Non melanoma skin cancer and subsequent cancer risk

Revolutionizing non-melanoma skin cancer treatment: Receptor tyrosine kinase inhibitors take the stage

BACKGROUND

Innovative treatments for non-melanoma skin cancers (NMSCs) are required to enhance patient outcomes.

AIMS

This review examines the effectiveness and safety of receptor tyrosine kinase inhibitors (RTKIs).

METHODS

A comprehensive review was conducted on the treatment potential of several RTKIs, namely cetuximab, erlotinib, gefitinib, panitumumab, and lapatinib.

RESULTS

The findings indicate that these targeted therapies hold great promise for the treatment of NMSCs. However, it is crucial to consider relapse rates and possible adverse effects. Further research is needed to improve treatment strategies, identify patient groups that would benefit the most, and assess the long-term efficacy and safety, despite the favorable results reported in previous studies. Furthermore, it is crucial to investigate the potential benefits of integrating RTKIs with immunotherapy and other treatment modalities to enhance the overall efficacy of therapy for individuals with NMSC.

CONCLUSIONS

Targeted therapies for NMSCs may be possible with the use of RTKIs. The majority of studies focused on utilizing epidermal growth factor receptor inhibitors as the primary class of RTKIs for the treatment of NMSC. Other RTKIs were only employed in experimental investigations. Research indicates that RTKIs could potentially serve as a suitable alternative for elderly patients who are unable to undergo chemotherapy and radiotherapy.

Common skin cancers and their association with other non-cutaneous primary malignancies: a review of the literature

It has long been recognized that a history of skin cancer puts one at risk for additional primary skin cancers. However, more variable data exists for the risk of developing a non-cutaneous primary cancer following a diagnosis of skin cancer. The data are most variable for Basal Cell Carcinoma (BCC), the most common and least aggressive type of skin cancer. While early studies imply that BCC does not impart a larger risk of other primary non-cutaneous cancers, more recent studies with larger populations suggest otherwise. The cancers most significantly associated with BCC are lip, oropharyngeal, and salivary gland cancer. There is also burgeoning evidence to suggest a link between BCC and prostate, breast, and colorectal cancer, but more data are needed to draw a concrete conclusion. Squamous Cell Carcinoma (SCC), the second most common type of skin cancer, has a slightly more defined risk to other non-cutaneous primary malignancies. There is a notable link between SCC and non-Hodgkin's lymphoma (NHL), possibly due to immunosuppression. There is also an increased risk of other cancers derived from squamous epithelium following SCC, including oropharyngeal, lip, and salivary gland cancer. Some studies also suggest an increased risk of respiratory tract cancer following SCC, possibly due to shared risk factors. Melanoma, a more severe type of skin cancer, shows a well-defined risk of additional primary non-cutaneous malignancies. The most significant of these risks include NHL, thyroid cancer, prostate cancer, and breast cancer along with a host of other cancers. Each of these three main skin cancer types has a profile of genetic mutations that have also been linked to non-cutaneous malignancies. In this review, we discuss a selection of these genes to highlight the complex interplay between different tumorigenesis processes.

Cutaneous malignancies in chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) is a common lymphoid malignancy that is associated with an increased risk of developing cutaneous malignancies. Clinical outcomes for these malignancies, including melanoma and keratinocyte cancers (KC), are worse for patients with CLL. Individuals with CLL develop an immunodeficiency of both the adaptive and innate immune system, which plays a role in the increased prevalence of skin cancers. This review focuses on the complex interplay between genetics, immunity, and pathogens that influence the cellular composition and biology of skin tumors and their microenvironment in CLL patients, and in comparison with other chronic hematological malignancies. It is paramount for dermatologists to be aware of the association between CLL (and chronic hematological malignancies more broadly) and cutaneous malignancies. This is a high-risk population who require regular and vigorous dermatologic follow-up.

Economic burden of skin cancer treatment in the USA: an analysis of the Medical Expenditure Panel Survey Data, 2012-2018

PURPOSE

We report the prevalence and economic cost of skin cancer treatment compared to other cancers overall in the USA from 2012 to 2018.

