Risk Group, Skin Lesion History, and Sun Sensitivity Reliability in Squamous Cell Skin Cancer Progression

Accuracy of periocular lesion assessment using telemedicine

Objectives

To assess the agreement in diagnosis and management plans reached between clinicians reviewing eyelid lesions remotely and in face-to-face clinics.

Methods

In this single-centre observational case series, data were prospectively collected on 50 consecutive adults referred with eyelid lesions suitable to be seen by a nurse. A proforma was completed to gather salient information. A nurse specialist saw patients in face-to-face clinics and collected information using the proforma, devising a diagnosis and management plan. Photographs of the eyelid lesions were taken by a medical photographer. A subsequent remote review was completed by an oculoplastic consultant using the proforma information and photographs in the absence of the patient. The diagnosis and management plan constructed by the nurse specialist were compared with those reached by the consultant.

Results

Complete data were available for 44 consecutive cases. There was an overall 91% agreement (40 cases out of 44) between the diagnoses reached by the nurse specialist, and the remote reviewer; kappa coefficient 0.88 (95% CI 0.76 to 0.99). There was an overall 82% agreement (36 out of 44 cases) in the management plans devised by the nurse-led clinic and remote reviewer; kappa coefficient 0.74 (95% CI 0.58 to 0.90). The average time taken for a remote reviewer to reach a diagnosis and management plan was 1 min and 20 s.

Conclusions

This study evaluated the feasibility of assessing eyelid lesions using asynchronous telemedicine. There was overall a high rate of concordance in the diagnosis reached, and management devised between the clinic and remote review.

Cancer risk in a large inception SLE cohort: Effects of demographics, smoking, and medications

OBJECTIVE

To assess cancer risk factors in incident SLE.

METHODS

Clinical variables and cancer outcomes were assessed annually among incident SLE patients. Multivariate hazard regression models (over-all risk, and most common cancers) included demographics and time-dependent medications (corticosteroids, antimalarial drugs, immunosuppressants), smoking, and adjusted mean SLE Disease Activity Index-2K.

RESULTS

Among 1668 patients (average 9 years follow-up), 65 cancers occurred: 15 breast, 10 non-melanoma skin, seven lung, six hematological, six prostate, five melanoma, three cervical, three renal, two each gastric, head and neck, and thyroid, and one each rectal, sarcoma, thymoma, and uterine cancers. Half of cancers (including all lung cancers) occurred in past/current smokers, versus one-third of patients without cancer. Multivariate analyses indicated over-all cancer risk was related primarily to male sex and older age at SLE diagnosis. In addition, smoking was associated with lung cancer. For breast cancer risk, age was positively and anti-malarial drugs were negatively associated. Anti-malarial drugs and higher disease activity were also negatively associated with non-melanoma skin cancer (NMSC) risk, whereas age and cyclophosphamide were positively associated. Disease activity was associated positively with hematologic and negatively with NMSC risk.

CONCLUSIONS

Smoking is a key modifiable risk factor, especially for lung cancer, in SLE. Immunosuppressive medications were not clearly associated with higher risk except for cyclophosphamide and NMSC. Antimalarials were negatively associated with breast cancer and NMSC risk. SLE activity was associated positively with hematologic cancer and negatively with NMSC. Since the absolute number of cancers was small, additional follow-up will help consolidate these findings.

Patient-related delay in presentation for cutaneous squamous cell carcinoma. A cross-sectional clinical study

BACKGROUND

Delayed diagnosis of squamous cell carcinoma (SCC) increases recurrence, metastatic potential, and management costs. This study aims to identify risk factors of patient-related delayed presentation in cutaneous SCC.

PATIENTS AND METHODS

A total of 513 patients, who first sought care for cutaneous lesions that were subsequently removed and histologically confirmed as SCCs, were included. Attitude to symptoms, psychosocial profile, and reasons for delayed presentation were obtained via a structured questionnaire-based interview. First presentation > 3 months from the onset of symptoms was considered as delayed.

RESULTS

Mean presentation time was 3.90 ± 2.05 months, while 186 patients delayed presentation. Multivariate logistic regression analysis revealed that serious co-morbidity (p = 0.003), low education level (p < 0.001), non-recognition of the seriousness of symptoms (p < 0.001), a 'wait and see' attitude (p < 0.001), and fatalism (p = 0.005) were independent determinants of significantly higher risk for delayed presentation. In contrast, female sex (p = 0.006), new lesion (p = 0.012), accessible topography (p = 0.019), size increase (p = 0.002), color change (p = 0.017), non-healing wound (p = 0.048), and presence of social support/advice (p < 0.001) were independent determinants significantly associated with early presentation.

CONCLUSION

Recognition of symptom seriousness and elimination of factors hindering self-referral may increase awareness and promote early patient presentation and diagnosis of cutaneous SCC.

Reliability of self-reported information on skin cancer among elderly patients with squamous cell carcinoma

PURPOSE

We aimed to evaluate reliability of self-reported information on skin cancer among individuals aged > 65 years with cutaneous squamous cell carcinoma (SCC).

