Assessment of Functionality in Elderly Patients When Determining Appropriate Treatment for Nonmelanoma Skin Cancers.

BACKGROUND: The treatment of nonmelanoma skin cancer (NMSC) in the elderly population is a source of significant debate. Mohs micrographic surgery (MMS) is a highly effective treatment option yet not every patient with a cutaneous malignancy that meets appropriate use criteria (AUC) should be treated with surgery. OBJECTIVE: The purpose of this study was to use the Karnofsky Performance Status (KPS) scale to categorize the functional status of patients aged 75 years and older who required treatment of NMSC. The authors wanted to see whether functionality played a role on the treatment selection. METHODS: Patients aged 75 years and older presenting for biopsy of a suspected NMSC that met AUC for MMS were included in the study. Trained medical assistants used the KPS scale to assess patient functionality. Treatment modality was recorded once the biopsy confirmed the NMSC. RESULTS: A cohort of 203 subjects met inclusion criteria for the study. There was a statistically significant difference in utilization of surgical treatments between high and low functionality patients (p = .03). CONCLUSION: Dermatologists consider patient functionality when selecting a treatment for NMSC and use less invasive modalities for patients with poor functional status, even when the tumor meets AUC.

Strategic mentoring: growth for mentor and mentee.

Mentoring is enriching for both the mentor and mentee, but often getting started can be a primary obstacle to this useful tool. This contribution focuses on how to embark on a mentoring relationship with a junior colleague. In addition to describing various approaches to being a mentor, it outlines unproductive traps to avoid, steps to establishing a successful mentoring relationship, including conversation starters, and professional skills one can continue to develop to improve mentoring outcomes.

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery.

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery.

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

Clinical case of the month. A young man with a persistent skin eruption. Mycosis fungoides.

There are many types of skin disease that fit into the classification of cutaneous lymphoma, but mycosis fungoides is by far the most common of this group. It is a non-Hodgkin's lymphoma of T-cell origin that presents in the skin. Mycosis fungoides often evolves for years without a specific diagnosis because it can present as an eczematous or psoriasiform eruption. Patients identified in the early stages and treated appropriately have a normal life expectancy.

Cutaneous T-cell lymphoma in a patient with neurofibromatosis type 1.

A variety of neoplasms may occur in association with neurofibromatosis type 1 (NF1). We describe a patient with NF1 and mycosis fungoides. Recommendations for the initial and long-term evaluations of patients with neurofibromatosis are presented.

Side effects and complications of laser therapy.

Laser skin surgery is not without risk and some degree of downtime in most situations. Patient satisfaction is key to the perceived success of the procedure. Therefore, the physician must fully explain all risks, potential complications, and expected morbidity associated with any laser treatment to be performed. Although many side effects can be avoided by use of appropriate intraoperative technique and adequate postoperative management, untoward effects may still occur and must be promptly identified and addressed. An informed patient is an important factor in the healing process and contributes to the success of the procedure.