Development of the Facial Skin Care Index: A Health-Related Outcomes Index for Skin Cancer Patients

Surgical delays of less than 1 year in Mohs surgery associated with tumor growth in moderately- and poorly-differentiated squamous cell carcinomas but not lower-grade squamous cell carcinomas or basal cell carcinomas: A retrospective analysis

BACKGROUND

Evidence is controversial and limited concerning whether surgical delays are associated with tumor growth for cutaneous squamous cell carcinomas (SCCs) and basal cell carcinomas.

OBJECTIVE

Identify tumor subpopulations that may demonstrate an association between tumor growth and surgical delay.

METHODS

We retrospectively analyzed 299 SCCs and 802 basal cell carcinomas treated with Mohs surgery at a single institution. Time interval from biopsy to surgery represented surgical delay. Change in major diameter (ΔMD) from size at biopsy to postoperative defect represented tumor growth. Independent predictors of ΔMD were identified by multivariate analysis. Linear regression was then utilized to assess for whether the ΔMD from these independent predictors trended with surgical delay.

RESULTS

Surgical delays ranged from 0 to 331 days. Among SCCs, histologic subtype and prior treatment were identified as independent predictors of ΔMD. Significant associations between ΔMD and surgical delay were found for poorly- and moderately-differentiated SCCs, demonstrating growth rates of 0.28 cm and 0.24 cm per month of delay, respectively. The ΔMD for SCCs with prior treatment and basal cell carcinoma subgroups did not vary with surgical delay.

LIMITATIONS

Retrospective design, single center.

CONCLUSION

Surgical delays of less than a year were associated with tumor growth for higher-grade SCCs, with effect sizes bearing potential for clinical significance.

Psychosocial distress in patients with cutaneous melanoma: validation of the Skin Cancer Index (SCI)

PURPOSE

The aim of this study is to examine the factor structure and psychometric properties of the Skin Cancer Index (SCI) in a sample of patients with melanoma.

METHODS

This study uses data from an observational study with longitudinal follow-up examining predictors of skin self-examination in melanoma patients from Montréal, Canada. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to investigate the factor structure of the 15-item SCI scale. Correlations with other psychosocial measures of anxiety and depression, fear of cancer recurrence, quality of life, and emotional well-being were computed to examine construct validity.

RESULTS

EFA results with 241 participants revealed a two-factor structure with acceptable fit and no significant cross-loadings. CFA results with a subsample of 173 participants examining the two-factor structure and second-order structure found equivalent fit for the two solutions. Cronbach's alpha for the total scale score and both subscales was high. Both factors showed positive associations with measures of anxiety and depression and fear of cancer and negative associations with quality of life and emotional well-being.

CONCLUSION

Our study suggests that the SCI functions as a reliable two-factor scale assessing emotional and social distress in patients with melanoma, with the total SCI score assessing overall psychosocial distress.

Long-Term Efficacy of Vismodegib After its Withdrawal and Patients' Health-Related Quality of Life Using the Dermatology Life Quality Index (DLQI)

Introduction

Although non-melanoma skin cancers (NMSCs) are associated with a very low mortality risk, they have been reported to have a major impact on patients’ health-related quality of life (HRQoL). Vismodegib is a therapy for patients who are affected by locally advanced basal cell carcinoma (BCC) or metastatic BCC who are ineligible for surgery and/or radiotherapy. The aim of the present clinical study was to assess the long-term efficacy of vismodegib after its withdrawal by evaluating the recurrence rate of advanced BCC, assessing also patients’ HRQoL after 3 and 6 months from drug withdrawal.

Methods

A retrospective study was performed to analyze patients with advanced and/or multiple BCCs that had been treated with vismodegib (150 mg daily) at the Non-Melanoma Skin Cancer Unit of the University of Naples Federico II (Italy) and had obtained a complete regression in 6 months. At the end of the 6-month treatment cycle, patients that reported total remission of the skin tumor were visited monthly in order to assess their therapeutic response. Moreover, to assess the specific impact of vismodegib on HRQoL, DLQI was administered before vismodegib treatment (baseline), at the end of the therapy cycle (6 months), as well as after 3 and 6 months from vismodegib discontinuation.

