Background: We identified factors that influence patient perceptions of their skin cancer surgery through a prospective study of patients referred to a single surgeon during 18 months.
Method: Patients having surgery resulting in a wound sutured and dressed were surveyed 6 to 9 months later. Monitoring for complaints continued for three years.
Results: In all, 74% of patients returned the survey (576 of 778). A total of 250 (43%) rated their scar excellent, 177 (31%) very good, 72 (12.5%) good, 40 fair (6.9%) and 14 (2.4%) poor or very poor. Age, sex, diagnosis, or closure method did not result in a variation in scar perception.
In all, 27.3% of scars (21 / 77) on the trunk were rated neutral or negative compared with 6.9% (33 / 476) of scars elsewhere, (p<.001) and 5% (15 / 305) of head and neck scars (p<.001). Complications did not change scar or overall evaluation ratings.
In all, 393 (68%) rated the overall service excellent, 145 (25%) very good, 22 (4%) good and 3 (0.5%) fair. No patient rated the service poor or very poor. Patients rating the service lower were most dissatisfied with scar appearance, time waiting before surgery, pain from the local anaesthetic, nursing care, follow up care, cost and written material.
In all, 99% of patients who rated their scar very good or excellent rated the overall service optimally, compared with only 85% of patients who rated their scar as good or worse.
Conclusion: Complications and patient complaints do not identify patient dissatisfaction from cutaneous surgery. The patients’ perception of their scars markedly influences their overall service perception. Patients experienced more dissatisfaction with repairs on the trunk.
Patient perception of skin cancer surgery is poorly understood. We have previously described a 9.8% incidence of neutral or negative response to long term scar appearance2. Others have described a similar 13% neutral or negative wound assessment after excision of basal cell carcinoma.221 Skin cancer is still predominantly managed by surgical excision and repair, and cosmetic outcomes from such procedures are usually well accepted, even in comparison to non operative procedures such as radiotherapy221. Using a randomized trial format the authors have previously demonstrated that the application of ointment to a wound does not change the overall patient assessment of cosmetic outcome.2 Many other wound management methods have been adopted with the hope of improving scars but have shown no significant benefit in formal randomised control trials.222, 223 Wounds repaired under some tension are predominantly closed with sutures, with similar or somewhat improved results when compared with wounds closed with glues224-228, staples126, 229 or tapes230-235.
Little is known of the aspects of skin cancer surgery that might result in a higher risk of the patient feeling neutral or negative toward their treatment experience or their scar. Patient perceptions of the outcomes of skin cancer management can differ from objective assessments236. It is not known how age, sex, diagnosis, type of procedure or complications affect patient satisfaction. It is possible that other aspects of skin cancer management might also alter patients’ perception of service; waiting period before surgery, pain, dressing type, local anaesthetic, the operation, nursing care, procedure counselling, pathology counselling,237 or even cost238, 239.
Outcomes of wounds assessed over weeks rather than months are less likely to demonstrate a significant difference as wound healing progresses over several months. Study of wound healing perception should extend out at least three months to allow for scar remodeling179.
Through a prospective longitudinal study, we sought to investigate whether patient demographics, diagnosis or treatment might influence a neutral or negative response to skin cancer surgery. This prospective study was conducted in accordance with the Declaration of Helsinki and was approved as part of a larger trial by the Barwon Health Research & Ethics Committee.
Newly referred patients who attended a dedicated skin cancer surgery centre between July 1st 2002 and December 31st 2003 were offered enrolment in the prospective trial. Inclusion criteria required that the patient:
Be referred for management of skin lesion.
Have incisional or excisional surgery.
Have treatment resulting in a wound that was closed with sutures and to which a dressing was subsequently applied. Suturing was predominantly simple interrupted, with usage of vertical and horizontal mattress sutures at times where appropriate. Buried deep absorbable sutures were used sparingly before polyamide, particularly on larger defects or those with increased tension.
Patients were excluded if the skin was contaminated or infected before surgery, the surgical site was not amenable to a moist occlusive dressing (eg. eyelid, lip), or the patient had a known allergy to the occlusive dressing.
