Exploring opposing arguments in the call for randomized controlled trials to demonstrate benefit of Mohs micrographic surgery for cutaneous melanoma.

Importance: The call for robust randomized clinical trials (RCTs) comparing Mohs micrographic surgery (MMS) with wide local excision for treatment of melanoma has stymied the development of guidelines for MMS despite growing evidence of benefit. This commentary explores the controversy by detailing opposing arguments, reviewing the relevant evidence supporting the use of MMS for early-stage melanoma, and discussing the role that RCTs may play in development of national guidelines for surgical treatment options for melanoma. Randomized clinical trials are considered the gold standard of clinical research, but there are no such trials currently to support MMS for melanoma. However, there is a growing literature base of retrospective and prospective cohorts and meta-analyses consistently demonstrating the efficacy and cost-effectiveness of MMS for melanoma. The dearth of clear consensus guidelines has contributed to confusion by referring specialties, controversy across specialties managing melanoma, and inequality in access. Recognizing that this is an ongoing area of discussion within dermatologic surgery, we explore opposing arguments with regard to the demand for RCT data to support dermatologic surgery practices.