Results

Thirty-five patients (27 male, 8 female), with a complete regression of their advanced BCC after vismodegib treatment, were included in the study. The duration of treatment for all patients was 6 months as set by study inclusion criteria. A BCC recurrence rate of 31% (11/35) was reported after a 6-month follow-up. The average reported Dermatology Life Quality Index (DLQI) score increased from a value of 0 at the end of the 6-month vismodegib treatment to a mean value of 2.4 after 3 months from drug withdrawal and 3.6 after 6 months from treatment discontinuation.

Conclusion

The results of this exploratory analysis of vismodegib withdrawal are consistent with a substantial link between treatment response and patients’ HRQoL. Furthermore, 11 out of 35 (31%) patients that reported a complete remission of the disease after 6 months of vismodegib treatment reported BCC recurrence. These data highlight the importance of continuous follow-up and perhaps different regimens of treatment, such as an alternate dose regimen to maintain disease control and reduce the adverse events as previously described in the literature.

Real-Life Effectiveness of Vismodegib in Patients with Metastatic and Advanced Basal Cell Carcinoma: Characterization of Adverse Events and Assessment of Health-Related Quality of Life using the Dermatology Life Quality Index (DLQI) Test

INTRODUCTION

Non-melanoma skin cancer (NMSC) is the most common type of human tumor, with an estimated five million new cases each year. NMSC has been described as having a major impact on the health-related quality of life of the patient. Vismodegib is a hedgehog pathway inhibitor therapy for patients who are affected by locally advanced basal cell carcinoma (laBCC) and metastatic basal cell carcinoma and are ineligible for surgery and/or radiotherapy. The objective of this study was to assess treatment-emergent adverse events reported by patients with advanced BCC who were undergoing hedgehog pathway inhibitor therapy with vismodegib, and to quantify their health-related quality of life using the Dermatology Life Quality Index (DLQI) questionnaire.

METHODS

Patients with advanced and/or multiple basal cell carcinomas treated with vismodegib at the Non-Melanoma Skin Cancer Unit of the University of Naples Federico II (Italy) were consecutively enrolled. Each patient was evaluated every month until the end of the treatment cycle to assess adverse events related to the drug and the patient's quality of life.

RESULTS

48 patients (35 males and 13 females) with advanced BCC were included in the study. Muscle spasms, alopecia, and dysgeusia were the most frequently reported adverse events. 41 patients completed the DLQI questionnaire at the baseline visit and after 6 months of treatment. The average reported DLQI score decreased from a mean value of 5.7 at the baseline visit to 0.4 after 6 months of treatment.

CONCLUSION

This is the first study to demonstrate a significant change in patient health-related quality of life from baseline to 6 months after hedgehog pathway inhibitor therapy initiation using the DLQI test. Interestingly, patients with BCC in visible areas such as the face or neck presented an overall DLQI score that was higher than that of patients with BCC located on the trunk and legs at the baseline visit, but the DLQI scores of these two groups were almost the same after 6 months of vismodegib therapy.

Basal cell carcinoma: Contemporary approaches to diagnosis, treatment, and prevention

As the most common human cancer worldwide and continuing to increase in incidence, basal cell carcinoma is associated with significant morbidity and cost. Continued advances in research have refined both our insight and approach to this seemingly ubiquitous disease. This 2-part continuing medical education series provides a comprehensive and contemporary review of basal cell carcinoma. The second article in this series will present both the current standard of care and newly developed approaches to diagnosis, treatment, and prevention of this disease.

How to decide which patient-reported outcome measure to use? A practical guide for plastic surgeons

The use of patient-reported outcome measures (PROMs) is increasing across all medical specialties, as their importance to patient care is validated. They are likely to play a particularly important role in plastic and reconstructive surgery where outcomes are often subjective, and the recent guidance from the Royal College of Surgeons of England advising their use in cosmetic surgery highlights this. To drive their routine use across our specialty, it is important that clinicians are capable of understanding the often complex and confusing language that surrounds their design and validation. In this article, we describe the process of PROM design and validation, and we attempt to 'demystify' the language used in the health outcome literature. We present the important steps that a well-designed PROM must go through and suggest a straightforward guide for selecting the most appropriate PROMs for use in clinical practice. We hope that this will encourage greater use of PROM data across plastic and reconstructive surgery and ultimately help improve outcomes for our patients.