METHODS

Using the Medical Expenditure Panel Survey full-year consolidated data files and associated medical conditions and medical events files, we estimate the prevalence, total costs, and per-person costs of treatment for melanoma and non-melanoma skin cancer among adults aged ≥ 18 years in the USA. To understand the changes in treatment prevalence and treatment costs of skin cancer in the context of overall cancer treatment, we also estimate the prevalence, total costs, and per-person costs of treatment for non-skin cancer among US adults.

RESULTS

During 2012-15 and 2016-18, the average annual number of adults treated for any skin cancer was 5.8 (95% CI: 5.2, 6.4) and 6.1 (95% CI: 5.6, 6.6) million, respectively, while the average annual number of adults treated for non-skin cancers rose from 10.8 (95% CI: 10.0, 11.5) to 11.9 (95% CI: 11.2, 12.6) million, respectively. The overall estimated annual costs rose from $8.0 (in 2012-2015) to $8.9 billion (in 2016-18) for skin cancer treatment and $70.2 to $79.4 billion respectively for non-skin cancer treatment.

CONCLUSION

The prevalence and economic cost of skin cancer treatment modestly increased in recent years. Given the substantial cost of skin cancer treatment, continued public health attention to implementing evidence-based sun-safety interventions to reduce skin cancer risk may help prevent skin cancer and the associated treatment costs.

Risk of Melanoma in Patients with Basal Cell Carcinoma: A Population-based Cohort Study

Basal cell carcinoma is the most prevalent cancer in Caucasians worldwide. The aim of this study was to examine the overall risk of melanoma among patients diagnosed with basal cell carcinoma. This population-based retrospective cohort study included data from January 2010 to December 2018 from the databases of the Clalit Health Maintenance Organization and 2 major pathology laboratories in North District, Israel. The incidence and hazard ratio of melanoma in patients with a diagnosis of basal cell carcinoma were determined. Of 466,700 participants, 51% were women and the mean (standard deviation) follow-up was 6.7 (2.9; range 1-9) years. A total of 3,338 patients were diagnosed with basal cell carcinoma during the study period, 82 of whom subsequently developed melanoma. Patients with basal cell carcinoma had a significantly higher incidence of melanoma than patients without basal cell carcinoma (2.46% vs 0.37%; p < 0.0001). Univariate Cox regression analysis revealed a hazard ratio of 6.6 (95% confidence interval: 3.6-12.1; p < 0.0001) for melanoma in patients with a diagnosis of basal cell carcinoma. In conclusion, a diagnosis of basal cell carcinoma confers a significant risk of melanoma.

Sequencing-based fine-mapping and in silico functional characterization of the 10q24.32 arsenic metabolism efficiency locus across multiple arsenic-exposed populations

Inorganic arsenic is highly toxic and carcinogenic to humans. Exposed individuals vary in their ability to metabolize arsenic, and variability in arsenic metabolism efficiency (AME) is associated with risks of arsenic-related toxicities. Inherited genetic variation in the 10q24.32 region, near the arsenic methyltransferase (AS3MT) gene, is associated with urine-based measures of AME in multiple arsenic-exposed populations. To identify potential causal variants in this region, we applied fine mapping approaches to targeted sequencing data generated for exposed individuals from Bangladeshi, American Indian, and European American populations (n = 2,357, 557, and 648 respectively). We identified three independent association signals for Bangladeshis, two for American Indians, and one for European Americans. The size of the confidence sets for each signal varied from 4 to 85 variants. There was one signal shared across all three populations, represented by the same SNP in American Indians and European Americans (rs191177668) and in strong linkage disequilibrium (LD) with a lead SNP in Bangladesh (rs145537350). Beyond this shared signal, differences in LD patterns, minor allele frequency (MAF) (e.g., rs12573221 ~13% in Bangladesh ~0.2% among American Indians), and/or heterogeneity in effect sizes across populations likely contributed to the apparent population specificity of the additional identified signals. One of our potential causal variants influences AS3MT expression and nearby DNA methylation in numerous GTEx tissue types (with rs4919690 as a likely causal variant). Several SNPs in our confidence sets overlap transcription factor binding sites and cis-regulatory elements (from ENCODE). Taken together, our analyses reveal multiple potential causal variants in the 10q24.32 region influencing AME, including a variant shared across populations, and elucidate potential biological mechanisms underlying the impact of genetic variation on AME.

