have to be as open-minded as she is smart. She can learn both.

I have no conflict of interest in the book.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

PHOENIX — Reimbursement for dermatologic procedures has not maintained a parallel increase with the cost of healthcare delivery, according to new study findings. Medicare cuts, which are expected to continue, have exacerbated this issue even further.

“This ongoing downward trend in inflation-adjusted reimbursement may lead to delayed patient access to quality dermatology surgical care,” said lead study author Lily Park, DO, a resident in the Department of Dermatology, Larkin Community Hospital, Miami. “This trend will lead to reduced access.”

Dr. Park emphasized that reimbursement for Mohs surgery has also been further affected by the multiple surgery reduction rule, which is where Medicare pays less for the second and subsequent procedures performed during the same patient encounter. Reductions may be calculated in several ways, depending on what kind of procedure or service is involved.

“The Mohs surgery community needs to be aware of this financial trend and actively engage with healthcare policymakers to ensure the establishment of a sustainable payment infrastructure,” she said.

Dr. Park presented the study results at the annual meeting of the American College of Mohs Surgery.

The landscape of healthcare economics continues to evolve and has been further complicated by rising inflation. In addition, a 2% cut to the Medicare payment conversion factor was implemented in 2023, followed by a further 3.37% cut in early 2024 — which was cut by half in March 2024, with an additional cut expected this year, she noted. “This has presented more challenges for dermatologic surgeons who are already dealing with the rising healthcare costs.”

However, despite these financial challenges, there is a lack of research on physician reimbursement for dermatologic procedures, including surgery.

Decreased Reimbursement for All Procedures

Dr. Park and colleagues analyzed trends in Medicare reimbursement rates for Mohs micrographic surgery and several other common dermatologic procedures. Beginning with 2007, they calculated the inflation-adjusted values for each year’s non-facility prices for all codes except Current Procedural Terminology (CPT) codes 11102 and 11104. For those two codes, inflation-adjusted prices were based on the prices in 2019, the year when the codes were first introduced. The authors estimated the inflation adjusted value for each year based on the non-facility price for 2007, and the difference between the rate of inflation and the change in physician reimbursement over time was calculated.

The six most commonly performed procedures in 2023, ranked in descending order of frequency, were identified as CPT 17000, used for the removal of actinic keratosis; CPT 11102, used for biopsy of skin; CPT 17110, used for the destruction of benign lesions such as seborrheic keratoses and warts; CPT 17311, used for the destruction of malignant lesions (including Mohs surgery); CPT 11104, which is also related to biopsy of skin; and CPT 10060, used for incision and drainage of abscess.

Their analysis showed that all CPT codes experienced a decline when compared with their inflation-adjusted values. Both Mohs surgery (17311) and benign destruction of premalignant lesions (17000) showed a decrease of 46% in reimbursement during an inflation-adjusted 18-year time span between 2007 and 2024.

When adjusted for inflation, Dr. Park noted, reimbursement for CPT 17311 and 17000 should actually be increased by 42% and 41% in 2024, respectively. The greatest declines in reimbursement were seen during the last 4 years.

“Future legislation, such as H.R.2474, a bill proposing inflation-based updates to physician pay, would aid us in the future if implemented,” said Dr. Park.
 

Dangerous Trend

The finding that payments have declined for many common dermatologic procedures since 2007 “is particularly important given the rising cost of healthcare delivery,” said Jesse M. Lewin, MD, who was asked to comment on the study results. “The administrative burden of electronic medical records, filing, and following up insurance claims has necessitated the employment of more non-physician staff to support these tasks,” he told this news organization.

“Declining reimbursement for Mohs surgery and other cancer-related procedures is a dangerous trend, as the ultimate impact will be the effect it has on quality and accessibility of skin cancer care for patients,” added Dr. Lewin, chief of Mohs micrographic and dermatologic surgery and vice chair of surgical operations at the Icahn School of Medicine at Mount Sinai, New York City. “This is an important study that reinforces physician engagement in healthcare policy and legislation to advocate for our specialty and patients.”