Validation of the English and French versions of the Brief Health Care Climate Questionnaire

Patient autonomy is a central value in medicine and critical component of adherence to medical advice. This article reports on a validation of the 6-item version of the Health Care Climate Questionnaire (HCCQ), a measure of autonomy support in health care settings, in a sample of 242 melanoma patients. The HCCQ showed excellent internal consistency (α = .91), structural validity (Tucker-Lewis index = .99; comparative fit index = .99; root mean square error of approximation = .06, 90 per cent confidence interval (.00, .11); standardized root mean square residual = .02; χ2 (8, N = 235) = 13.99, p = .08) and construct validity (92.31% of hypothesized correlations with other measures confirmed). Acceptable 3-month test-retest reliability was observed (r = .55, p < .001; intraclass correlation coefficient (A, 1) = .54, p < .001). The French version was found equivalent to the English version.

Reliability and validity of the Advanced Basal Cell Carcinoma Index (aBCCdex)

BACKGROUND

Patient-reported outcome (PRO) questionnaires were recently developed specifically for use with patients with advanced basal cell carcinoma (aBCC) and basal cell carcinoma naevus syndrome (BCCNS).

OBJECTIVES

To evaluate the measurement properties of PRO questionnaires for use in patients with aBCC or BCCNS.

METHODS

In total 129 patients from 10 clinical sites in the U.S.A. and the BCCNS Support Network completed the two newly developed questionnaires multiple times over 3 months. Patients also completed the Skindex-16 and the 12-Item Short-Form Health Survey as collateral measures. Psychometric properties of the questionnaires were evaluated, including internal consistency and test-retest reliability, construct and known-groups validity, and responsiveness.

RESULTS

Based on the results of exploratory factor analysis and clinical input, the two newly developed questionnaires were combined into a single questionnaire, called the aBCCdex, which is relevant for patients with both aBCC and BCCNS. The internal consistency reliability was acceptable, and all aBCCdex scale scores correlated significantly with conceptually similar scales. When divided into groups that differed based on scores from collateral measures, aBCCdex scale scores differentiated between groups (known-groups validity) and were responsive to change.

CONCLUSIONS

The aBCCdex is a brief and comprehensive questionnaire appropriate for use with patients with aBCC and BCCNS. Its reliability and validity have been confirmed. Further research is necessary to estimate the minimally important difference in a larger patient population.

A Spanish version of the Skin Cancer Index: a questionnaire for measuring quality of life in patients with cervicofacial nonmelanoma skin cancer

INTRODUCTION

The Skin Cancer Index (SCI) is the first specific patient-reported outcome measure for patients with cervicofacial nonmelanoma skin cancer. To date, only the original English version has been published.

OBJECTIVES

To develop a Spanish version of the SCI that is semantically and linguistically equivalent to the original, and to evaluate its measurement properties in this different cultural environment.

MATERIAL AND METHODS

A cross-sectional study was conducted of the cultural adaptation and empirical validation of the questionnaire, analysing the psychometric properties of the new index at different stages.

RESULTS

Of 440 patients recruited to the study, 431 (95%) completed the Spanish version of the SCI questionnaire, in a mean time of 6·3 min (SD 2·9). Factor analysis of the scale revealed commonality and loading values of < 0·5 for three of the 15 items. The remaining 12 items converged into two components: appearance/social aspects (seven items) and emotional aspects (five items). Both domains presented a high level of internal consistency, with Cronbach's alpha values above 0·8. The convergent-discriminant validity analysis produced correlations higher than 0·3 for the mental component of the Short Form Health Survey-12v2 Health Questionnaire (correlation coefficient 0·39) and the Dermatology Quality of Life Index (correlation coefficient -0·30). In the test-retest, nine of the 12 items produced a weighted kappa value exceeding 0·4, and for the remaining three items, the absolute agreement percentage exceeded 60%.

CONCLUSIONS

The Spanish version of the SCI quality of life scale has been satisfactorily adapted and validated for use in Spanish-speaking countries and populations.

Tomotherapy concomitant with cetuximab, followed by cetuximab as single-agent therapy for unresectable squamous cell carcinoma of the skin: a case report

BACKGROUND

Cutaneous squamous cell carcinoma (SCC) is the second most frequency of all skin tumors. Incidence of SCC has risen significantly due to an increased sun exposure and the number of immunodeficient patients. Cutaneous SCC is characterized by high Epidermal growth factor receptor (EGFR) expression with low frequency of RAS mutations. Generally, locoregional surgery is curative and systemic therapy is not indicated. We evaluated the activity and toxicity profile of tomotherapy concomitant with Cetuximab, followed by Cetuximab as single agent therapy in a patient affected by unresectable, locally advanced cutaneous SCC.

