Trends in the Access and Cost of Photodynamic Therapy Among Medicare Beneficiaries in the United States, 2012-2017

Systematic review of randomized controlled trials of topicals for actinic keratosis field therapy

Cutaneous field cancerization in dermatology describes the anatomic region of photodamaged skin with actinic keratoses (AKs) or cutaneous squamous cell carcinoma (cSCC) that is surrounded by cellular atypia, forming a dysplastic field. The concept of field cancerization is especially relevant in dermatology, as actinic keratoses and the surrounding dysplastic region can progress to carcinomas, necessitating the treatment of the field. Recent research has focused on field-directed therapy using topical agents. This study aims to systematically review randomized controlled trials on topical treatments for actinic keratosis field cancerization, following the PRISMA guidelines. Clinical recommendations were based on the Oxford Centre for Evidence-Based Medicine. We identified 20 original randomized controlled trials for topical cutaneous field therapy. 0.5% 5-Fluorouracil/salicylic acid and 0.5% 5-fluorouracil received a clinical recommendation grade of A, while diclofenac sodium received a clinical recommendation grade of B. Calcipotriol/5-fluorouracil, Imiquimod, sunscreen combination therapies, and tirbanibulin received a recommendation grade of C. This review provides a framework for clinicians when considering topical treatments for patients with field cancerization.

Photodynamic Therapy in Treating a Subset of Basal Cell Carcinoma: Strengths, Shortcomings, Comparisons with Surgical Modalities, and Potential Role as Adjunctive Therapy

Basal cell carcinoma (BCC) is the most common skin cancer, for which there are multiple treatment options, including the gold standard Mohs micrographic surgery (MMS), surgical excision, electrodesiccation and curettage, radiation therapy, cryosurgery, and photodynamic therapy (PDT). While PDT is currently approved for treating actinic keratosis, it has been used off-label to treat BCC patients who may not tolerate surgery or other treatment modalities. We present a review of the efficacy of these modalities and describe important considerations that affect the usage of PDT and MMS. ALA-PDT and MAL-PDT are both efficacious treatment options for lower-risk BCC that can serve as non-invasive alternatives to surgical excision with favorable cosmetic outcomes in patients unsuitable to undergo surgery. In particular, PDT may be considered an adjuvant for the prevention and treatment of BCC lesions in patients with some genetic syndromes such as Gorlin syndrome, and in combination with surgical excision in lesions presenting in certain locations. Limitations to PDT include lack of margin control to prevent recurrence, pain, and cost of certain photosensitizers. Future studies should investigate the role of PDT as adjunctive therapy, standardization of protocols, and causes and ways to address recurrence following PDT treatment.

Assessment of Photodynamic Therapy Services Performed Among Medicare Beneficiaries from 2018 to 2019

OBJECTIVE

Photodynamic therapy (PDT) is a useful treatment modality for premalignant skin lesions. We sought to describe PDT utilization on a national level in the Medicare population post-CPT code revision in 2018 to better understand trends in volume and distribution as well as what factors may influence service performance.

METHODS

We used the 2018-2019 Medicare Physician and Other Supplier Public Use File to assess PDT services performed during this period.

RESULTS

We found that there was an increasing trend of PDT utilization in the Medicare population. While there was less PDT performed without direct involvement of a healthcare professional, an increasing number of PDT services requiring debridement were performed for severe lesions. Although the majority of PDT volume was attributable to dermatologists, non-physician clinicians assumed greater involvement in PDT services. Dermatologists practicing in academic and non-metropolitan settings were less likely to be directly involved with PDT delivery.

CONCLUSION

There is a considerable volume of PDT performed among Medicare beneficiaries, with several utilization trends that may be explained by geographic location and practice setting, among other factors. These findings provide insight to PDT service distribution on a national level and highlight practice patterns that may influence PDT delivery.