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. 2022 Mar 25;14(3):e23487.
doi: 10.7759/cureus.23487. eCollection 2022 Mar.

Hiding in Plain Sight: A Retrospective Review of Unrecognized Tumors During Dermatologic Surgery

Alexander Reid  1 , Emily Weig  1 , Kirsten Dickinson  2 , Faraaz Zafar  1 , Roshan Abid  1 , Marta VanBeek  1 , Nkanyezi Ferguson  1
Affiliations

Hiding in Plain Sight: A Retrospective Review of Unrecognized Tumors During Dermatologic Surgery

Alexander Reid et al. Cureus. .

Abstract

Background: Mohs micrographic surgery requires focused attention that may lead to tunnel vision bias, contributing to not recognizing skin cancer at nearby sites.

Objective: It is to determine if a subsequently diagnosed skin cancer was visible at the time of Mohs surgery.

Methods: A retrospective chart review was performed at a single academic center from 2008 to 2020. Patients who underwent at least two distinct MMS procedures, separated in time to capture subsequent tumors, were included.

Results: Four hundred and four individual patients were identified with at least two distinct Mohs procedures, which generated 1,110 Mohs sequences. Fifty-one (4.6%) clinically apparent tumors went unrecognized and 127 (11.4%) tumors were identified and biopsied during the visit. High-risk tumor histology was identified in 10 (20%) unrecognized tumors and 31 (24%) recognized tumors (p-value 0.491).

Conclusion: Our study suggests that Mohs surgeons may be overlooking adjacent skin cancers when focusing only on the tumor being surgically treated. Tunnel vision bias may account for part of this phenomenon.

Keywords: cognitive bias; decision making process; dermatology and dermatologic surgery; heuristic decision; quality improvement and patient safety.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. Outline of the method used to determine the number of Mohs sequences generated by an example patient’s chart. Photographs of the defect at the subsequent Mohs procedure were compared to photographs taken at the time of the prior Mohs procedure to determine if the defect corresponded to a visible but unrecognized skin lesion.
Figure 2
Figure 2. Unrecognized squamous cell carcinoma (at least in situ) on the right cheek at the time of Mohs surgery.
Figure 3
Figure 3. Unrecognized basal cell carcinoma on the right forehead at the time of Mohs surgery.
See this image and copyright information in PMC

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