CASE PRESENTATION

At our institution, on March 2012 we treated a 45 years-old patient affected by locally advanced, unresectable G1 SCC of the lumbar region. At our first observation, the patient was asthenic, with severe pain and functional limitations. There was also a superinfection due to Pseudomonas Aeruginosa resistant to antibiotics, and a G3 anemia secondary to the bleeding lesion. ECOG Performance Status was 2. Tomotherapy has been performed concomitant with the Cetuximab (400 mg/m2, followed by weekly doses of 250 mg/m2) at the total dose of 60 Gy (2 Gy/fx), followed by Cetuximab monotherapy.The lesion reduced progressively until disappear even after the suspension of the treatment and the patient achieved complete response. Toxicity resulted in G1 cutaneous rash and G2 toxicity to the nails, appeared after 5 months of treatment, typical toxicity profile of the anti-EGFR therapies. After one month of therapy the Pseudomonas Aeruginosa superinfection totally disappeared. Quality of life resulted significantly improved with reduction until discontinuation of the anti-pain drugs, and progressive increase of the hemoglobin levels. At follow up of 15 months there was no evidence of active disease and the ECOG Performance Status was 0 (zero).

CONCLUSION

The treatment was effective and feasible. Considering these excellent results, further studies about concomitant tomotherapy with Cetuximab for advanced/inoperable SCC of the skin are needed.

Quality of life assessment in patients treated for metastatic cutaneous squamous cell carcinoma of the head and neck

BACKGROUND

Treatment for metastatic cutaneous head and neck squamous cell carcinoma is usually multimodal and associated with morbidity. This study aimed to evaluate the impact of treatment on patients' quality of life.

METHOD

Cross-sectional survey of 42 patients (35 men, 7 women) at least 6 months after metastatic cutaneous head and neck squamous cell carcinoma treatment, using two standardised quality of life questionnaires: the Functional Assessment of Cancer Therapy - Head and Neck questionnaire and the Facial Disability Index, with statistical analysis to identify potential predictors of outcome.

RESULTS

Female gender correlated with significantly lower Facial Disability Index physical function scores (p = 0.017). Alcohol consumption correlated with significantly better scores for Functional Assessment social well-being (p = 0.016), general total score (p = 0.041) and overall total score (p = 0.033), and for Facial Disability Index physical function (p = 0.034). Marital status, education, employment, chemotherapy, time from last treatment, parotidectomy and facial nerve sacrifice did not affect quality of life. The commonest patient complaints were dry mouth (76 per cent), altered voice quality and strength (55 per cent), and physical appearance (45 per cent).

CONCLUSION

Female gender predicts worse quality of life, while alcohol consumption (versus none) predicted for better quality of life.

A systematic review of patient-reported outcome instruments of nonmelanoma skin cancer in the dermatologic population

BACKGROUND

Treatment of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) has traditionally focused on minimizing recurrence and complication rates. However, the assessment of patient satisfaction and quality of life (QOL) is also important. These outcomes are best assessed by patient-reported outcome (PRO) instruments.

OBJECTIVES

We sought to conduct a systematic review of published PRO instruments purporting to measure aspects associated with QOL and/or patient satisfaction in the dermatologic BCC/SCC population and evaluate their development, content, and psychometric properties.

METHODS

PubMed, Embase, Cochrane via Wiley, PsycINFO, CINAHL, and HaPI from inception to April 2011 were searched. Articles that discussed the instrument development and validation process were included.

RESULTS

A total of 2212 articles were identified. Twenty met our inclusion criteria resulting in 6 PRO instruments: 3 general dermatology (Skindex, Dermatology Life Quality Index, dermatology quality of life scales), 1 general plastic surgery (Patient Outcomes of Surgery-Head/Neck), and 2 skin cancer-specific (Skin Cancer Index, disease-specific questionnaire). The 6 instruments all underwent some degree of formal development and validation, however, only the Skin Cancer Index was developed and validated in the BCC/SCC population.

LIMITATIONS

The review may not have included all relevant PRO instruments.

CONCLUSIONS

The Skin Cancer Index demonstrates the most evidence of its usefulness in patients with BCC/SCC. The Skindex-16, Dermatology QOL Scales, and Dermatology Life Quality Index target different aspects of QOL and should be used depending on the specific question being investigated. The Patient Outcomes of Surgery-Head/Neck may be beneficial to assess perceptions in appearance before and after surgical intervention.

