Nonmelanoma skin cancer: an episode of care management approach

Keratinocyte cancer excisions in Australia: Who performs them and associated costs

BACKGROUND/OBJECTIVE

To describe the clinical settings in which keratinocyte cancers are excised in Queensland and describe the types of practitioners who excise them; to examine costs; and to identify predictors of hospital admission.

METHODS

We used linked data for participants from the QSkin study (n = 43 794), including Medicare claims and Queensland hospital admissions relating to treatment episodes for incident keratinocyte cancers from July 2011 to June 2015. We used multinomial logistic regression to measure associations between demographic and clinical characteristics and treatment setting. The median costs of Medicare claims (AU$) were calculated.

RESULTS

During 4 years of follow-up, there were 18 479 skin cancer excision episodes among 8613 people. Most excisions took place in private clinical rooms (89.7%), the remainder in hospitals (7.9% private; 2.4% public). Compared with other anatomical sites, skin cancers on the nose, eyelid, ear, lip, finger or genitalia were more likely to be treated in hospitals than in private clinical rooms (public hospital OR 5.7; 95%CI 4.5-7.2; private hospital OR 8.3; 95%CI 7.3-9.4). Primary care practitioners excised 83% of keratinocyte cancers, followed by plastic surgeons (9%) and dermatologists (6%). The median Medicare benefit paid was $253 in private clinical rooms and $334 in private hospitals. Out-of-pocket payments by patients treated in private hospitals were fourfold higher than those in private clinical rooms ($351 vs $80).

CONCLUSIONS

Most keratinocyte cancers are excised in primary care, although more than 10% of excisions occur in hospital settings.

Differential expression of degradome components in cutaneous squamous cell carcinomas

Although the cure rate for cutaneous squamous cell carcinoma is high, the diverse spectrum of squamous cell carcinoma has made it difficult for early diagnosis, particularly the aggressive tumors that are highly associated with mortality. Therefore, molecular markers are needed as an adjunct to current staging methods for diagnosing high-risk lesions, and stratifying those patients with aggressive tumors. To identify such biomarkers, we have examined a comprehensive set of 200 histologically defined squamous cell carcinoma and normal skin samples by using a combination of microarray, QRT-PCR and immunohistochemistry analyses. A characteristic and distinguishable profile including matrix metalloproteinase (MMP) as well as other degradome components was differentially expressed in squamous cell carcinoma compared with normal skin samples. The expression levels of some of these genes including matrix metallopeptidase 1 (MMP1), matrix metallopeptidase 10 (MMP10), parathyroid hormone-like hormone (PTHLH), cyclin-dependent kinase inhibitor 2A (CDKN2A), A disintegrin and metalloproteinase with thrombospondin motifs 1 (ADAMTS1), FBJ osteosarcoma oncogene (FOS), interleukin 6 (IL6) and reversion-inducing-cysteine-rich protein with kazal motifs (RECK) were significantly differentially expressed (P≤0.02) in squamous cell carcinoma compared with normal skin. Furthermore, based on receiver operating characteristic analyses, the mRNA and protein levels of MMP1 are significantly higher in aggressive tumors compared with non-aggressive tumors. Given that MMPs represent the most prominent family of proteinases associated with tumorigenesis, we believe that they may have an important role in modulating the tumor microenvironment of squamous cell carcinoma.

Randomized trial of tailored skin cancer prevention for children: the Project SCAPE family study

This study evaluated a tailored intervention to promote sun protection in parents and their children, hypothesizing that the tailored intervention would lead to improved skin cancer prevention behaviors compared to generic materials. Families were recruited through schools and community centers and were included if there was 1 child in Grades 1-3 at moderate to high risk for skin cancer. Participants were randomized into one of two intervention groups: a tailored intervention, in which they received personalized skin cancer education through the mail; or a control group who received generic skin cancer information materials. Before and after intervention, parents completed questionnaires about their and their children's skin cancer risk and prevention knowledge and behaviors. Parents also completed 4-day sun exposure and protection diaries for their child and themselves. Tailored group participants demonstrated significantly greater positive changes in prevention behavior after the intervention, including children's use of sunscreen, shirts, and hats, and parents' use of shade, and skin examinations. Effect sizes were small and perceived benefits and social norms mediated intervention effects. Findings from this study support the efficacy of focusing tailored communications to families in order to change skin cancer prevention practices in young children.

