MOHS vs Standard Surgical Excision for Facial Basal Cell Carcinoma

Abstract & Commentary

Synopsis: In a randomized, clinical trial, patients with primary or recurrent basal-cell carcinoma were treated either by traditional surgical excision or Mohs’ micrographic surgery. At 30 months of follow-up, recurrence rates were low in both groups. For those with recurrent disease, there was a suggestion that the Mohs technique might be superior with regard to later recurrence. However, there were no aesthetic differences and overall costs were significantly higher for the Mohs technique. For those with larger lesions or recurrent disease, there was a trend towards more favorable outcome with the Mohs technique.

Source: Smeets NJ, et al. Lancet. 2004;364:1766-1772.

Basal-cell carcinoma is the most common skin cancer in Caucasians and its incidence continues to rise.1 Although such carcinomas rarely metastasize, some cause substantial morbidity and even mortality,2 particularly those that are larger or incompletely resected. Complete tumor removal (ie, prevention of recurrence), preservation of healthy skin, aesthetic outcome, and costs are important in the treatment of this predominantly facial skin tumor. Most basal-cell carcinomas are treated by surgical excision (SE) although radiotherapy remains an alternative approach. Mohs’ micrographic surgery (MMS) has been shown to improve cure rates over SE, cryosurgery or radiation for these tumors. However, basal-cell cure rates by SE are quite high and the need for MMS has been questioned. Inasmuch as MMS is more time consuming and expensive, Smeets and colleagues from the Netherlands performed a randomized trial comparing SE with MMS in the treatment of primary and recurrent facial basal-cell carcinoma.

Patients with primary and recurrent facial carcinomas were randomized to SE or MMS and tumor recurrence after 30 months was the primary outcome for analysis. Of the patients with primary tumors (n = 397) 198 were randomized to MMS and 197 to SE. For those with recurrent basal-cell carcinomas (n = 201), 99 received MMS and 102 SE. Of the primary carcinomas, 5 (3%) recurred after SE compared with 3 (2%) after MMS during the 30 months of follow-up. Of the recurrent carcinomas, 3 (3%) recurred after SE and none after MMS. Furthermore, although there did not appear to be any differences in post-operative complications (ie, infection, necrosis, bleeding, etc) or aesthetic outcomes for those that received SE or MMS, this was not true for those who were operated upon for recurrent disease. More complications occurred after SE than after MMS (19 [19%] vs 8 [8%]; P = 0.021) for recurrent carcinomas. Although the differences in recurrence rates were not statistically significant, the total operative costs were almost twice as high for MMS.

Comment by William B. Ershler, MD

Physicians commonly encounter patients with basal-cell cancers and a number of options are currently available for treatment. It has been apparent that surgical approaches are most satisfactory but a comparison between the traditional surgical excisions and the more precise, albeit more cumbersome Mohs technique had not, heretofore been examined in a prospective, randomized trial. In this report, it is evident for those receiving primary treatment the recurrence is low by either technique. For those with recurrence there is a trend suggesting the Mohs technique might be more efficacious. Smeets et al suggest that this trend might become more evident upon later analysis, such as at 5 years, or in another trial with a larger sample size.

This was a well conducted clinical trial that, unfortunately, was insufficiently powered to demonstrate either a difference or no difference. The reader gets a sense from Smeets et al, and in the accompanying editorial,3 that the Mohs technique might be a superior approach, but unnecessary for the management of small and uncomplicated primary basal-cell carcinomas. For larger or recurrent lesions, it is likely that the added time and expense of the Mohs technique will ultimately be shown to be worth the effort. Yet, despite the laudatory efforts put forth in the current trial, the data remains inconclusive. Accordingly, factors other than clearly demonstrated evidence will drive which of these techniques surfaces as the standard approach in any specific community.


1. Holmes SA, et al. Br J Dermatol. 2000;143: 1224-1229.

2. Robinson JK, Dahiya M. Arch Dermatol. 2003; 139:643-648.

3. Willford PM, Feldman SR. Lancet. 2004;364: 1732-1733

William B. Ershler, MD, INOVA Fairfax Hospital Cancer Center, Fairfax, VA; Director, Institute for Advanced Studies in Aging, Washington, DC, is Editor for Clinical Oncology Alert.