The burden of non-melanoma skin cancers in Auckland, New Zealand

Prevalence, incidence and trends of keratinocyte carcinoma in Denmark 2007-2021: A population-based register study

INTRODUCTION

The incidence of keratinocyte carcinoma (KC), i.e., basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is increasing worldwide, placing a significant burden on healthcare resources. This is especially the case for tumors requiring surgical intervention. It remains unclear whether this increase is a result of the population aging or a genuine increase in risk of skin cancer. Understanding age-adjusted incidence trends of KC is crucial for improving future management of the disease. We studied these trends in a large nationwide cohort, focusing on large, invasive, and surgically challenging tumors.

METHODS

Information on all incident cases of BCC and SCC in Denmark was extracted from population-based databases in the calendar years 2007-2021. Age-adjusted incidence rates were calculated, standardized to the 2013 European Standard Population. Average annual percentage changes were estimated using Joinpoint regression models. Incidence trends for larger, more invasive tumors (tumor (T) category of ≥T2), and of those in the head and neck area, were elucidated with descriptive statistics.

RESULTS

We found 183,338 patients with a first-time incidence of BCC and 42,233 patients with a first-time incidence of SCC in the period 2007-2021. The incidence rate, adjusted for age, increased from 252 to 338 per 100,000 for BCC and from 49 to 104 per 100,000 for SCC. For SCC, the increase was particularly pronounced in the last two years of the study period. Tumors ≥T2, and those in the head and neck area, increased markedly.

CONCLUSION

KC is the most common type of cancer worldwide, and the age-adjusted incidence rates of BCC and SCC increased significantly from 2007 to 2021, as did tumors with a higher T category and those located in anatomically sensitive areas. Since the primary treatment for many of these tumors is surgical, this raises concern about the strain on future healthcare resources.

Analysis of Prevalence, Socioeconomic and Disease Trends of Non-Melanoma Skin Cancer in New Zealand from 2008 to 2022

BACKGROUND

Skin cancer shows geographic and ethnic variation. New Zealand-with a predominantly fair-skinned populations, high UV indices and outdoor lifestyles-has high rates of skin cancer. However, population prevalence data is lacking. This study aimed to determine the demographics and socioeconomic disease trends of non-melanoma skin cancer prevalence in New Zealand from a large targeted-screening study.

METHODS

A targeted screening programme was conducted among 32,839 individuals, Fitzpatrick Skin Types I to IV in Auckland, New Zealand during the 2008-2022 period. This data was analyzed retrospectively. Linear regression models were used to assess statistical trends of skin cancer prevalence over time, along with associated factors that included demographics, disease trends and overall prevalence.

RESULTS

A total of 32,839 individuals were screened and 11,625 skin cancers were detected. 16,784 individuals were females who had 4,378 skin cancers. 16,055 individuals were males who had 5,777 skin cancers. 54 males and 65 females had multiple skin cancers. The article presents detailed descriptions of tumour types and subtypes detected, age groups, demographic and socioeconomic information. regarding the non-melanoma skin cancers detected.

CONCLUSION

Overall men have more non-melanoma skin cancer (NMSC) than females; however females develop more BCC on the lips. BCC is three times more common in the 31-50 age group, whereas SCC are significantly more prevalent after age 80. Prevalence of BCC has not changed over the 15-year timeframe of the study but SCC has increased. Older ages and higher incomes are associated with higher rates of NMSC in New Zealand.

Improving access to dermatology specialist care: review of a dermatologist- and general practitioner-integrated clinic model

Introduction This study presents an innovative model of integrated dermatology service delivery. Kauri HealthCare (KHC) is a general practice serving around 19 000 patients in Palmerston North, New Zealand. A 'mini clinic' is provided by an on-site dermatologist that is available for patients of KHC. Referring practitioners are required to attend with the patient to present their case and seek dermatologist input. This allows for patients to receive a specialist opinion, as well as for the referrer to receive practical and academic teaching, record findings, and arrange any further investigations, follow-up, or management. Aim To describe the nature of patient presentations and clinical outcomes of a novel dermatologist-general practitioner integrated clinic based in a provincial healthcare practice. Methods Descriptive analysis of all referrals to the Kauri HealthCare dermatology mini clinic from April 2017 to December 2022. Results During the study period, 964 diagnoses were recorded across 806 patients booked into the mini clinic. The most common presenting conditions were: (1) eczema; (2) psoriasis; (3) actinic keratoses; (4) naevi; and (5) seborrheic keratosis. Practitioners sought dermatology opinion on the diagnosis and/or management of skin conditions. Further referral to secondary care was not required for 86% of patients. Discussion Improvements could be made to better serve those of Māori and Pacific ethnicity, or living in high socioeconomic deprivation. Results indicate where teaching could be prioritised for practitioners, postgraduates, and medical students. Overall, this is an innovative clinic model, which seeks to provide equitable care, medical education, and collaboration between primary and secondary services.

