Nonmelanoma skin cancer

Recommendations for Cost-Conscious Treatment of Basal Cell Carcinoma

BACKGROUND

Basal cell carcinoma (BCC) affects 3.3 million Americans annually. Treatment modalities for BCC include many surgical and nonsurgical options. The cost of BCC treatment can pose a substantial burden to patients and the healthcare system. Cost can be an important consideration in BCC treatment planning.

OBJECTIVE

We present an approach to the management of BCC when cost reduction is a priority.

METHODS

A PubMed literature search identified studies on effectiveness of current BCC therapies. Treatment prices were obtained from the Medicare National Fee Schedule, GoodRx, and pharmaceutical companies. The American Academy of Dermatology's (AAD) guidelines for treating BCC were used to develop recommendations for cost-reductive treatment.

RESULTS

The cost of treating a primary superficial BCC < 0.5 cm arising on Area M (cheeks, forehead, scalp, neck, jawline, pretibial surface) was $143 with curettage and electrodesiccation (C&E), $143 with cryosurgery, $210 with standard excision and simple reconstruction (SE), $1221 with Mohs Micrographic Surgery (MMS) and simple reconstruction, $472 with imiquimod, $186 with 5-fluorouracil (5-FU), and $354-$371 for photodynamic therapy (PDT). The cost of treating a primary nodular BCC 1.1-2 cm arising on Area L (trunk and extremities, excluding pretibial surface, hands, feet, nail units and ankles) was $183 with C&E, $183 with cryosurgery, $251 with SE and simple reconstruction, $1163-1351 with MMS and simple reconstruction, $472 with imiquimod, $186 with 5-FU, and $354-$371 for photodynamic therapy (PDT). The cost of treating a giant BCC (BCC > 10 cm with aggressive behavior) was $465-3311 with radiation, $139,560 with vismodegib, $144,452 with sonidegib, ~ $44.5 with cisplatin (medication cost only), and at least $184,836 with cemiplimab-rwlc.

CONCLUSIONS

For a primary superficial BCC < 0.5 cm arising on Area M, the cost-conscious algorithm prioritizes C&E or cryosurgery. For a primary nodular BCC 1.1-2 cm arising on Area L, the cost-conscious algorithm prioritizes C&E, cryosurgery, or 5-FU. For a giant BCC, the cost-conscious algorithm identifies superficial radiation therapy as first line.

Mohs surgery for squamous cell carcinoma

Cutaneous squamous cell carcinoma (SCC) is the second most common human cancer and can behave aggressively. Mohs micrographic surgery offers the highest cure rates for high-risk SCCs and is particularly useful for SCCs on challenging anatomic sites.

A plesiotherapy technique for the post-operative treatment of skin cancer using Ir192 microSelectron

We describe a technique of postoperative irradiation of skin cancer using plesiotherapy with Ir192 high dose rate microSelectron afterloading system (Nucletron, Veenendaal, Netherlands). The clinically defined area is drawn on the skin and the flexible ‘skin applicator’ is then orientated so that the drawn skin area is encompassed within the catheter defined surface. Using a thin pewter wire, the skin drawn area is copied on the air‐adjacent surface of the applicator. Ex vivo CT simulation follows. The data are then transferred to the radiotherapy planning computer and the catheters are virtually reconstructed. The isodose curve chosen to prescribe the dose is 3 mm to 5 mm away from the skin surface. Three fractions of 8Gy are scheduled, 1 week apart, delivering a radiobiological equivalent of 48Gy of standard radiotherapy within 2 weeks. Our preliminary experience shows excellent early skin tolerance. The study is ongoing to assess efficacy and late effects.

PACS number: 87.53.Jw

Treatment Patterns and Cost of Nonmelanoma Skin Cancer Management

INTRODUCTION

Nonmelanoma skin cancer (NMSC) is the most common form of cancer in the United States, more common than all other cancers combined. The factors that affect the cost of skin cancer management are not well defined.

OBJECTIVE

The objective was to estimate cost of episodes of NMSC care and the factors that impact those costs.

DESIGN

Medicare Current Beneficiary Survey (MCBS) data from 1999 to 2000 were used to assess costs of episodes of NMSC care. MCBS estimates of the number of episodes occurring in three service settings (physician's office, outpatient/ambulatory surgical center, or hospital) and demographics were obtained.

RESULTS

There were 497 episodes of care in 372 patients. Half the episodes were treated by dermatologists, and two-thirds were managed in physicians' offices. The mean episode cost for management in the office setting was 500 dollars (SD, +/- 487 dollars), and costs were higher when the episodes were treated in either the ambulatory surgical center or the hospital settings, 935 dollars (SD, +/- 456 dollars) and 4,345 dollars (SD, +/- 4939 dollars), respectively.

CONCLUSION

With the rising incidence and cost of NMSC to Medicare, it is increasingly important to preserve the low-cost management of this disease. Maintaining care of NMSC in the office-based setting is more cost-efficient than utilizing ambulatory surgical centers or hospital operating rooms.

Nonmelanoma Skin Cancer

Each year, there are as many cases of nonmelanoma skin cancer as all other cancers combined. Although there is relatively low attributable mortality, the morbidity and expense of treatment is significant. Unlike many other malignancies, host and environmental factors relevant to the pathophysiology have been clearly demonstrated. Surgical ablation remains the mainstay of treatment.

