"You may have seen it performed in real time on ABCs Good Morning America. Or maybe you caught actor Hugh Jackman telling David Letterman about having it. Or you may be among the legions of people who have personally undergone it. It is Mohs micrographic surgery the preferred treatment for the two most common types of skin cancer basal cell and squamous cell. Although rarely lifethreatening these tumors can become disfiguring without timely removal and they are being diagnosed at the staggering clip of more than four million a year. During Mohs surgery  named for Frederic E. Mohs the Wisconsin surgeon who developed it in the s  a thin disk of skin is cut out and while the patient waits examined under a microscope. This process is repeated until the entire malignancy and a border of healthy tissue have been removed. Compared to conventional excision  cutting out the tumor plus a safety margin in one swoop  Mohs spares more tissue produces better cosmetic results and has superior cure rates. Heres the rub Mohs is also more expensive and use soared  percent from  to  Medicare data show. About a quarter of patients with nonmelanoma skin cancers are now treated with Mohs compared to  percent in . In response to concerns about overuse Medicare has tightened rules and cut reimbursement rates for Mohs and medical groups have issued guidance about when to use it. Money definitely is a factor said Clifford Perlis director of Mohs and other dermatologic surgeries at Fox Chase Cancer Center. So theres a builtin controversy about when is Mohs appropriate. A related controversy involves who should do it. You can go to a dermatologist who like Perlis spent a year or more being trained to do Mohs which requires the surgeon to double as the pathologist the specialist who evaluates cells under a microscope. Or you can go to a dermatologist who took a fourday course on Mohs. Its no news that skin cancer is increasingly common. The factors include overexposure to the suns harmful rays an aging population the Earths thinning ozone layer maybe tanningbed use. Still the magnitude of the epidemic is shocking. The average annual number of adults treated for skin cancer jumped from . million in  to . million in  while the costs more than doubled from . billion to . billion according to a recent study by the U.S. Centers for Disease Control and Prevention. Melanoma the deadliest skin cancer is part of this upward trend. But it is nonmelanomas  primarily basalcell and squamouscell lesions  that account for almost  percent of all skin malignancies. Early on these lesions may appear innocuous. Basal lesions often look like small sores red patches or shiny bumps and squamous cancers may start as scaly red patches open sores or wartlike growths. Usually nonmelanomas can be treated in a doctors office under a local anesthetic. Therapeutic options include topical drugs freezing or lasering. But when a biopsy confirms a nonmelanoma on a cosmetically important area Mohs is optimal. In  expert groups including the American Academy of Dermatology and the American College of Mohs Surgery said the procedure was appropriate for nonmelanomas on the head and neck as well as those anywhere on the body that were recurrent or aggressive. Mohs is usually not necessary the groups say for lesions on the torso. To understand Mohs advantages consider that with traditional excision the surgeon has to estimate how extensively to cut in hopes of nabbing a safety margin of healthy tissue. If the pathologist finds cancer in that margin the patient has to return for a deeper excision. Worse the pathologist may conclude the surgery achieved clear margins when it actually didnt. This happens up to  percent of the time studies show because random samples of the excised tissue are examined not the entire specimen. With Mohs in contrast each layer of removed tissue is frozen by a technician cut horizontally into micronthin slices and entirely examined under the microscope by the surgeon. This misses cancer only  percent to  percent of the time  a cure rate of  percent to  percent studies show. Mohs also has a system for colorcoding and segmenting each disk of tissue so the surgeon can tell precisely where to cut deeper at the surgical site. For patients that means the smallest possible or no scar plus immediate repair of the surgical wound. Tina McDonnell  of Palmyra went to Perlis just after Christmas for Mohs on her left ear. She is confident the results will be as good as on her nose where she has had two squamouscell lesions removed in the last decade. People cannot believe I had surgery on my nose said McDonnell operations director at the Ronald McDonald House in Philadelphia. You would never know. Thats not to suggest Mohs is magical. Deborah Edmiston  a busy mother of six in Northeast Philadelphia put up with a raw flaky red spot on the corner of a nostril assuming it was just psoriasis. By the time it became painful in May the basalcell tumor was deep. Perlis removed it with Mohs but enlisted a plastic surgeon for the multistep reconstruction which is almost complete. Now I tell everybody Make sure you cover up and use your sunscreen said the fairskinned redhead. On average Mohs costs about  per case compared to about  for excision said Howard W. Rogers a Norwich Conn. dermatologist who sits on the public policy committee of the American College of Mohs Surgery. He believes Mohs is misperceived as expensive when its actually a bargain because a single payment is made to one doctor. With excision reimbursement is spread out to the surgeon pathologist and lab. Nonetheless beginning in  the Centers for Medicare and Medicaid made changes that cut payments for Mohs  percent to  percent. Last year Medicares administrative contractor for Florida also proposed to limit reimbursement for Mohs to physicians who had completed a yearlong fellowship that included performing at least  cases. The fellowship program was created in the s by the American College of Mohs Surgery. Such a restriction would be a blow to Florida dermatologists who took a considerably shorter route  the fourday course offered by the American Society of Mohs Surgery. The society was founded in  when demand for Mohs surgeons far outstripped the number being produced by the fellowship program. The proposed restriction was dropped amid backlash from medical groups. But it highlighted a controversy within the evolving field of Mohs Is the procedure just an arrow in the skincancer specialists quiver Or is Mohs a medical subspecialty by itself The latter said Cincinnati dermatologist Brett Coldiron president of the American Academy of Dermatology and an eminent Mohs surgeon. He envisions a time when Mohs surgeons will have to meet standards and pass a certification exam. The specialty is moving that way Coldiron said but you cant do it overnight or there will be an uproar. Meanwhile he advises patients to ask questions. Id tell patients to look at their doctors experience and ask how many cases theyve done Coldiron said. Ive done . WHERE TO FIND A MOHS SURGEON Heres a link to the American College of Mohs Surgery surgeon finder. These are all fellowshiptrained Mohs surgeons httpacms.execinc.comediboSurgeonFinder mmcculloughphillynews.com"