High-fidelity detection, subtyping, and localization of five skin neoplasms using supervised and semi-supervised learning

Background

Skin cancers are the most common malignancies diagnosed worldwide. While the early detection and treatment of pre-cancerous and cancerous skin lesions can dramatically improve outcomes, factors such as a global shortage of pathologists, increased workloads, and high rates of diagnostic discordance underscore the need for techniques that improve pathology workflows. Although AI models are now being used to classify lesions from whole slide images (WSIs), diagnostic performance rarely surpasses that of expert pathologists.

Objectives

The objective of the present study was to create an AI model to detect and classify skin lesions with a higher degree of sensitivity than previously demonstrated, with potential to match and eventually surpass expert pathologists to improve clinical workflows.

Methods

We combined supervised learning (SL) with semi-supervised learning (SSL) to produce an end-to-end multi-level skin detection system that not only detects 5 main types of skin lesions with high sensitivity and specificity, but also subtypes, localizes, and provides margin status to evaluate the proximity of the lesion to non-epidermal margins. The Supervised Training Subset consisted of 2188 random WSIs collected by the PathologyWatch (PW) laboratory between 2013 and 2018, while the Weakly Supervised Subset consisted of 5161 WSIs from daily case specimens. The Validation Set consisted of 250 curated daily case WSIs obtained from the PW tissue archives and included 50 "mimickers". The Testing Set (3821 WSIs) was composed of non-curated daily case specimens collected from July 20, 2021 to August 20, 2021 from PW laboratories.

Results

The performance characteristics of our AI model (i.e., Mihm) were assessed retrospectively by running the Testing Set through the Mihm Evaluation Pipeline. Our results show that the sensitivity of Mihm in classifying melanocytic lesions, basal cell carcinoma, and atypical squamous lesions, verruca vulgaris, and seborrheic keratosis was 98.91% (95% CI: 98.27%, 99.55%), 97.24% (95% CI: 96.15%, 98.33%), 95.26% (95% CI: 93.79%, 96.73%), 93.50% (95% CI: 89.14%, 97.86%), and 86.91% (95% CI: 82.13%, 91.69%), respectively. Additionally, our multi-level (i.e., patch-level, ROI-level, and WSI-level) detection algorithm includes a qualitative feature that subtypes lesions, an AI overlay in the front-end digital display that localizes diagnostic ROIs, and reports on margin status by detecting overlap between lesions and non-epidermal tissue margins.

Conclusions

Our AI model, developed in collaboration with dermatopathologists, detects 5 skin lesion types with higher sensitivity than previously published AI models, and provides end users with information such as subtyping, localization, and margin status in a front-end digital display. Our end-to-end system has the potential to improve pathology workflows by increasing diagnostic accuracy, expediting the course of patient care, and ultimately improving patient outcomes.

Interventions After First Post-Transplant Cutaneous Squamous Cell Carcinoma: A Proposed Decision Framework

Cutaneous squamous cell carcinoma (CSCC) is a major cause of morbidity and mortality after organ transplant. Many patients subsequently develop multiple CSCC following a first CSCC, and the risk of metastasis and death is significantly increased compared to the general population. Post-transplant CSCC represents a disease at the interface of dermatology and transplant medicine. Both systemic chemoprevention and modulation of immunosuppression are frequently employed in patients with multiple CSCC, yet there is little consensus on their use after first CSCC to reduce risk of subsequent tumors. While relatively few controlled trials have been undertaken, extrapolation of observational data suggests the most effective interventions may be at the time of first CSCC. We review the need for intervention after a first post-transplant CSCC and evidence for use of various approaches as secondary prevention, before discussing barriers preventing engagement with this approach and finally highlight areas for future research. Close collaboration between specialties to ensure prompt deployment of these interventions after a first CSCC may improve patient outcomes.