The study was independently supported. Dr. Park and Dr. Lewin, who was not involved with the study, reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

PHOENIX — Reimbursement for dermatologic procedures has not maintained a parallel increase with the cost of healthcare delivery, according to new study findings. Medicare cuts, which are expected to continue, have exacerbated this issue even further.

“This ongoing downward trend in inflation-adjusted reimbursement may lead to delayed patient access to quality dermatology surgical care,” said lead study author Lily Park, DO, a resident in the Department of Dermatology, Larkin Community Hospital, Miami. “This trend will lead to reduced access.”

Dr. Park emphasized that reimbursement for Mohs surgery has also been further affected by the multiple surgery reduction rule, which is where Medicare pays less for the second and subsequent procedures performed during the same patient encounter. Reductions may be calculated in several ways, depending on what kind of procedure or service is involved.

“The Mohs surgery community needs to be aware of this financial trend and actively engage with healthcare policymakers to ensure the establishment of a sustainable payment infrastructure,” she said.

Dr. Park presented the study results at the annual meeting of the American College of Mohs Surgery.

The landscape of healthcare economics continues to evolve and has been further complicated by rising inflation. In addition, a 2% cut to the Medicare payment conversion factor was implemented in 2023, followed by a further 3.37% cut in early 2024 — which was cut by half in March 2024, with an additional cut expected this year, she noted. “This has presented more challenges for dermatologic surgeons who are already dealing with the rising healthcare costs.”

However, despite these financial challenges, there is a lack of research on physician reimbursement for dermatologic procedures, including surgery.

Decreased Reimbursement for All Procedures

Dr. Park and colleagues analyzed trends in Medicare reimbursement rates for Mohs micrographic surgery and several other common dermatologic procedures. Beginning with 2007, they calculated the inflation-adjusted values for each year’s non-facility prices for all codes except Current Procedural Terminology (CPT) codes 11102 and 11104. For those two codes, inflation-adjusted prices were based on the prices in 2019, the year when the codes were first introduced. The authors estimated the inflation adjusted value for each year based on the non-facility price for 2007, and the difference between the rate of inflation and the change in physician reimbursement over time was calculated.

The six most commonly performed procedures in 2023, ranked in descending order of frequency, were identified as CPT 17000, used for the removal of actinic keratosis; CPT 11102, used for biopsy of skin; CPT 17110, used for the destruction of benign lesions such as seborrheic keratoses and warts; CPT 17311, used for the destruction of malignant lesions (including Mohs surgery); CPT 11104, which is also related to biopsy of skin; and CPT 10060, used for incision and drainage of abscess.

Their analysis showed that all CPT codes experienced a decline when compared with their inflation-adjusted values. Both Mohs surgery (17311) and benign destruction of premalignant lesions (17000) showed a decrease of 46% in reimbursement during an inflation-adjusted 18-year time span between 2007 and 2024.

When adjusted for inflation, Dr. Park noted, reimbursement for CPT 17311 and 17000 should actually be increased by 42% and 41% in 2024, respectively. The greatest declines in reimbursement were seen during the last 4 years.

“Future legislation, such as H.R.2474, a bill proposing inflation-based updates to physician pay, would aid us in the future if implemented,” said Dr. Park.
 

Dangerous Trend

The finding that payments have declined for many common dermatologic procedures since 2007 “is particularly important given the rising cost of healthcare delivery,” said Jesse M. Lewin, MD, who was asked to comment on the study results. “The administrative burden of electronic medical records, filing, and following up insurance claims has necessitated the employment of more non-physician staff to support these tasks,” he told this news organization.

“Declining reimbursement for Mohs surgery and other cancer-related procedures is a dangerous trend, as the ultimate impact will be the effect it has on quality and accessibility of skin cancer care for patients,” added Dr. Lewin, chief of Mohs micrographic and dermatologic surgery and vice chair of surgical operations at the Icahn School of Medicine at Mount Sinai, New York City. “This is an important study that reinforces physician engagement in healthcare policy and legislation to advocate for our specialty and patients.”