Successful management of in-transit cutaneous squamous cell carcinoma with anti-PD-1 immunotherapy

This report describes the case of a 70-year-old man with metastatic squamous cell carcinoma (SCC) of the right lower leg. Soon after definitive surgical management of the primary and nodal metastases with curative intent, he relapsed, developing aggressive in-transit metastatic disease and recurrent nodal disease. The patient was treated with systemic immunotherapy alone, which not only prompted the progressive nodal metastases to regress, but also resulted in a complete response of the in-transit disease. This situation is previously undescribed in the medical literature.

Teledermatology for Enhancing Skin Cancer Diagnosis and Management: Retrospective Chart Review

BACKGROUND

Skin cancer rates are at all-time highs, but the shortage of dermatologists compels patients to seek medical advice from general practitioners. A new referral pathway called the Suspected Skin Cancer (SSC) service was established to provide general practitioners in Waikato, New Zealand, with rapid diagnosis and treatment advice for lesions suspicious for skin cancer.

OBJECTIVE

The aim of this study was to assess the quantity, quality, and characteristics of referrals to the SSC teledermatology service during its first 6 months.

METHODS

A retrospective chart review of all referrals sent to the SSC teledermatology service during the first 6 months of its operation was conducted. Time to advice, diagnoses, diagnostic discordance, adherence to advice, and time to treatment were recorded. Diagnostic discordance between general practitioners, dermatologists, and pathologists was calculated.

RESULTS

The SSC service received 340 referrals for 402 lesions. Dermatologists diagnosed 256 (63.7%) of these lesions as benign; 56 (13.9%) were histologically confirmed as malignant, including 19 (4.7%) melanomas. The overall discordance between referrer and dermatologist on specific and broad (ie, benign or malignant) diagnoses for 402 lesions was 47% and 26% (κ=0.58, SD 0.07), respectively; 44% and 26% (κ=0.61, SD 0.15) between referrer and pathologist; and 18% and 12% (κ=0.82, SD 0.12) between dermatologist and pathologist. The mean time between referral submission and receiving advice was 1.02 days. The average time to action (eg, excision) was 64.8 days.

CONCLUSIONS

An electronic referral system can be an effective form of teledermatology for providing prompt diagnosis and management advice for benign and malignant skin lesions.

The effects of exposure to solar radiation on human health

This assessment by the Environmental Effects Assessment Panel (EEAP) of the Montreal Protocol under the United Nations Environment Programme (UNEP) evaluates the effects of ultraviolet (UV) radiation on human health within the context of the Montreal Protocol and its Amendments. We assess work published since our last comprehensive assessment in 2018. Over the last four years gains have been made in knowledge of the links between sun exposure and health outcomes, mechanisms, and estimates of disease burden, including economic impacts. Of particular note, there is new information about the way in which exposure to UV radiation modulates the immune system, causing both harms and benefits for health. The burden of skin cancer remains high, with many lives lost to melanoma and many more people treated for keratinocyte cancer, but it has been estimated that the Montreal Protocol will prevent 11 million cases of melanoma and 432 million cases of keratinocyte cancer that would otherwise have occurred in the United States in people born between 1890 and 2100. While the incidence of skin cancer continues to rise, rates have stabilised in younger populations in some countries. Mortality has also plateaued, partly due to the use of systemic therapies for advanced disease. However, these therapies are very expensive, contributing to the extremely high economic burden of skin cancer, and emphasising the importance and comparative cost-effectiveness of prevention. Photodermatoses, inflammatory skin conditions induced by exposure to UV radiation, can have a marked detrimental impact on the quality of life of sufferers. More information is emerging about their potential link with commonly used drugs, particularly anti-hypertensives. The eyes are also harmed by over-exposure to UV radiation. The incidence of cataract and pterygium is continuing to rise, and there is now evidence of a link between intraocular melanoma and sun exposure. It has been estimated that the Montreal Protocol will prevent 63 million cases of cataract that would otherwise have occurred in the United States in people born between 1890 and 2100. Despite the clearly established harms, exposure to UV radiation also has benefits for human health. While the best recognised benefit is production of vitamin D, beneficial effects mediated by factors other than vitamin D are emerging. For both sun exposure and vitamin D, there is increasingly convincing evidence of a positive role in diseases related to immune function, including both autoimmune diseases and infection. With its influence on the intensity of UV radiation and global warming, the Montreal Protocol has, and will have, both direct and indirect effects on human health, potentially changing the balance of the risks and benefits of spending time outdoors.