Outcome measures in facial plastic surgery: patient-reported and clinical efficacy measures

OBJECTIVE

To survey the existing literature to identify, summarize, and evaluate procedure- and condition-specific outcome measures for use in facial plastic and reconstructive surgery.

METHODS

A review of the English-language literature was performed to identify outcomes instruments specific for targeted facial plastic surgery interventions and conditions. A search was performed using MEDLINE (1950 to September 2007), CINAHL (Cumulative Index to Nursing & Allied Health) (1982 to September 2007), and PsychINFO (1806 to September 2007). Outcomes instruments were categorized as patient-reported or clinical efficacy measures (observer-reported or objective measures). Instruments were then categorized to include relevant details on the intervention, degree of validation, and subsequent use.

RESULTS

Sixty-eight distinct instruments were identified (23 patient-reported, 35 observer-reported, and 10 objective measures), with some overlap among categories. Most patient-reported measures (76%) and half observer-reported instruments (51%) were developed in the past 10 years. The rigor of validation varied widely among measures, with formal validation being most common among the patient-reported outcome measures.

CONCLUSIONS

Validated outcomes measures are present for many common facial plastic surgery conditions and have become more prevalent during the past decade, especially for patient-reported outcomes. Challenges remain in harmonizing patient-reported, observer-based, and other objective measures to produce standardized clinically meaningful outcome measures.

Measurement of utility in nonmelanoma skin cancer

BACKGROUND

Quality of life is an important variable in assessing the impact of a condition on patients. The current literature shows a minimal effect of nonmelanoma skin cancer (NMSC) on patients' quality of life. This contrasts with our own experience. Given this disparity, we sought to perform an additional study in this area. Past studies have used multiattribute methods to assess quality of life. In contrast, the present study uses health utility methods, which rate a patient's quality of life from 0 to 1, with 1 representing perfect health.

METHODS

Forty-one patients were guided through two standardized scenarios using a standard gamble process with a trained interviewer. Health utility scores were determined for both basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) using various NMSC treatment modalities.

RESULTS

All patients had health utility scores of 0.99 or higher. The standard gamble method showed no statistically significant differences in health utility scores for any treatment scenario for BCC or SCC using raw data comparisons. However, a modified standard gamble approach showed significantly higher health utility scores for both BCC and SCC treated using surgical modalities.

CONCLUSION

Using the standard gamble health utility method in patients with BCC or SCC, it appears that these tumors have a minimal impact on the quality of life in the present study group. However, the results may simply reflect the poor sensitivity of the standard gamble health utility method to accurately assess quality of life changes in patients with NMSC. A modification of the standard gamble method did show that patients with NMSC associated surgical treatments with a better health outcome. New outcome measures need to be devised to accurately assess the toll of NMSC on patients.

The skin cancer index: clinical responsiveness and predictors of quality of life

OBJECTIVE

To establish the clinical responsiveness of the Skin Cancer Index (SCI), a new disease-specific quality of life (QOL) instrument, and to assess demographic and clinical factors which impact QOL in patients with nonmelanoma skin cancer (NMSC).

STUDY DESIGN

Prospective study of 183 patients with NMSC of the face and neck referred to a tertiary care Mohs surgery clinic.

METHODS

The SCI is a 15 item, validated, disease-specific QOL instrument with 3 distinct subscales, Emotion, Social, and Appearance. Higher scores reflect better QOL. The SCI and the Dermatology Life Quality Index (DLQI), a general dermatology instrument, was administered at initial consultation and 4 months after surgical treatment. Multivariate analysis was conducted to assess demographic and clinical factors predictive of QOL for both instruments.

RESULTS

The SCI total score and all three subscale scores increased with treatment, demonstrating strong evidence of responsiveness over time (P < .001) in contrast with the DLQI (P = .46). Predictors of poorer QOL for the SCI included female sex and cancers located on the lip. Patients who demonstrated greatest improvement in QOL with treatment included those who were younger (<50 yr) and had lower reported household income. Also, first time NMSC patients and those patients who underwent less extensive reconstructions demonstrated greater improvements in QOL.

CONCLUSION

The SCI is a sensitive and responsive QOL instrument for patients with NMSC. Distinct demographic and clinical variables that impact QOL have been demonstrated using this multidimensional, disease-specific instrument.