History of keratinocyte carcinoma and survival after a second primary malignancy: the Moffitt Cancer Center patient experience

PURPOSE

History of keratinocyte carcinoma (KC) has been associated with survival following the diagnosis of a second primary malignancy (SPM), with the direction of the association varying by cancer type. Research is needed to elucidate the role of other key factors in this association.

METHODS

A retrospective cohort study was conducted among patients newly diagnosed and/or treated at Moffitt Cancer Center in December 2008-April 2020 with breast cancer, lung cancer, melanoma, colon cancer, prostate cancer, and non-Hodgkin lymphoma/chronic lymphocytic leukemia (NHL/CLL) (n = 29,156). History of KC was obtained from new patient intake questionnaires. Age- and stage-adjusted hazard ratios (HR) and 95% confidence intervals (CI) were calculated to estimate the association between history of KC and survival following each cancer, stratified by demographic/clinical characteristics.

RESULTS

KC history was most prevalent in patients with melanoma (28.7%), CLL (19.8%) and lung cancer (16.1%). KC history was associated with better overall survival following prostate cancer (HR = 0.74, 95% CI = 0.55-0.99) and poorer overall survival following CLL (HR = 1.73, 95% CI = 1.10-2.71). Patients with a history of KC experienced better survival within the first four years of a melanoma diagnosis (HR = 0.79, 95% CI = 0.67-0.92); whereas poorer survival was observed for patients who survived 7 + years after a melanoma diagnosis (HR = 2.18, 95% CI = 1.17-4.05). Stratification by treatment and stage revealed directional differences in the associations between KC history and survival among patients with breast cancer and melanoma.

CONCLUSIONS

KC history may be a predictor of survival following an SPM, possibly serving as a marker of immune function and/or DNA damage repair capacity.

Risk Factors and Clinicopathological Features for Developing a Subsequent Primary Cutaneous Squamous and Basal Cell Carcinomas

BACKGROUND

Patients with diagnosed keratinocyte carcinomas (KCs) have an increased risk of subsequent skin cancers development. Current studies indicate that patients with subsequent tumors should be followed up regularly. However, none of the studies indicate the connection between the specific subtypes and an increased risk for further KCs development. The study assesses the differences in the risk of developing a subsequent skin cancer after a previous diagnosis of KC, especially considering individual types of skin malignances, and identifies potential factors associated with an increased risk of new cutaneous tumor describing non-invasive diagnosis and monitoring.

METHODS

Pathology and medical records were examined to identify the characteristics of patients with multiple KCs diagnosed between 1999 and 2019.

RESULTS

The study group comprised 13,913 KCs occurring in 10,083 patients. Multiple KCs were observed in 2300 patients (22.8%). The analysis showed aggressive subtypes, multiple tumors, and male sex as significant prognostic factors.

CONCLUSIONS

The most crucial risk factors for developing subsequent KC are being of a male gender, an aggressive tumor subtype, and previous history of multiple skin cancers. Basal cell carcinoma subtypes, such as infiltrative basosquamous, with aggressive growth patterns predispose not only to increased risk for the recurrence but are also expected to be at higher risk of subsequent KCs.

Investigating DNA methylation as a potential mediator between pigmentation genes, pigmentary traits and skin cancer

Pigmentation characteristics are well-known risk factors for skin cancer. Polymorphisms in pigmentation genes have been associated with these traits and with the risk of malignancy. However, the functional relationship between genetic variation and disease is still unclear. This study aims to assess whether pigmentation SNPs are associated with pigmentary traits and skin cancer via DNA methylation (DNAm). Using a meta-GWAS of whole-blood DNAm from 36 European cohorts (N = 27,750; the Genetics of DNA Methylation Consortium, GoDMC), we found that 19 out of 27 SNPs in 10 pigmentation genes were associated with 391 DNAm sites across 30 genomic regions. We examined the effect of 25 selected DNAm sites on pigmentation traits, sun exposure phenotypes and skin cancer and on gene expression in whole blood. We uncovered an association of DNAm site cg07402062 with red hair in the Avon Longitudinal Study of Parents and Children (ALSPAC). We also found that the expression of ASIP and CDK10 was associated with hair colour, melanoma and basal cell carcinoma. Our results indicate that DNAm and expression of pigmentation genes may play a role as potential mediators of the relationship between genetic variants, pigmentation phenotypes and skin cancer and thus deserve further scrutiny.