Salivary gland tumours: an epidemiological review of non-neoplastic and neoplastic pathology

Salivary gland tumours (SGT) demonstrate geographical variation. The primary objective of this study was to determine the types, frequency, distribution, and demographics of non-neoplastic and neoplastic salivary gland pathology at Waikato Hospital, New Zealand (NZ) over a 10-year period. Following this we conducted a 10-year retrospective review of SGT epidemiology from international literature. In total 825 patients were identified, 31% (256/825) with non-neoplastic salivary gland pathology, 34% (284/825) with benign neoplastic pathology, 14% (118/825) with primary malignant lesions, 18% (146/825) with metastatic SGTs, and 3% (21/825) with lymphoma. Patients had a mean (range) age of 58 (3-102) years, were predominantly male (58%, 476/825), and NZ European (65%, 536/825). Tumours were most prevalent in the parotid gland (85%, 484/569), of which 44% (211/484) were malignant. Pleomorphic adenoma was the most common benign (71%, 203/284) and overall (36%, 203/569) tumour, while mucoepidermoid carcinoma (25%, 29/118) and squamous cell carcinoma (SCC) (73%, 106/146) were the most common primary malignant and metastatic SGTs, respectively. Our literature review identified 18 studies consisting of 33,933 patients, of whom 71% (24,013/33,933) had benign SGTs. Pleomorphic adenoma (68%, 16404/24013) and mucoepidermoid carcinoma (29%, 2826/9621) were the most common benign and malignant SGTs, respectively. Low numbers of non-neoplastic and metastatic SGTs were reported in the literature. This research provides a greater understanding of differences in their global distribution. Consistent with previous literature, pleomorphic adenoma and mucoepidermoid carcinoma were the most common benign and malignant SGTs. In NZ, we found high rates of malignant SCC to the parotid gland, consistent with the epidemiology of non-melanoma skin cancer in the country.

Changing trends in the disease burden of non-melanoma skin cancer globally from 1990 to 2019 and its predicted level in 25 years

Background

The disease burden of non-melanoma skin cancer (NMSC) has become a significant public health threat. We aimed to conduct a comprehensive analysis to mitigate the health hazards of NMSC.

Methods

This study had three objectives. First, we reported the NMSC-related disease burden globally and for different subgroups (sex, socio-demographic index (SDI), etiology, and countries) in 2019. Second, we examined the temporal trend of the disease burden from 1990 to 2019. Finally, we used the Bayesian age-period-cohort (BAPC) model integrated nested Laplacian approximation to predict the disease burden in the coming 25 years. The Norpred age-period-cohort (APC) model and the Autoregressive Integrated Moving Average (ARIMA) model were used for sensitivity analysis.

Results

The disease burden was significantly higher in males than in females in 2019. The results showed significant differences in disease burden in different SDI regions. The better the socio-economic development, the heavier the disease burden of NMSC. The number of new cases and the ASIR of basal cell carcinoma (BCC) were higher than that of squamous cell carcinoma (SCC) in 2019 globally. However, the number of DALYs and the age-standardized DALYs rate were the opposite. There were statistically significant differences among different countries. The age-standardized incidence rate (ASIR) of NMSC increased from 54.08/100,000 (95% uncertainty interval (UI): 46.97, 62.08) in 1990 to 79.10/100,000 (95% UI: 72.29, 86.63) in 2019, with an estimated annual percentage change (EAPC) of 1.78. Other indicators (the number of new cases, the number of deaths, the number of disability-adjusted life years (DALYs), the age-standardized mortality rate (ASMR), and the age-standardized DALYs rate) showed the same trend. Our predictions suggested that the number of new cases, deaths, and DALYs attributable to NMSC would increase by at least 1.5 times from 2020 to 2044.