Nonmelanoma skin cancer: an episode of care management approach

BACKGROUND

The incidence of nonmelanoma skin cancers (NMSCs) was estimated at 1.3-million cases for the year 2000 and is on the rise. It is the most common form of cancer in the United States, more common than all other cancers combined. To determine the contributors to the cost of NMSC care, an episode of care of NMSC needed to be defined.

OBJECTIVE

To define and validate an episode of NMSC care.

DESIGN

Using survey and Medicare part A and part B claims data of the Medicare Current Beneficiary Survey (MCBS), 1992 to 1995, an algorithm was created to define an episode of care for the diagnosis and treatment of an NMSC. MCBS estimates of the number of episodes occurring in three service settings (physician's office, outpatient/ambulatory surgical center, or hospital) and demographics were compared to data from independent datasets, including the National Ambulatory Medical Care Survey (NAMCS, 1995), the National Survey of Ambulatory Surgery (NSAS, 1994 to 1996), and the National Hospital Discharge Survey (NHDS, 1992 to 1997).

RESULTS

Pathology claims for NMSC diagnosis served as the indicator of NMSC episodes. The procedures, office visits, and tests that resulted in and from the pathology specimen were identified. The sum of the associated charges to Medicare or Medicare payments for all identified claims equaled the total cost of the episode of NMSC care. For example, these preliminary results demonstrated significant differences between medical and surgical subspecialties.

CONCLUSION

This study defined and validated a model of an episode of NMSC care. This model's initial results serve as preliminary data for the design of further studies addressing the differences between specialties and settings. The use of this model will allow identification of factors that determine the cost of NMSC treatment and that are associated with higher cost of care.

Skin pigmentation enhancers

The highest incidences of cancer are found in the skin, but endogenous pigmentation is associated with markedly reduced risk. Agents that enhance skin pigmentation have the potential to reduce both photodamage and skin cancer incidence. The purpose of this review is to evaluate agents that have the potential to increase skin pigmentation. These include topically applied substances that simulate natural pigmentation: dihydroxyacetone and melanins; and substances that stimulate the natural pigmentation process: psoralens with UVA (PUVA), dimethylsulfoxide (DMSO), L-tyrosine, L-Dopa, lysosomotropic agents, diacylglycerols, thymidine dinucleotides, DNA fragments, melanocyte stimulating hormone (MSH) analogs, 3-isobutyl-1-methylxanthine (IBMX), nitric oxide donors, and bicyclic monoterpene (BMT) diols. These agents are compared with regards to efficacy when administered to melanoma cells, normal human epidermal melanocytes, animal skin, and human skin. In addition, mechanisms of action are reviewed since these may reveal issues related to both efficacy and safety. Both dihydroxyacetone and topically applied melanins are presently available to the consumer, and both of these have been shown to provide some photoprotection. Of the pigmentation stimulators, only PUVA and MSH analogs have been tested extensively on humans, but there are concerns about the safety and side effects of both. At least some of the remaining pigmentation stimulators under development have the potential to safely induce a photoprotective tan.

Cryopeeling (extensive cryosurgery) for treatment of actinic keratoses: an update and comparison

BACKGROUND

The treatment of actinic keratoses is the most common procedure in dermatology and liquid nitrogen freezing is the most used method of destruction. Yet it is criticized for its limitations of treating only small areas and its tendency to leave hypopigmented skin. 5-fluorouracil (5-FU) treatment is also widely utilized. It has the advantage of treating large areas, but the disadvantages of length of treatment, morbidity, and only partial effectiveness in removing deep or hyperkeratotic actinic keratoses.

OBJECTIVE

Long-term follow-up results are reported on the use of extensive cryosurgery to treat areas of widespread solar damage. The literature is reviewed comparing the advantages and disadvantages versus 5-FU treatment.

METHODS

Three hundred and seventy-three patients were initially treated for extensive actinic keratoses in a private dermatology office in an retirement community in Florida. Individual lesions were counted under good lighting conditions with the aid of a 2.5x stereoscopic lens. The treated areas were predominately on the face and scalp areas, although some arms and hands were treated. A total of 34,604 were initially treated by spraying each individual keratosis with liquid nitrogen as well as the entire surrounding skin area.

RESULTS

The data show that cryopeeling was approximately twice as effective as 5-FU when measured at 1-3 years postoperatively. In addition, the ease of application, its availability, the low cost of materials, its versatility in treating all forms of actinic keratoses, the reduced healing times, and its predictably good cosmetic results make this procedure a logical choice for treating widespread actinic keratoses. The number of squamous cell carcinoma recorded over the entire 6. 5-year study was 33 with no metastases, much lower than predicted for patients with actinic keratoses left untreated.

CONCLUSION

Extensive cryosurgery (cryopeeling) is a highly effective method for removing actinic keratoses and preventing recurrences. The subsequent incidence of squamous cell carcinoma is also greatly reduced.

Sun exposure and skin cancer prevention in children and adolescents

Skin cancer is the most common form of malignancy today, and its incidence is rapidly increasing worldwide. Sun exposure is believed to be the primary factor behind this trend. Nearly 80% of a person's lifetime sun exposure occurs before age 21. Many skin cancer risk behaviors begin in early childhood; therefore, it is important to target the pediatric population for skin cancer prevention education. Parents, teachers, day care providers, and health care professionals should make sun safety a regular part of their practice. School nurses, in particular, are in a prime setting for educating the greatest number of children about sun safety. Age-appropriate skin cancer prevention education should become a routine part of the health curriculum at all grade levels. Numerous on-line resources are available to assist school nurses in the development of age-appropriate teaching materials and sun exposure policies for schools.