Any patient who had more than one procedure during the trial period had the trial pertain to the first procedure only. Where patients had multiple tumours needing excision, the most concerning tumour was excised first.
One dermatologic surgeon (A.J.D) performed all procedures in one of two operating rooms. All surgery was undertaken using sterile surgical gloves, drapes and equipment. The surgeon wore a surgically clean gown and a face mask. The site of all removed lesions were recorded and all specimens sent for histopathological examination. The dressings were moist and occlusive in nature127, 128 and were applied by an experienced nurse who chose a dressing appropriate to site and patient considerations. Each patient was given a detailed postoperative instruction sheet, highlighting wound management and warning signs for complications. Patients who had a large excision and / or flap or graft were contacted by telephoned the day after surgery. Wounds were followed up clinically until wound healing was complete, at least until removal of sutures, and longer if there was skin flap or graft surgery involved or a complication was experienced.
Patients were counseled verbally and in writing, including a one page information sheet.
Any infected wounds were recorded and classified in the following predetermined groupings: purulent site, suture abscess, cellulitis, infective necrosis, large subcuticular abscess, regional lymphadenitis and septicemia. Wound infections were assessed clinically unless there was abscess formation or evidence of involvement beyond the local site. In these circumstances, a wound swab for culture was taken. In the absence of suppuration, a wound was considered infected if three of the following were present: discharge, pain, erythema, or induration. All wound infections were treated with oral Dicloxacillin (500mg four times daily) unless sensitivity or allergy deemed this to be inappropriate.
Complications were detailed and recorded. Adverse scar outcomes were classified as, wound spread, suture marking, hypertrophic scar, keloid, hyperpigmentation, hypopigmentation, wound depression, wound elevation, pronouncement of dog ears, and scar contracture.
Other adverse outcomes recorded included post operative bleeding, contact allergy to dressing, contact allergy to skin preparation, other contact dermatitis, recurrence of tumor, nodal or distant metastasis, dehiscence, pruritus, and persistent pain or nerve damage. Other adverse outcomes to be noted were; ectropion, nodal involvement, and distant metastases.
Six months after surgery, each patient was mailed a one-page survey to complete and return. (Figure 1) Patients not returning surveys were sent a repeated survey at 8 - 9 months after surgery. Patients who had multiple surgeries were asked to rate only their first procedure so as to minimize confusion.
All complaints either verbal or written, made by a patient about the doctor or the skin cancer surgery centre either direct or through a third party was documented for at least 36 months after each surgery.
All key outcome incidences were analyzed using the chi-square test and the positive responders were compared with neutral or negative responders individually using 2 x 2 tables. The same process was used when examining other hypotheses. The only exception was our analysis of overall service perceptions. There were no negative responders to this question so we compared very good and excellent (optimal) responses with good and fair (sub optimal) responses with, chi-square test with 2 X 2 tables.
A total of 926 patients were referred for surgery between July 1st 2002 and December 31st, 2003. A total of 148 patients were excluded from the study for the following reasons: wound sites were not amenable to a dressing (n=96), allergy to dressings (n=25), contaminated wounds at time of surgery (n=8), patient declined (n=13), age under 18 years (n=4) and patient unable to understand (n=2). The study group consisted of 778 patients with an average age was 59.3 ± 18 years.
These 778 patients had a total of 1801 surgical procedures during the 18 month study period.
In all, 69.4% of wounds were closed with elliptical excisions and direct closure. In all, 29.9% involved a random pattern skin flap and 0.7% required a skin graft.
Post operative complications are detailed in Table 1. There were a total of 32 wound infections, (1.8%). Infections were predominantly local abscesses and cellulitis, and were treated with and responded to oral antibiotics, predominantly Dicloxacillin. There were no abscesses that needed draining; no infections required intravenous antibiotics, or hospitalization. No patient had more than one wound that became infected.
A sub-analysis of the excision region found a significant increase in the risk of wound infection in lower limb lesions. There were 225 lower limb lesions with an infection incidence of 4.4% compared with 1.4% for the remaining body areas (p<.001).