METHODS

A test-retest was performed with patients completing two questionnaires one month apart.

RESULTS

Among 102 recruited patients the response rate was 97.1% (mean age 80.9 years, 74.8% men). The majority of items showed substantial agreement: history of skin cancer screening (k = 0.88), past skin cancer in general (k = 0.92), basal cell carcinoma (k = 0.75), patient delay (k = 0.64) and total delay (k = 0.86). Agreement was high also for ages > 80 years. Recall of past SCCs (k = 0.48) and sunscreen use (k = 0.38) was less accurate.

CONCLUSIONS

Our study provided evidence on the reliability of patient reported skin cancer information among elderly individuals, who represent the majority of affected cases.

Factors associated with large cutaneous squamous cell carcinomas

BACKGROUND

Large cutaneous squamous cell carcinoma (SCC) is associated with a higher risk of disfigurement, local recurrence, and metastasis; however, little is known about factors associated with tumor size at diagnosis.

OBJECTIVES

We sought to evaluate factors associated with SCC size, including diagnostic/treatment delay and patient and tumor characteristics.

METHODS

We studied a stratified sample of 308 patients with SCC recently treated at a dermatologic referral center in Italy. Medical records were reviewed and telephone interviews conducted. Multiple logistic regression was used to examine factors associated with SCC size.

RESULTS

With univariate analyses, among both invasive and in situ cases, SCC greater than 2 cm was significantly associated with male gender, tumors arising in chronic lesions, and tumors located on not easily visible sites. Long delay before surgical removal was significantly associated with large SCC size only for invasive SCC (P < .001). Among patients with invasive SCC, when controlling for age and gender, multivariate analysis showed a significantly higher likelihood of SCC greater than 2 cm with a total delay longer than 18 months before surgical removal (odds ratio=4.18; 95% confidence interval 2.45-7.13) and for tumors arising in chronic lesions (odds ratio=6.42; 95% confidence interval 3.13-13.2).

LIMITATIONS

The study was cross-sectional and based on a single center.

CONCLUSIONS

Long total delay in removal significantly increased the likelihood of invasive SCC greater than 2 cm. Our findings highlight the importance of early detection and treatment to prevent large invasive SCCs, which are associated with a higher risk of disfigurement, recurrence, and metastasis. Particular attention should be paid to chronic skin lesions and not easily visible body sites during physician- and patient-performed examinations.

The association between skin characteristics and skin cancer prevention behaviors

BACKGROUND

Behaviors such as sunscreen use and wearing sun-protective clothing are thought to prevent certain types of skin cancer and precancerous lesions, but few studies have examined differences in these prevention behaviors by skin type.

METHODS

We carried out a cross-sectional study (n = 6,858) nested within a community-based prospective cohort in Washington County, Maryland. We measured the associations between skin type, complexion, freckling, and eye color, and sunscreen and sun-protective clothing use.

RESULTS

The prevalence of regular sunscreen use was 23% and regular sun-protective clothing use was 21%. There were consistent trends indicating those with the most sun-sensitive skin type were most likely to engage in prevention behaviors. For example, compared with those who tan without burning, those who develop blistering sunburns were more likely to use sunscreen [odds ratio (OR), 6.04; 95% confidence interval (95% CI), 2.82-12.95 men; OR, 4.89; 95% CI, 3.34-7.16 women] and sun-protective clothing (OR, 2.87; 95% CI, 1.71-4.80 men; OR, 4.44; 95% CI, 2.88-6.85 women). Health-related characteristics such as body mass index and cigarette smoking were also significantly inversely associated with prevention behaviors.

CONCLUSION

The overall prevalence of prevention behaviors was low. Those with phenotypic risk factors for skin cancer were most likely to use sunscreen and sun-protective clothing. Those with high-risk skin cancer phenotypes may also be those who are most receptive to skin cancer prevention educational interventions.

Spatiotemporal and Spatial Threshold Models for Relating UV Exposures and Skin Cancer in the Central United States

The exact mechanisms relating exposure to ultraviolet (UV) radiation and elevated risk of skin cancer remain the subject of debate. For example, there is disagreement on whether the main risk factor is duration of the exposure, its intensity, or some combination of both. There is also uncertainty regarding the form of the dose-response curve, with many authors believing only exposures exceeding a given (but unknown) threshold are important. In this paper we explore methods to estimate such thresholds using hierarchical spatial logistic models based on a sample of a cohort of x-ray technologists for whom we have self-reports of time spent in the sun and numbers of blistering sunburns in childhood. A preliminary goal is to explore the temporal pattern of UV exposure and its gradient. Changes here would imply that identical exposure self-reports from different calendar years may correspond to differing cancer risks.

Quality of life in the actinic neoplasia syndrome: The VA Topical Tretinoin Chemoprevention (VATTC) Trial

BACKGROUND

Keratinocyte carcinomas (KCs) are the most common malignancies of the skin. As lesions have a low mortality rate, understanding quality-of-life (QoL) factors is necessary in their management.

