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In patients with primary high-stage cutaneous squamous cell carcinoma, Mohs surgery was associated with significantly better outcomes—including lower recurrence, metastasis, and disease-specific mortality—compared with wide local excision.

High-stage cutaneous squamous cell carcinoma (cSCC) has an increased risk of recurrence, metastasis, and mortality. However, studies examining the outcomes of high-stage cSCC among patients treated with Mohs surgery vs those treated with wide local excision (WLE) are limited.

New research addressing this gap by David M. Wang, MD, and colleagues found that Mohs surgery was associated with improved outcomes compared with WLE in patients with primary high-stage cSCC, demonstrating benefit across all outcome measures including lower rates of recurrence, metastasis, and disease-specific mortality. The findings were reported in JAMA Dermatology.

The retrospective cohort study was conducted at Brigham and Women’s Hospital, Boston, between 2000 and 2019. A total of 216 patients (mean age, 73.5 years) with primary high-stage cSCC treated with Mohs surgery or WLE were included. Of the cohort, 69.9% were men and 30.1% were women.

The primary end points included local recurrence, nodal metastasis, distant metastasis, any recurrence (ie, a composite outcome of recurrence or metastasis), and disease-specific death. The median follow-up time was 33.1 months.

Dr. Wang and colleagues found the baseline characteristics were well balanced between the WLE and Mohs surgery treatment arms, with absolute standardized differences of less than 0.10 across all characteristics. Overall, all adverse outcomes were greater among the patients in the WLE arm compared with those in the Mohs surgery arm.

After inverse probability of treatment weighting, the 3-year cumulative incidence of local recurrence was 19.8% for WLE compared with 9.6% for Mohs surgery (cause-specific HR, 2.33; 95% CI, 1.39-3.92; P=0.001). The cumulative prevalence of nodal metastasis was 17.9% vs 11.0% for WLE and Mohs surgery, respectively (HR, 1.80; 95% CI, 1.07-3.02; P=0.03). The researchers did not observe a significant difference in occurrence of distant metastasis between WLE and Mohs surgery (8.4% vs 4.4% respectively; HR, 2.10; 95% CI, 0.97-4.57; P=0.06). The cumulative incidence of any recurrence was 32.0% for WLE vs 15.8% for Mohs surgery (HR, 2.38; 95% CI, 1.57-3.61; P<0.001) and disease-specific death (17.5% vs 7.1%, respectively; (HR, 2.74; 95% CI, 1.54-4.88; P=0.001).

“The findings of this cohort study suggest that Mohs surgery was associated with improved outcomes in the treatment of primary high-stage cSCC compared with WLE. These findings further suggest that Mohs surgery or alternative methods of peripheral and deep en face margin assessment should be offered as first-line treatment,” the authors concluded.