Amelanotic melanoma of the head and neck: analysis of tumor characteristics from the National Cancer Database

BACKGROUND

Amelanotic melanoma is an extremely rare subtype of cutaneous melanoma. The tumor characteristics are still not well understood, especially for those located in the head and neck.

METHODS

Tumor characteristics of patients diagnosed with amelanotic melanoma of the head and neck (AMHN) from January 1, 2004, to December 31, 2015, were analyzed by querying the National Cancer Database. Characteristics of AMHN were subsequently compared with common malignant melanoma of the head and neck (CMMHN).

RESULTS

Three hundred and sixty-eight patients were diagnosed with AMHN, and 69,267 were diagnosed with CMMHN. Of those with AMHN, 128 (34.8%) had melanoma located on the scalp and neck, and 172 (46.7%) were diagnosed with an early disease stage (i.e., 0, I, or II). When compared with CMMHN, patients with AMHN were more likely to be diagnosed after 80 years of age (25.3% vs. 18.2%; odds ratio [OR], 3.28; 95% CI, 1.09-9.84; P = 0.03), when Breslow depth was between 2.01 and 4.00 mm (28.5% vs. 6.5%; OR, 1.92; 95% CI, 1.15-3.19; P = 0.01), when ulceration was present (36.7% vs. 9.0%; OR, 1.99; 95% CI, 1.34-2.97; P = 0.001), and when mitotic count was 1 or more/mm² (40.5% vs. 12.8%; OR; 2.53; 95% CI, 1.09-5.89; P = 0.03). No statistical difference was found for sex, specific location, stage, or lymph node involvement.

CONCLUSION

Our study determined that AMHN is associated with older age, increased Breslow depth, presence of ulceration, and greater mitotic count when compared with CMMHN.

Sunscreen application technique amongst patients with a history of skin cancer

BACKGROUND

Data on how patients with a history of skin cancer apply sunscreen are lacking.

OBJECTIVE

To characterize (1) gender differences in sunscreen application technique (quantity used, anatomic site coverage, and time allocated) and (2) differences in sunscreen application to unaffected skin versus previous skin cancer sites.

METHODS

Subjects with a history of skin cancer were asked to apply sunscreen to their head as they normally would. The amount of sunscreen used and application time were recorded. Before and after photos were taken. Using Wood's lamp lighting, an anatomic site coverage score was rated on an ordinal scale (1 = 0-25%, 2 = 26-50%, 3 = 51-75%, 4 = 76-100% coverage).

RESULTS

Males used 530 mg more sunscreen (p < 0.001) and applied approximately 5 mg/cm² of sunscreen versus women, who applied 2 mg/cm². The average coverage score was 3.27. Males were 7.61 times more likely to adequately apply sunscreen to the ears (p = 0.001). No differences were noted in application times. Coverage scores were similar for unaffected skin and previous skin cancer sites.

LIMITATIONS

Observations in a controlled setting may not reflect usual sunscreen application practices.

CONCLUSIONS

Overall, skin cancer survivors of both genders effectively applied sunscreen in line with recommended quantity guidelines, but men were significantly better at protecting their ears.

Patient and physician factors associated with Oncotype DX and adjuvant chemotherapy utilization for breast cancer patients in New Hampshire, 2010-2016

BACKGROUND

Oncotype DX® (ODX) is used to assess risk of disease recurrence in hormone receptor positive, HER2-negative breast cancer and to guide decisions regarding adjuvant chemotherapy. Little is known about how physician factors impact treatment decisions. The purpose of this study was to examine patient and physician factors associated with ODX testing and adjuvant chemotherapy for breast cancer patients in New Hampshire.