Conclusions

The disease burden attributable to NMSC will continue to increase or remain stable at high levels. Therefore, relevant policies should be developed to manage NMSC, and measures should be taken to target risk factors and high-risk groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09940-3.

Characterisation of the immune microenvironment of cutaneous squamous cell carcinoma in immunosuppression

Cutaneous squamous cell carcinoma (cSCC) is a common cancer. Systemic immunosuppression with drugs such as Prednisone results in more aggressive disease. We hypothesise that more aggressive disease in immunosuppression is the result of immune changes in the tumour microenvironment. We characterised T cell, phagocytic and antigen presenting cell subsets in cSCC, and determined if these infiltrates were altered by immunosuppressive therapy. We found a dominant 'CD8 profile' in the centre of cSCC lesions, with CD8 cells correlating with Tbet, FoxP3, OX40 and 'M2-like' macrophages, whereas a 'Tbet and granulocyte profile' with associated inflammation predominated at the margin of the tumour. Individuals on systemic immunosuppressive therapy had lesions that were comparable in size, stage and number of vessels to immune competent individuals however the number of CD11c positive cells in the lesion centre was significantly reduced. We conclude that cSCC lesions are immunologically heterogeneous across the lesion and that systemically immunosuppressed individuals have reduced CD11c positive cells in the centre of the lesion. The role and detailed phenotype of CD11c positive cells in cSCC lesions warrants further investigation.

Body site locations of basal cell carcinoma, squamous cell carcinoma and actinic keratosis in patients referred to the Waikato District Health Board teledermoscopy clinic

Introduction Basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and actinic keratosis (AK) are usually located on sun-exposed areas of the body. Aims Our main aims were to identify the common body site locations of BCC, SCC and AK in patients attending the Waikato District Health Board teledermoscopy clinic, also known as the Waikato Virtual Lesion Clinic, as well as to analyse whether the distribution of location changes with age and sex. Methods This is a retrospective study where the body site location of 3272 keratinocytic lesions was determined and analysed in 1864 patients attending the Waikato District Health Board teledermoscopy clinics between 2010 and 2021. Results All three types of lesion were most commonly located in the head and neck region (40.9% of BCCs, 38% of SCCs, 83.2% of AKs), followed by 26.8% on the trunk for BCC, 32.3% on the lower extremities for SCC, and 11.6% on the upper extremities for AK. Discussion Our findings of body site locations for keratinocytic lesions were consistent with other studies. Patients were commonly diagnosed with multiple keratinocytic lesions.

Cancer Progression Gene Expression Profiling Identifies the Urokinase Plasminogen Activator Receptor as a Biomarker of Metastasis in Cutaneous Squamous Cell Carcinoma

Cutaneous squamous cell carcinoma (cSCC) of the head and neck region is the second most prevalent skin cancer, with metastases to regional lymph nodes occurring in 2%–5% of cases. To further our understanding of the molecular events characterizing cSCC invasion and metastasis, we conducted targeted cancer progression gene expression and pathway analysis in non-metastasizing (PRI-) and metastasizing primary (PRI+) cSCC tumors of the head and neck region, cognate lymph node metastases (MET), and matched sun-exposed skin (SES). The highest differentially expressed genes in metastatic (MET and PRI+) versus non-metastatic tumors (PRI-) and SES included PLAU, PLAUR, MMP1, MMP10, MMP13, ITGA5, VEGFA, and various inflammatory cytokine genes. Pathway enrichment analyses implicated these genes in cellular pathways and functions promoting matrix remodeling, cell survival and migration, and epithelial to mesenchymal transition, which were all significantly activated in metastatic compared to non-metastatic tumors (PRI-) and SES. We validated the overexpression of urokinase plasminogen activator receptor (uPAR, encoded by PLAUR) in an extended patient cohort by demonstrating higher uPAR staining intensity in metastasizing tumors. As pathway analyses identified epidermal growth factor (EGF) as a potential upstream regulator of PLAUR, the effect of EGF on uPAR expression levels and cell motility was functionally validated in human metastatic cSCC cells. In conclusion, we propose that uPAR is an important driver of metastasis in cSCC and represents a potential therapeutic target in this disease.