OBJECTIVE

To assess QoL and associated patient characteristics in those with a history of keratinocyte carcinomas.

METHODS

We conducted a cross-sectional study of veterans with a history of KCs enrolled in a randomized controlled trial for chemoprevention of keratinocyte carcinomas. Study dermatologists counted actinic keratoses (AKs) and assessed for skin photodamage. QoL was assessed using Skindex-29 and KC-specific questions. Demographics were self-reported.

RESULTS

Participants (n = 931) enrolled at 5 clinical sites had worse QoL on all subscales (emotions, functioning, and symptoms) compared to a reference group of patients without skin disease. Univariate analysis demonstrated worse QoL associated with higher AK count, past 5-fluorouracil (5-FU) use, and greater sun sensitivity. Multivariate analysis demonstrated that higher AK count and past 5-FU use were independently related to diminished QoL. Higher comorbidities showed modest associations on the symptoms and functioning subscales. Number of previous KCs was not independently associated with any QoL differences.

LIMITATIONS

Study population may not be generalizable to the general population. Counting of AKs is of limited reliability. Previous 5-FU use is self reported.

CONCLUSIONS

A history of ever use of 5-FU and present AKs was strongly associated with worse QoL. We find it more useful to consider these patients as having the chronic condition "actinic neoplasia syndrome," whose burden may be best measured by factors other than their history of KCs.

The Queensland Study of Melanoma: environmental and genetic associations (Q-MEGA); study design, baseline characteristics, and repeatability of phenotype and sun exposure measures

Cutaneous malignant melanoma (CMM) is a major health issue in Queensland, Australia, which has the world's highest incidence. Recent molecular and epidemiologic studies suggest that CMM arises through multiple etiological pathways involving gene-environment interactions. Understanding the potential mechanisms leading to CMM requires larger studies than those previously conducted. This article describes the design and baseline characteristics of Q-MEGA, the Queensland Study of Melanoma: Environmental and Genetic Associations, which followed up 4 population-based samples of CMM patients in Queensland, including children, adolescents, men aged over 50, and a large sample of adult cases and their families, including twins. Q-MEGA aims to investigate the roles of genetic and environmental factors, and their interaction, in the etiology of melanoma. Three thousand, four hundred and seventy-one participants took part in the follow-up study and were administered a computer-assisted telephone interview in 2002-2005. Updated data on environmental and phenotypic risk factors, and 2777 blood samples were collected from interviewed participants as well as a subset of relatives. This study provides a large and well-described population-based sample of CMM cases with follow-up data. Characteristics of the cases and repeatability of sun exposure and phenotype measures between the baseline and the follow-up surveys, from 6 to 17 years later, are also described.

Polymorphisms in XPD (Asp312Asn and Lys751Gln) genes, sunburn and arsenic-related skin lesions

BACKGROUND

Single-nucleotide polymorphisms in genes related to DNA repair capacity and ultraviolet exposure have not been well investigated in relation to skin lesions associated with arsenic exposure. This population based case-control study, of 600 cases and 600 controls, frequency matched on age and gender in Pabna, Bangladesh, in 2001-2002, investigated the association and potential effect modification between polymorphisms in Xeroderma Pigmentosum complementation group D (XPD) (Lys751Gln and Asp312Asn) genes, tendency to sunburn and arsenic-related skin lesions.

METHODS

Unconditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULT

No significant association was observed between skin lesions and the XPD 312 Asp/Asn (adjusted OR = 0.87, 95% CI = 0.65-1.15) Asn/Asn (adjusted OR = 0.76, 95% CI = 0.50-1.15) (referent Asp/Asp); XPD 751 Lys/Gln (adjusted OR = 0.92, 95% CI = 0.69-1.23) Gln/Gln (adjusted OR = 0.98, 95% CI = 0.66-1.45) (referent Lys/Lys). While we did not observe any evidence of effect modification of these polymorphisms on the association between well arsenic concentration and skin lesions, we did observe effect modification between these polymorphisms and sunburn tendency and arsenic-related skin lesions. Individuals with the heterozygote or homozygote variant forms (Asp/Asn or Asn/Asn) had half the risk of skin lesions (OR = 0.45, 95% CI = 0.29-0.68) compared with those with the wild-type XPDAsp312Asn genotype (Asp/Asp) and individuals with heterozygote or homozygote variant forms (Lys/Gln or Gln/Gln) had half the risk of skin lesions (OR = 0.47, 95% CI = 0.31-0.72) compared with those with the wild-type XPDLys751Gln genotype (Lys/Lys), within the least sensitive strata of sunburn severity. We observed effect modification on the multiplicative scale for XPD 751 and XPD 312.

CONCLUSION

XPD polymorphisms modified the relationship between tendency to sunburn and skin lesions in an arsenic exposed population. Further study is necessary to explore the effect of XPD polymorphisms and sun exposure on risk of arsenic-related skin lesions.