Preventative topical diclofenac treatment differentially decreases tumor burden in male and female Skh-1 mice in a model of UVB-induced cutaneous squamous cell carcinoma

Ultraviolet B (UVB) light is the major environmental carcinogen contributing to non-melanoma skin cancer (NMSC) development. There are over 3.5 million NMSC diagnoses in two million patients annually, with men having a 3-fold greater incidence of squamous cell carcinoma (SCC) compared with women. Chronic inflammation has been linked to tumorigenesis, with a key role for the cyclooxygenase-2 (COX-2) enzyme. Diclofenac, a COX-2 inhibitor and non-steroidal anti-inflammatory drug, currently is prescribed to patients as a short-term therapeutic agent to induce SCC precursor lesion regression. However, its efficacy as a preventative agent in patients without evidence of precursor lesions but with significant UVB-induced cutaneous damage has not been explored. We previously demonstrated in a murine model of UVB-induced skin carcinogenesis that when exposed to equivalent UVB doses, male mice had lower levels of inflammation but developed increased tumor multiplicity, burden and grade compared with female mice. Because of the discrepancy in the degree of inflammation between male and female skin, we sought to determine if topical treatment of previously damaged skin with an anti-inflammatory COX-2 inhibitor would decrease tumor burden and if it would be equally effective in the sexes. Our results demonstrated that despite observed sex differences in the inflammatory response, prolonged topical diclofenac treatment of chronically UVB-damaged skin effectively reduced tumor multiplicity in both sexes. Unexpectedly, tumor burden was significantly decreased only in male mice. Our data suggest a new therapeutic use for currently available topical diclofenac as a preventative intervention for patients predisposed to cutaneous SCC development before lesions appear.

Methodological issues in using multiple years of the Medicare current beneficiary survey

BACKGROUND

The analysis presented in this paper examines the multi-year capacity of the Medicare Current Beneficiary Survey (MCBS).

METHODS

We systematically reviewed the literature for methodological approaches in research using multiple years of the MCBS and categorized the studies by study design, use of survey sampling weights, and variance adjustments. We then replicated the approaches in an empirical demonstration using functional status (activities of daily living (ADL) and 2005-2007 MCBS data.

RESULTS

In the systematic review, we identified 22 pooled, 17 repeated cross-sectional, and 17 longitudinal studies. Less than half of these studies explicitly described the weighting approach or variance estimation. In the empirical demonstration, we showed that different study designs and weighting approaches will yield statistically different estimates.

CONCLUSION

There is a variety of methodological approaches when using multiple years of the MCBS, and some of them provide biased results. Research needs to improve in describing the methods and preferred approaches for using these complex data.

Metatypical basal cell carcinoma: a clinical review

Background

Metatypical cell carcinoma can be considered as a new entity of skin cancer, being an intermediate typology between basal cell carcinomas and squamous cell carcinomas. The behaviour of the metatypical cell carcinoma lies between these two varieties of skin cancer. It is difficult to perform a differential diagnosis based on morphological and clinical features – therefore it is only possible by accurate histology.

Methods

The authors have retrospectively analysed clinical records of 240 patients who were affected by metatypical skin cancer and who were treated by surgery, radiotherapy and chemotherapy.

Results

MTC affected more males than females (62.5% vs 37.5%) than males. The most affected site was the cervicofacial area, 71.7%; then the trunk, 10%; the limbs, 9.6%; the scalp 3.7%; and other regions 5%. A recurrence occurred in 24 cases (10%), mainly in head and neck area.

Conclusion

In this manuscript, the authors have emphasised the importance of conducting a differential diagnosis, and the importance of the specific treatment for metatypical skin cancer, even though more clinical studies and long-term follow-ups are required before establishing specific guidelines.

Évaluation médico-économique de la prise en charge des carcinomes basocellulaires superficiels et des kératoses actiniques multiples par les dermatologues français

INTRODUCTION

To date, no prospective studies have been conducted in France describing the management of actinic keratoses (AK) and superficial basal cell carcinomas (sBCC). The aim of the present study was to describe the therapeutic modalities for AK and sBCC adopted by French dermatologists and to determine the direct annual medical costs.

PATIENTS AND METHODS

This was a prospective, observational study conducted in France between January and June 2004 in a random selection of representative dermatologists (n=202). The first 5 adult patients seen for one or more sBCCs and the first patient with at least 4 AKs over a period of four non-consecutive weeks were included in the study. The following data were recorded using a standardized questionnaire at inclusion: date of birth, gender, habitat, professional activity, social insurance regimen, site, number and maximum size of lesions. The therapeutic modalities, the physicians involved and the laboratory examinations during the 3 months following diagnosis were recorded prospectively. Medical management costs were calculated taking into account the usual parameters (e.g. French nomenclature of medical acts).

