AUSTIN, Texas — For geriatric patients and patients with skin cancer at the end of their lives, providers may be discussing the following decision: “To Mohs, or not to Mohs?” That is the question, Brooke Walterscheid, MD, a micrographic surgery and dermatologic oncology fellow at the Cleveland Clinic in Cleveland, told attendees at the American College of Mohs Surgery (ACMS) Annual Meeting 2026.

Drawing inspiration from Shakespeare’s famous Hamlet soliloquy, Walterscheid reframed this question in the context of risks and benefits for adults in their golden years: “Whether ’tis nobler in the patient’s mind to suffer the scalpels and sutures of outrageous efforts or to take pause against a sea of surgical fatigue and by opposing, forgo treatment? To live, to rest; to rest: perchance to palliate: ay, there’s the rub.” 

“In geriatric and end-of-life patient populations, the literature supports that the risks of most can often outweigh the benefits,” Walterscheid said. Those risks can include isolation, pain, limited mobility, intraoperative discomfort, fall hazards, wound care challenges, and prolonged wound healing.

Moreover, for low-risk nonmelanoma skin cancer, the risk for metastases for basal cell carcinoma is just 0.0028%-0.55%, and less than 5% of squamous cell carcinoma in situ cases progress to invasive squamous cell carcinoma. 

“So, at this point, we pause, and we ask ourselves, what is our intention in management?” Walterscheid said. “Is it a cure to alleviate symptom burden, and what is the lag time to benefit? When will patients see the benefit? Will they see it in their lifetime?” 

She acknowledged that when patients and their families are given options beyond Mohs surgery, they sometimes “can almost feel confronted by the onslaught of choices” because the list of possibilities can be overwhelming, including radiation, targeted therapy with checkpoint inhibitors and Hedgehog inhibitors, or field therapy with 5-fluorouracil, imiquimod, or photodynamic therapy. Surgical options besides Mohs include shave removal, cryotherapy, wide local excision, and electrodesiccation and curettage. 

Current assessment tools for determining whether Mohs surgery is appropriate for a patient include the Charleston Comorbidity Index score; the Karnofsky Performance Status scale, which takes into account a patient’s functional status, need for care, and activities of daily living; and the G8 tool, which assesses frailty and the need for comprehensive assessment. While Walterscheid’s institution has been using the G8 tool for this discussion, they found that it’s not quite meeting the needs of their patient population.

Mohs-Specific G8 Score

The researchers therefore aimed to develop a Mohs-specific assessment tool that could triage older and end-of-life patients for surgical candidacy and identify those who may be more appropriately managed with observation or less invasive treatments, Walterscheid said. They therefore conducted a retrospective chart analysis going back 18 months to identify isolated “no go” cases. 

They identified 18 patients with 29 tumors and incorporated pertinent findings from these cases into a new G8-based scoring system that they called the G8 modified scoring system (G8/MMS).

Walterscheid described the tool as assigning a score of 0, 1, or 2 for 13 questions falling under the categories of postoperative management, patient health status, and tumor-specific features. Postoperative management considers activities of daily living, including a patient’s mobility and ability to care for themselves, as well as the patient’s support system and whether they are on anticoagulant therapy, which considers their bleeding risk and need for wound care assistance. 

The patient’s health status considers their age — which can help inform whether the tumor is likely to impact the patient in their lifetime — as well as any recent hospitalizations, high-risk comorbidities (such as an internal malignancy or thromboembolic risk), or recent health events, such as falls, heart attacks, strokes, or other events. The assessment of a patient’s health status also considers their surgical fatigue, their neuropsychosocial conditions (dementia and depression), and whether they have experienced weight loss in the previous 3 months, which could affect wound healing and nutrition during recovery. 

Finally, tumor-specific features consider whether the tumor is a high-risk subtype, whether it’s in a high-risk location, and what the anticipated repair recovery time would be. After considering all these factors, a score of 0-7 would lead to a recommendation of gold-standard surgical management, while a score of 14-20 would lead to a recommendation of no treatment and observation alone. A score of 8-13 would indicate a discussion of treatment options and their risks and benefits. 

When the researchers applied the G8/MMS assessment retroactively to the 18 patients whose charts they reviewed, they determined that nine of the 29 lesions would have been managed differently. Walterscheid gave examples of applying the G8/MMS to the previous cases, including “Ms Fiona,” a 94-year-old avid golfer who had a nodular basal cell carcinoma on the nasal ala whose only medication was an antihypertensive. With a score of 6, the tool indicated that Mohs surgery was appropriate for her. 

“Mr Wilson,” on the other hand, was a 90-year-old man with micronodular basal cell carcinoma on the shin whose score would have been a 12. He had undergone Mohs surgery and is still facing wound care challenges a year later. 

Walterscheid suggested that providers could incorporate this assessment tool into their practice workflow to help with triaging cases, offering consult visits, and optimizing surgical slots, thereby resulting in better utilization of practice resources for both patients and providers.

“It’s important to remember that we practice the art of medicine, in which an ‘x’ diagnosis does not necessarily mean a ‘y’ treatment, even when ‘y’ is the gold standard, because what is gold to patients in their golden years?” Walterscheid said. “Instead, we rearrange the equation in which ‘x’ is shared decision-making that protects the patient’s dignity.”

After the presentation, Nathan Jensen, MD, dermatology resident at the University of Utah Health, Salt Lake City, told Medscape Medical News that he could see this G8/MMS tool being highly useful, particularly in his work doing skin checks at the Veterans Administration.

“A lot of the patients are older veterans,” Jensen said. “When we diagnose a new basal cell cancer on their nose or another skin cancer, we’re trying to decide how best to proceed.” Sometimes the choice is obvious, he said, such as with patients who already have a terminal diagnosis of some sort, when they likely would not even biopsy the potential cancer. 

“But there are a lot of these patients who are in the middle ground, and it’s nice, especially when the patient isn’t sure what they want to do, having that questionnaire and saying, ‘You know, this doesn’t quite fit with your goals.’” The tool would be particularly helpful during a busy day when providers have less time to sit down and discuss the options at length with patients, he commented.

No external funding was noted. Walterscheid and Jensen both reported having no disclosures. 

Tara Haelle is a science/health journalist based in Dallas.