A sub-analysis of the first lesion versus second or subsequent lesions managed on each of the 778 patients revealed no significant difference in the incidence of skin infection, wound problems, bleeding and total complications between groups. (data not shown)
Survey at 6-months
A total of 576 patients returned the survey (74%). In all, 65.5% of men patients returned the survey (274 out of 418) compared with 83.9% of women (302 out of 360) (p<.001). Non-responders were not significantly different from responders with regard to age, sites of wounds or complication incidence.
Of the 576 respondents, 250 patients (43.4%) rated their scar as excellent, 177 (30.7%) rated their scar very good and 72 (12.5%) rated their scar as good. A further 40 patients (6.9%) rated their scar fair, 8 (1.4%) poor and 6 (1.0%) very poor. Sex and age did not correlate with the likelihood of rating a scar neutral or negatively, with responders in each age quartile demonstrating around a 10% neutral or negative scar assessment.
We analysed all the responses of patients who rated their wound neutral or negatively. (Table 2). Of note, scars to the trunk were more likely than scars elsewhere to be rated as fair or worse. In all, 21 out of 77 trunk wounds (27.3%) were rated fair, poor or very poor compared with 33 out of 476 (6.9%) elsewhere on the body (p<.001). In all, 4.9% of patients (15 of 305) with surgery to the head and neck rated their scar fair or worse compared with 9.2% of lower limb scars (6/65) and 12.4% on the upper limb (12/97).
Analysis of face and head wounds was noteworthy for the high level of long term wound satisfaction. Of 305 head and neck wounds, 149 (48.9%) were rated excellent, 91 (29.8%) were rated very good, 41 (13.4%) good, 13 (4.3%) fair and 2 (0.7%) poor. No head and neck scar was rated very poor.
Patients were more likely to rate a scar neutral or negative if they were unhappy with the time taken to undertake surgery or that the pathology explanation was suboptimal. When a patient was unhappy with their scar they were more likely to be unhappy with the overall service. (Table 2).
Larger defects were more likely to be closed with a flap or a graft than direct closure. However, the choice or reconstruction did not affect patient satisfaction.
The presence or absence of complications in the post operative period did not correlate with a subsequent dissatisfaction. Patients with malignant and benign tumour surgery had equal rates of satisfaction. Patient’s assessment of the duration before the first appointment with the doctor did not correlate with subsequent wound assessment. Details of the patient’s assessment of the quality of practice explanations and timeliness of the service are in Table 3.
Of the 576 respondents, 187 (32.5%) reported no post operative pain, 221 (38.4%) reported minimal pain that required no analgesia, 135 (23.4%) reported pain that was controlled with paracetamol, 16 (2.8%) required analgesia stronger than paracetamol and 4 patients (0.7%) described severe pain that did not respond to combined oral analgesics.
In all, 284 of the 576 respondents (49.3%) found the dressing to be no inconvenience to them. 259 (45%) rated the dressing as a nuisance while only 12 patients (2.1%) found the dressing to be disruptive or intolerable.
When asked for their overall assessment of the service 6 to 9 months after surgery, 393 of the 576 (68.2%) rated the service excellent, 145 (25.2%) very good, 22 (3.8%) good, and 3 (0.5%) fair. No respondent described the overall service as poor or very poor.
We sought to further analyse aspects that resulted in the 25 patients rating the service good or fair (suboptimal) rather than very good or excellent, (optimal).
Answers to questions from the 25 respondents who rated service as suboptimal were compared with those rating the service optimally. (Table 4).The following characteristics correlated with a suboptimal rating: male sex, perceived undue time taken between consultation and surgery, assessment of the local anaesthetic, rating of the actual operation, nursing care assessment, follow up care rating, cost of service rating, rating of written material provided and self scar assessment.
There were four aspects of service that were consistently and repeatedly highlighted by those rating the overall service as suboptimal. These were scar assessment, cost of service, follow up care, and written material provided. In each of these 4 parameters, over two thirds of respondents providing a suboptimal rating came from the 25 patients who rated the overall service as suboptimal. In contrast, less than one third of respondents providing a suboptimal rating for these parameters came from the 538 patients that considered the overall service optimally. In each case the difference was highly significant.