RESULTS

512 patients with sBCC (mean age: 69 years; sex-ratio M/F: 0.92) were included in the study. sBCC was isolated in 80% of cases, measured less than 2 cm in 90%, and was located on the head/neck in 51% and on the trunk in 37%. Histological confirmation of diagnosis of BCC was obtained in 85% of cases. Treatment comprised surgical excision in 70% of cases, cryotherapy in 13%, topical therapy in 7% and curettage/electrodessication in 4%. Clinical follow-up was performed in 79% of cases. The mean cost per patient over 3 months was 139 euros (CI95%: 125-153). In addition, 226 patients with AK (mean age: 76 years; sex-ratio M/F: 2.1) were included in the study. AKs were located on the head/neck in 74% of cases and on the trunk in 6%. Treatment consisted of cryotherapy in 92% of cases. The mean cost per patient over 3 months was calculated at 85 euros (CI95%: 71-99). An on-site audit of 5% of the investigators gave a concordance rate of 98.8%.

DISCUSSION

This is the first study conducted in France to evaluate both the medical approach and treatment costs of sBCC and AK. Finally, the mostly surgical treatment of sBCC observed is in accordance with the recent French ANAES guidelines. When extrapolating the results of the present study, the annual cost of treatment of sBCC by French dermatologists may be estimated at between 10.2 and 10.6m euros.

Outpatient dermatology major surgery: a 1-year experience in a Spanish tertiary hospital

INTRODUCTION

The constant increase in the incidence of skin cancer together with the requirement for maximum exploitation of available medical resources has meant that dermatological major surgery on an outpatient basis has greatly increased in recent years.

OBJECTIVE

This article reviews the practice of dermatological surgery in an outpatient setting over a 1-year period. Its purpose is to analyse the number of surgical procedures, the type of cutaneous processes treated and the kind of surgical intervention and anaesthesia used. We also assessed the percentage of cancellations, postsurgical hospital admission and postsurgical complications. Clinicopathological correlation and complete tumour removal were also evaluated.

MATERIAL AND METHODS

Our clinical experience of major surgery of outpatients at the dermatology department of the Hospital Juan Canalejo in A Coruña (Spain), analysing 565 patients in a non-randomized pilot study running from January to December 2003, is presented.

RESULTS

Six hundred and forty-four surgical procedures were performed on a total of 565 patients. The three main cutaneous processes treated were basal cell carcinoma (240), squamous cell carcinoma (117) and melanoma (77). The most frequent type of procedure was direct closure (346), followed by exeresis and flap (133) and partial- or full-thickness skin graft (29), nail apparatus surgery (56) and lip surgery (33). Twelve patients were admitted to hospital after surgery owing to the complexity of their operations or to complications arising during surgery. Five hundred and fifty-three patients were discharged after being kept under observation for a few hours. Seventeen patients (3%) suffered complications following surgery, which consisted of partial implant failure (six cases), infection of the surgical wound (six cases), intense pain (four cases) and haemorrhage (one case). There was a good clinicopathological correlation in 90.78% of non-melanoma skin cancers, of which 92.03% were completely removed.

CONCLUSIONS

Medium and high complexity operations for dermatological processes, traditionally performed on hospitalized patients, can be conducted on an outpatient basis. This allows hospitalization costs and waiting lists to be reduced and affords the possibility of achieving better morbidity rates and medical care than in the standard hospital setting.

Surgical Margins in the Treatment of Nonmelanoma Skin Cancer and Mohs Micrographic Surgery

Traditional surgical treatment of nonmelanoma skin cancer includes excision with subsequent evaluation of surgical margins, either via frozen sections intraoperatively or after excision and closure. Accurate communication between surgeon and pathologist regarding the meaning of surgical margins should be confirmed. Recurrences of tumor growth may in part be attributed to asymmetrical tumor growth patterns with extension of tumor in an unanticipated direction. Mohs micrographic surgery is an outpatient procedure that maximizes surgical margin evaluation while minimizing the amount of tissue that must be excised. This article will discuss the concept of surgical margins in excisions of nonmelanoma skin cancer and the role of Mohs micrographic surgery.

Trends of nonmelanoma skin cancer from 1960 through 2000 in a Canadian population

Nonmelanoma skin cancer (NMSC) is the most common malignancy diagnosed in Caucasian populations, but little is known about its occurrence in Canada. We sought to determine the historical change of the occurrence and risk of NMSC. All first diagnoses of NMSC reported in Manitoba between 1960 and 2000 were identified. Rates were reported as well as lifetime risk of developing the disease. Basal cell carcinoma was the predominant form of NMSC, accounting for 79% of all NMSCs. The annual percentage change of basal cell and squamous cell carcinoma increased 2.4%, mainly in people older than 40 years of age from the early 1970s to 2000. The lifetime risk of being diagnosed with NMSC increased by two to three times in the 1990s compared to the 1960s. We concluded that because of the potentially high impact of NMSC on resource utilization and treatment-related costs as well as its easily preventable character, priority should be given to prophylactic measures.