METHODS

We examined New Hampshire State Cancer Registry data on 5630 female breast cancer patients diagnosed from 2010 to 2016. We performed unadjusted and adjusted hierarchical logistic regression to identify factors associated with a patient's receipt of ODX, being recommended and receiving chemotherapy, and refusing chemotherapy. We calculated intraclass correlation coefficients (ICCs) to examine the proportion of variance in clinical decisions explained by between-physician and between-hospital variation.

RESULTS

Over the study period, 1512 breast cancer patients received ODX. After adjustment for patient and tumor characteristics, we found that patients seen by a male medical oncologist were less likely to be recommended chemotherapy following ODX (OR = 0.50 (95% CI = 0.34-0.74), p < 0.01). Medical oncologists with more clinical experience (reference: less than 10 years) were more likely to recommend chemotherapy (20-29 years: OR = 4.05 (95% CI = 1.57-10.43), p < 0.01; > 29 years: OR = 4.48 (95% CI = 1.68-11.95), p < 0.01). A substantial amount of the variation in receiving chemotherapy was due to variation between physicians, particularly among low risk patients (ICC = 0.33).

CONCLUSIONS

In addition to patient clinicopathologic characteristics, physician gender and clinical experience were associated with chemotherapy treatment following ODX testing. The significant variation between physicians indicates the potential for interventions to reduce variation in care.

The evolving field of Dermato-oncology and the role of dermatologists: Position Paper of the EADO, EADV and Task Forces, EDF, IDS, EBDV-UEMS and EORTC Cutaneous Lymphoma Task Force

BACKGROUND

The incidence of skin cancers has been increasing steadily over the last decades. Although there have been significant breakthroughs in the management of skin cancers with the introduction of novel diagnostic tools and innovative therapies, skin cancer mortality, morbidity and costs heavily burden the society.

OBJECTIVE

Members of the European Association of Dermato-Oncology, European Academy of Dermatology and Venereology, International Dermoscopy Society, European Dermatology Forum, European Board of Dermatovenereology of the European Union of Medical Specialists and EORTC Cutaneous Lymphoma Task Force have joined this effort to emphasize the fundamental role that the specialist in Dermatology-Venereology has in the diagnosis and management of different types of skin cancer. We review the role of dermatologists in the prevention, diagnosis, treatment and follow-up of patients with melanoma, non-melanoma skin cancers and cutaneous lymphomas, and discuss approaches to optimize their involvement in effectively addressing the current needs and priorities of dermato-oncology.

DISCUSSION

Dermatologists play a crucial role in virtually all aspects of skin cancer management including the implementation of primary and secondary prevention, the formation of standardized pathways of care for patients, the establishment of specialized skin cancer treatment centres, the coordination of an efficient multidisciplinary team and the setting up of specific follow-up plans for patients.

CONCLUSION

Skin cancers represent an important health issue for modern societies. The role of dermatologists is central to improving patient care and outcomes. In view of the emerging diagnostic methods and treatments for early and advanced skin cancer, and considering the increasingly diverse skills, knowledge and expertise needed for managing this heterogeneous group of diseases, dermato-oncology should be considered as a specific subspecialty of Dermatology-Venereology.

Premalignant lesions, basal cell carcinoma and melanoma in patients with cutaneous squamous cell carcinoma