Remote Skin Cancer Diagnosis: Adding Images to Electronic Referrals Is More Efficient Than Wait-Listing for a Nurse-Led Imaging Clinic

Simple Summary

Skin cancer is a significant cause of death and disability, particularly in New Zealand. Expert diagnosis reduces unnecessary excision of benign lesions, reduces patient anxiety, and allows early identification of skin cancer, particularly of melanoma. The study assessed an electronic referral pathway for teledermatology—diagnosing skin lesions remotely using a standardised template with regional, close-up, and dermoscopic images—and compared this to scheduled nurse-led teledermoscopy clinics. A dermatology opinion was reached more rapidly with comparable efficacy when referrals include good quality images, compared to nurse-led imaging clinics.

Abstract

We undertook a retrospective comparison of two teledermatology pathways that provide diagnostic and management advice for suspected skin cancers, to evaluate the time from referral to diagnosis and its concordance with histology. Primary Care doctors could refer patients to either the Virtual Lesion Clinic (VLC), a nurse-led community teledermoscopy clinic or, more recently, to the Suspected Skin Cancer (SSC) pathway, which requires them to attach regional, close-up, and dermoscopic images. The primary objective of this study was to determine the comparative time course between the SSC pathway and VLC. Secondary objectives included comparative diagnostic concordance, skin lesion classification, and evaluation of missed skin lesions during subsequent follow-up. VLC referrals from July to December 2016 and 2020 were compared to SSC referrals from July to December 2020. 408 patients with 682 lesions in the VLC cohort were compared with 480 patients with 548 lesions from the 2020 SSC cohort, matched for age, sex, and ethnicity, including histology where available. Median time (SD) from referral to receipt of teledermatology advice was four (2.8) days and 50 (43.0) days for the SSC and VLC cohorts, respectively (p < 0.001). Diagnostic concordance between teledermatologist and histopathologist for benign versus malignant lesions was 70% for 114 lesions in the SSC cohort, comparable to the VLC cohort (71% of 122 lesions). Referrals from primary care, where skin lesions were imaged with variable devices and quality resulted in faster specialist advice with similar diagnostic performance compared to high-quality imaging at nurse-led specialist dermoscopy clinics.

The significance of regional metastasis location in head and neck cutaneous squamous cell carcinoma

BACKGROUND

Regional metastasis of head and neck cutaneous squamous cell carcinoma (HNcSCC) can be seen in either parotid and/or cervical lymph nodes. The aim of this study was to assess whether there was a difference in prognosis between parotid and cervical nodal metastases.

METHODS

Patients with regional metastasis from HNcSCC were identified from an institutional database. Disease-specific (DSS) and overall survival (OS) were calculated using the Kaplan-Meier method and Cox proportional hazards models.

RESULTS

Five hundred and thirty-five patients were identified with median follow-up of 26.4 months (3-255 months). Two hundred and thirty-five patients had parotid metastasis, 96 patients had neck metastasis, and 204 patients had both. On multivariable analysis, any regional metastasis to the neck when compared to parotid alone conferred worse DSS (HR 1.8, p = 0.007) and OS (HR 1.3, p = 0.024).

CONCLUSION

Regional metastasis of HNcSCC to the neck confers worse outcomes compared to metastasis to the parotid alone.