The study was independently supported. Dr. Park and Dr. Lewin, who was not involved with the study, reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

PHOENIX — Reimbursement for dermatologic procedures has not maintained a parallel increase with the cost of healthcare delivery, according to new study findings. Medicare cuts, which are expected to continue, have exacerbated this issue even further.

“This ongoing downward trend in inflation-adjusted reimbursement may lead to delayed patient access to quality dermatology surgical care,” said lead study author Lily Park, DO, a resident in the Department of Dermatology, Larkin Community Hospital, Miami. “This trend will lead to reduced access.”

Dr. Park emphasized that reimbursement for Mohs surgery has also been further affected by the multiple surgery reduction rule, which is where Medicare pays less for the second and subsequent procedures performed during the same patient encounter. Reductions may be calculated in several ways, depending on what kind of procedure or service is involved.

“The Mohs surgery community needs to be aware of this financial trend and actively engage with healthcare policymakers to ensure the establishment of a sustainable payment infrastructure,” she said.

Dr. Park presented the study results at the annual meeting of the American College of Mohs Surgery.

The landscape of healthcare economics continues to evolve and has been further complicated by rising inflation. In addition, a 2% cut to the Medicare payment conversion factor was implemented in 2023, followed by a further 3.37% cut in early 2024 — which was cut by half in March 2024, with an additional cut expected this year, she noted. “This has presented more challenges for dermatologic surgeons who are already dealing with the rising healthcare costs.”

However, despite these financial challenges, there is a lack of research on physician reimbursement for dermatologic procedures, including surgery.

Decreased Reimbursement for All Procedures

Dr. Park and colleagues analyzed trends in Medicare reimbursement rates for Mohs micrographic surgery and several other common dermatologic procedures. Beginning with 2007, they calculated the inflation-adjusted values for each year’s non-facility prices for all codes except Current Procedural Terminology (CPT) codes 11102 and 11104. For those two codes, inflation-adjusted prices were based on the prices in 2019, the year when the codes were first introduced. The authors estimated the inflation adjusted value for each year based on the non-facility price for 2007, and the difference between the rate of inflation and the change in physician reimbursement over time was calculated.

The six most commonly performed procedures in 2023, ranked in descending order of frequency, were identified as CPT 17000, used for the removal of actinic keratosis; CPT 11102, used for biopsy of skin; CPT 17110, used for the destruction of benign lesions such as seborrheic keratoses and warts; CPT 17311, used for the destruction of malignant lesions (including Mohs surgery); CPT 11104, which is also related to biopsy of skin; and CPT 10060, used for incision and drainage of abscess.

Their analysis showed that all CPT codes experienced a decline when compared with their inflation-adjusted values. Both Mohs surgery (17311) and benign destruction of premalignant lesions (17000) showed a decrease of 46% in reimbursement during an inflation-adjusted 18-year time span between 2007 and 2024.

When adjusted for inflation, Dr. Park noted, reimbursement for CPT 17311 and 17000 should actually be increased by 42% and 41% in 2024, respectively. The greatest declines in reimbursement were seen during the last 4 years.

“Future legislation, such as H.R.2474, a bill proposing inflation-based updates to physician pay, would aid us in the future if implemented,” said Dr. Park.
 

Dangerous Trend

The finding that payments have declined for many common dermatologic procedures since 2007 “is particularly important given the rising cost of healthcare delivery,” said Jesse M. Lewin, MD, who was asked to comment on the study results. “The administrative burden of electronic medical records, filing, and following up insurance claims has necessitated the employment of more non-physician staff to support these tasks,” he told this news organization.

“Declining reimbursement for Mohs surgery and other cancer-related procedures is a dangerous trend, as the ultimate impact will be the effect it has on quality and accessibility of skin cancer care for patients,” added Dr. Lewin, chief of Mohs micrographic and dermatologic surgery and vice chair of surgical operations at the Icahn School of Medicine at Mount Sinai, New York City. “This is an important study that reinforces physician engagement in healthcare policy and legislation to advocate for our specialty and patients.”

The study was independently supported. Dr. Park and Dr. Lewin, who was not involved with the study, reported no relevant financial relationships.

A version of this article appeared on Medscape.com.