No patient rated the overall service as suboptimal unless at least two of these four aspects were rated sub optimally. Four patients nominating the service as good indicated two areas in which their assessment was suboptimal. Five patients highlighted 3 of these 4 parameters as suboptimal, thirteen listed all 4 parameters. The three patients who rated the overall service as fair indicated all 4 parameters were suboptimal.
Aside from the surveys, no complaints were made by any patient during the trial period up or until December 31st 2006. There was no verbal or written complaint to the doctor or the staff. Further, no complaints were made to any third parties about us and then forwarded or reported to us. The survey invited respondents to add comments after the specific questions. (Figure 1) No patient chose to make a complaint within the “comments” section.
Just more than 90% of patients in this study rated their long term scars as excellent, very good or good. This is consistent with previous smaller studies.221 These data showed that more than 99% of patients who rated their scar very good or excellent also rated the overall service very good or excellent. In contrast, only 85% of patients who rated their scar good, fair, or worse rated the overall service very good or excellent. It is clear that end points for quality can be very different from end points of service as assessed by the patients. Although surgeons are conscious of complications such as tumour recurrence and strive to minimise such adverse outcomes, patients did not associate complications with suboptimal scars or poor quality of service.
This study demonstrated that patients were more likely to consider the scar suboptimal when it was on the trunk, including the chest, back and abdomen. In contrast, patients were overwhelmingly very satisfied with surgical scars to the face and head.
In response to these findings, we have developed a fact sheet explaining the characteristics of scars to the trunk, including the higher and problematic incidence of hypertrophic scars, wound spread and keloid formation.
Surgeons excising lesions from the trunk may consider using reconstructive techniques that reduce the incidence of widened scars, hypertrophic scars and keloids. These include the modified buried vertical mattress suture79and the incorporation of both deep subcuticular and epidermal sutures. Such deeper sutures have been demonstrated to result in better patient scar acceptance when used after abdominal240, hip241, 242 and leg surgery126. Other studies, however, have not found such an advantage.135, 229
The infection incidence and distribution of infection in this study is consistent with previously published data in a larger study.1 Patients scheduled for excisions below the knee can be advised that they are subject to higher rates of infection and that more prolonged and involved post operative care can be expected.
Other than location on the body, this study demonstrated that patients were more likely to rate a scar poorly with a perceived delay before surgery or if they were not fully satisfied with the explanation of the pathology results. Patients expressed dissatisfaction with delays as short as several days between learning that a skin lesion needed excision and the eventual surgery.
There were several instances when the patient scar assessment did not correlate with our assessment. For example, there were two patients seen over six months after surgery who rated their scar as poor despite the fact that the study investigators had to check photographic records to identify the site of surgery as no visible scar was apparent. Similarly, there were patients who rated their scar excellent when the surgeon would have preferred a more aesthetic result. A more formal analysis of patient versus clinician assessment of scar was not possible as relatively few patients were examined 6 to 9 months after their procedure.
Two thirds of the patients did not require analgesia after excision of skin lesion. Those who required analgesia predominantly controlled their pain with paracetamol. Wound dressings were well tolerated by patients with few regarding dressing as more than just a minor nuisance.
The study has many limitations other than reliance on patient scar assessment in the absence of an independent evaluator. The study involved only a single experienced skin cancer surgeon in a southern Australian temperate climate. Wound infections can be substantially higher in more tropical regions, including northern Australia.182 The study surgeon may be more experienced and skilled at facial surgery than trunk surgery, possibly accounting for the large discrepancy in wound satisfaction between trunk scars and other scars. Women were more likely to return the survey than men. It is unclear whether this had any effect on the validity of the study.
Five patients who had no out of pocket expense for their skin cancer management rated the cost of the service as “fair”. These were pensioners who assigned the total cost of their treatment to the public health system (Medicare Australia). They may have chosen to describe the cost as “fair” in the belief that a fair cost for pensioners is that Medicare Australia should meet the entire account. As such, the wording of our cost question may have been inadequate.
To maximise patient satisfaction with respect to surgical skin cancer services, the surgeon needs to consider aspects of service beyond minimising tumour recurrence, minimising complications and addressing complaints if and when they are made.
The most important factor influencing a patient’s overall assessment of a skin cancer service is their perception of the final aesthetic outcome of the wound.