Reducing the Incidence of Skin Cancer through Landscape Architecture Design Education

There is a high and growing incidence of skin cancer associated with overexposure to the sun. Most of a person’s exposure occurs during their first eighteen years of life. While many children are taught to wear hats and sunscreen, studies indicate these are inadequate. There is a pressing need to improve the design of our landscapes to reduce exposure. Landscape architects can play a key role in driving this process, but only if they understand the factors determining sun protection behaviours among children in the landscape, and how to design for these. We introduced a systematic evidence-based teaching approach to landscape architecture students in New Zealand where the incidence of skin cancer is one of the highest in the world. In this paper, we describe the methods we used to integrate scientific information into a creative design process that included four design phases: (1) review, summary and translation of evidential theory into design guidelines; (2) inventory and analysis of existing schoolyard; (3) redesign of schoolyard; and (4) final design evaluation. We found this process was effective in developing student appreciation for the need to improve sun protection through design, for increasing their understanding of the evidential science, in addition to developing their ability to translate, often inaccessible, evidential data into its spatial form implications. Furthermore, the process led to a high degree of confidence and pride among many students as their resulting design solutions were not only supported by evidence but were often highly creative. Such evidence-based design courses are essential for preparing future landscape architects to design landscapes that significantly reduce the incidence and health effects of skin cancer.

Growth rate of clinically diagnosed superficial basal cell carcinoma and changes in dermoscopic features over time

BACKGROUND/OBJECTIVES

Basal cell carcinoma (BCC) is the most commonly occurring skin cancer. BCCs have been found to generally grow slowly. Data are limited on how the dermoscopic characteristics of BCCs evolve. We set out to determine the growth rate of superficial BCCs (sBCC) and assess the change in dermoscopic features over time.

METHODS

A retrospective review was performed of clinically diagnosed sBCC. Images, demographic and dermoscopic data were collected by a melanographer. Mixed effects linear regression models were used to investigate sBCC growth and associations between size and dermoscopic/demographic variables. We tested differences in trends over time in dermoscopic features using non-parametric trend tests.

RESULTS

100 individual sBCC were evaluated in 70 patients (mean age 62; 59% male), 69% had Fitzpatrick skin phototype 1 or 2, and 81% had some degree of actinic damage. sBCC were present on the back in 58% and 22% of men and women, respectively. The median surface area was 41.9 mm² with a growth rate of 0.81 mm² /month. Males had larger sBCC than females. There was no association between sBCC size and Fitzpatrick skin phototype, history of skin cancer or family history of melanoma. There is some evidence larger sBCC gain shiny white structures (P = 0.053) over time.

CONCLUSIONS

sBCC grow at a rate unlikely to adversely affect patient outcomes associated with long wait times. Our data suggest that dermoscopy can aid in appropriate treatment selection for sBCC.

Environmental effects of stratospheric ozone depletion, UV radiation and interactions with climate change: UNEP Environmental Effects Assessment Panel, update 2019

This assessment, by the United Nations Environment Programme (UNEP) Environmental Effects Assessment Panel (EEAP), one of three Panels informing the Parties to the Montreal Protocol, provides an update, since our previous extensive assessment (Photochem. Photobiol. Sci., 2019, 18, 595-828), of recent findings of current and projected interactive environmental effects of ultraviolet (UV) radiation, stratospheric ozone, and climate change. These effects include those on human health, air quality, terrestrial and aquatic ecosystems, biogeochemical cycles, and materials used in construction and other services. The present update evaluates further evidence of the consequences of human activity on climate change that are altering the exposure of organisms and ecosystems to UV radiation. This in turn reveals the interactive effects of many climate change factors with UV radiation that have implications for the atmosphere, feedbacks, contaminant fate and transport, organismal responses, and many outdoor materials including plastics, wood, and fabrics. The universal ratification of the Montreal Protocol, signed by 197 countries, has led to the regulation and phase-out of chemicals that deplete the stratospheric ozone layer. Although this treaty has had unprecedented success in protecting the ozone layer, and hence all life on Earth from damaging UV radiation, it is also making a substantial contribution to reducing climate warming because many of the chemicals under this treaty are greenhouse gases.

E-referrals and teledermatoscopy grading for melanoma: a successful model of care

BACKGROUND/OBJECTIVES

An e-referral system was developed at a tertiary care hospital in Auckland, New Zealand in 2014 for suspected cutaneous malignancy. E-referrals include patient information, a description of the lesion(s), biopsy results and/or attached photograph(s). Experienced surgical oncologists prioritised the referrals and selected a management option or referred them for a teledermatoscopy opinion. Our aim was to review the efficacy of e-referrals for improving diagnostic accuracy for melanoma.

METHODS

Referrals received in 2016 including images and categorisation as confirmed, likely or suspected melanoma by the triage specialist were evaluated. Concordance of the pathological diagnosis with the triage diagnosis and teledermatoscopy diagnosis was determined for each referral.

RESULTS

809 of 3470 e-referrals for skin cancer were categorised as confirmed, likely or suspected melanoma. 230 (28.4%) of these included a referral histopathology confirming melanoma/melanoma in situ. Of the remaining 579 referrals, 315 were sent for urgent diagnostic excision and 264 were referred for teledermatoscopy. 120 of the 315 sent for urgent excision were confirmed as melanoma (53) or melanoma in situ (67) on histopathology: a positive predictive value (PPV) of 38.1% and number needed to excise (NNE) of 2.6. Less than 10% of referrals triaged for teledermatoscopy were confirmed as melanoma (24/264). Almost half of all referrals (374/809, 45.6%) included melanoma/melanoma in situ. The melanoma: melanoma in situ ratio was 1: 1.18.

CONCLUSIONS

The e-referral and teledermatoscopy service for suspected melanoma has proven fewer unnecessary excisions of benign lesions than previously reported.

Potential of Polymeric Films Loaded with Gold Nanorods for Local Hyperthermia Applications

Current strategies for the treatment of superficial non-melanoma skin cancer (NMSC) lesions include topical imoquimod, 5-fluorouracil, and photodynamic therapy. Although these treatments are effective, burning pain, blistering, and dermatitis have been reported as frequent side effects, making these therapies far from ideal. Plasmonic materials have been investigated for the induction of hyperthermia and use in cancer treatment. In this sense, the effectiveness of intratumorally and systemically injected gold nanorods (GnRs) in inducing cancer cell death upon near-infrared light irradiation has been confirmed. However, the in vivo long-term toxicity of these particles has not yet been fully documented. In the present manuscript, GnRs were included in a crosslinked polymeric film, evaluating their mechanical, swelling, and adhesion properties; moreover, their ability to heat up neonatal porcine skin (such as a skin model) upon irradiation was tested. Inclusion of GnRs into the films did not affect mechanical or swelling properties. GnRs were not released after film swelling, as they remained entrapped in the polymeric network; moreover, films did not adhere to porcine skin, altogether showing the enhanced biocompatibility of the material. GnR-loaded films were able to heat up the skin model over 40 °C, confirming the potential of this system for non-invasive local hyperthermia applications.

Use of the Skin Cancer Quality of Life Impact Tool (SCQOLIT) - a feasibility study in non-melanoma skin cancer

BACKGROUND

Incidence of non-melanoma skin cancers (NMSCs) is increasing and can significantly impact on quality of life (QOL), yet there are few studies evaluating patient-reported outcome measures (PROMs) in NMSC populations. We undertook a prospective feasibility study to evaluate a skin cancer-specific PROM, the Skin Cancer Quality of Life Impact Tool (SCQOLIT), in patients with a new diagnosis of NMSC.

OBJECTIVES

(i) To establish acceptability of SCQOLIT in dermatology clinics, (ii) a descriptive analysis of SCQOLIT scores in NMSC.

METHODS

Patients with histologically confirmed NMSC completed SCQOLIT, EQ-5D and a transition item. Questionnaires were completed at baseline and 3 months for group 1 ('low-risk' NMSC) and group 2 ('high-risk' NMSC) with additional questionnaires at 6-9 months for group 2. Patients participated in structured interviews. Clinician experience was captured through staff evaluation forms and a focus group. Acceptability and psychometric properties of SCQOLIT were assessed.

RESULTS

Overall, 318 patients consented to participate. Mean SCQOLIT score at baseline was 5.33, with 2.6% of patients scoring ≥20. No ceiling effects were observed, whilst 13.9% scored 0. Validity was demonstrated against EQ-5D. Cronbach's alpha 0.84 demonstrated internal consistency. Thirteen patients were interviewed and thought SCQOLIT was comprehensive, captured impact on health-related QOL and helped express their needs to clinicians. Most clinicians found SCQOLIT 'very useful' or 'useful to some extent' in facilitating discussions.

CONCLUSIONS

This feasibility study demonstrates that SCQOLIT is acceptable to patients and staff in dermatology skin cancer clinics. The psychometric properties of SCQOLIT confirm its utility in NMSC populations.

Targeted Therapy Against the Cell of Origin in Cutaneous Squamous Cell Carcinoma

Squamous cell carcinomas (SCC), including cutaneous SCCs, are by far the most frequent cancers in humans, accounting for 80% of all newly diagnosed malignancies worldwide. The old dogma that SCC develops exclusively from stem cells (SC) has now changed to include progenitors, transit-amplifying and differentiated short-lived cells. Accumulation of specific oncogenic mutations is required to induce SCC from each cell population. Whilst as fewer as one genetic hit is sufficient to induce SCC from a SC, multiple events are additionally required in more differentiated cells. Interestingly, the level of differentiation correlates with the number of transforming events required to induce a stem-like phenotype, a long-lived potential and a tumourigenic capacity in a progenitor, a transient amplifying or even in a terminally differentiated cell. Furthermore, it is well described that SCCs originating from different cells of origin differ not only in their squamous differentiation status but also in their malignant characteristics. This review summarises recent findings in cutaneous SCC and highlights transforming oncogenic events in specific cell populations. It underlines oncogenes that are restricted either to stem or differentiated cells, which could provide therapeutic target selectivity against heterogeneous SCC. This strategy may be applicable to SCC from different body locations, such as head and neck SCCs, which are currently still associated with poor survival outcomes.

Inflammation: A key process in skin tumorigenesis

The extremely delicate shift from an inflammatory process to tumorigenesis is a field of major scientific interest. While the inflammation induced by environmental agents has well known underlying mechanisms, less is known concerning the oncogenic changes that follow an inflammatory chronic status in the tissue microenvironment that can lead to pro-tumorigenic processes. Regardless of the origin of the environmental factors, the maintenance of an inflammatory microenvironment is a clear condition that favors tumorigenesis. Inflammation sustains the proliferation and survival of malignant transformed cells, can promote angiogenesis and metastatic processes, can negatively regulate the antitumoral adaptive and innate immune responses and may alter the efficacy of therapeutic agents. There is an abundance of studies focusing on molecular pathways that trigger inflammation-mediated tumorigenesis, and these data have revealed a series of biomarkers that can improve the diagnosis and prognosis in oncology. In skin there is a clear connection between tissue destruction, inflammation and tumor onset. Inflammation is a self-limiting process in normal physiological conditions, while tumor is a constitutive process activating new pro-tumor mechanisms. Among skin cancers, the most commonly diagnosed skin cancers, squamous cell carcinoma and basal cell carcinoma (BCC) have important inflammatory components. The most aggressive skin cancer, melanoma, is extensively research in regards to the new context of novel developed immune-therapies. In skin cancers, inflammatory markers can find their place in the biomarker set for improvement of diagnosis and prognosis.

Human health in relation to exposure to solar ultraviolet radiation under changing stratospheric ozone and climate

The Montreal Protocol has limited increases in the UV-B (280-315 nm) radiation reaching the Earth's surface as a result of depletion of stratospheric ozone. Nevertheless, the incidence of skin cancers continues to increase in most light-skinned populations, probably due mainly to risky sun exposure behaviour. In locations with strong sun protection programs of long duration, incidence is now reducing in younger age groups. Changes in the epidemiology of UV-induced eye diseases are less clear, due to a lack of data. Exposure to UV radiation plays a role in the development of cataracts, pterygium and possibly age-related macular degeneration; these are major causes of visual impairment world-wide. Photodermatoses and phototoxic reactions to drugs are not uncommon; management of the latter includes recognition of the risks by the prescribing physician. Exposure to UV radiation has benefits for health through the production of vitamin D in the skin and modulation of immune function. The latter has benefits for skin diseases such as psoriasis and possibly for systemic autoimmune diseases such as multiple sclerosis. The health risks of sun exposure can be mitigated through appropriate sun protection, such as clothing with both good UV-blocking characteristics and adequate skin coverage, sunglasses, shade, and sunscreen. New sunscreen preparations provide protection against a broader spectrum of solar radiation, but it is not clear that this has benefits for health. Gaps in knowledge make it difficult to derive evidence-based sun protection advice that balances the risks and benefits of sun exposure.