The incidence of keratinocyte carcinomas is increasing worldwide and currently there is no standardised strategy for the follow-up of patients with multiple tumours. The objective of this study was to assess the prevalence of premalignant lesions, i.e., actinic keratosis and Bowen’s disease, as well as basal cell carcinoma (BCC) and cutaneous melanoma (CM) among patients with cutaneous squamous cell carcinoma (cSCC). Pathology database search was performed to identify all cSCC patients diagnosed in the Pirkanmaa region of Finland in 2006–2015. Details of the patients and tumours were obtained through medical record review. The cohort consisted of 774 patients with 1131 cSCC tumours. Overall 559 patients (72%) had premalignant lesions. A total of 316 patients (41%) had BCC and 52% of these (n = 164) had more than one BCC tumour. 50 patients (6%) had CM. Overall 180 cSCC patients (23%) had no premalignant changes, BCC or CM. The median age of these patients was 6 years less than that of the patients with premalignant lesions (p < 0.001) or BCC (p < 0.001). The invasion depth of the tumours was deeper in the patients with only cSCC (median 3 mm, interquartile range 2–6) than in those with premalignant lesions or BCC (median 2 mm, interquartile range 1–3), p < 0.001. CSCC patients have a high risk of developing multiple skin cancers and need long-term follow-up.

Risk of melanoma following keratinocyte malignancies

Patients diagnosed with keratinocyte cancer experience heightened risk for melanoma, yet patients who go on to develop this malignancy have not been well-characterized. We followed a population-based cohort of 2243 participants with histologically confirmed KC identified from dermatology and pathology practices who did not have a history of internal malignancy (1363 BCC, 880 SCC). A total of 77 participants went on to develop melanoma. Individual-level data were collected via personal interviews including demographic information and skin cancer risk factors, as well as KC tumor characteristics such as anatomic site and histologic subtype. Using adjusted Cox proportionate hazards models, older patients (age 61 or older vs 60 or younger) were at twofold increased risk for developing melanoma following KC (age 61-65 HR = 2.5; 95% CI = 1.3-4.6) (age > 65 HR = 2.0; 95% CI = 1.2-3.4) and women were at reduced risk compared to men (HR = 0.5; 95% CI = 0.3-0.8). Among patients with BCC, those with tumors on the trunk/limbs compared to the head/neck were at greater risk for subsequent melanoma (HR = 2.7; 95% CI = 1.3-5.7). Subsequent risk of melanoma also related to established risk factors including blond/red vs dark hair (HR = 1.9; 95% CI = 1.1-3.4), tendency to burn rather than tan (HR = 1.7; 95% CI = 1.0-2.7), ≥1 nevi on their back compared to no nevi (HR = 2.2; 95% CI = 1.2-3.8) and a history of ≥1 painful childhood sunburns vs none (HR = 2.1; 95% CI = 1.2-3.6). Thus, in addition to pigmentary traits, ultraviolet radiation (UVR)-related factors and clinical features of KC such as anatomic site may be useful in identifying patients at increased risk for melanoma after KC.

S2k Guidelines for Cutaneous Basal Cell Carcinoma - Part 2: Treatment, Prevention and Follow-up

Basal cell carcinoma (BCC) is the most common malignant tumor among fair-skinned individuals, and its incidence had been steadily rising in the past decades. In order to maintain the highest quality of patient care possible, the German S2k guidelines were updated following a systematic literature search and with the participation of all professional societies and associations involved in the management of the disease. Part 2 addresses issues such as proper risk stratification, the various therapeutic approaches, and prevention as well as follow-up of patients with basal cell carcinoma.

Influence of family history on risk of second primary cancers and survival in patients with squamous cell skin cancer

BACKGROUND

Patients with squamous cell skin cancer (SCC) have an excellent prognosis but second primary cancers (SPCs) weaken survival prospects. Family history is a known risk factor for cancer but whether it is a risk factor for SPC in patients with SCC is not known.

OBJECTIVES

To quantify the risk of family history on SPCs in patients with SCC and estimate survival probabilities of patients with SPCs depending on family history.

METHODS

With 13 945 histologically verified SCCs, relative risks (RRs) were estimated for family history using a generalized regression model. For survival analysis, hazard ratios (HRs) were assessed using a multivariable Cox proportional-hazards model.

RESULTS

Family history of invasive SCC increased risk of second invasive SCC [RR = 42·92, 95% confidence interval (CI) 33·69-50·32] compared with risk without family history (RR 19·12, 95% CI 17·88-21·08). Family history of any nonskin cancer in invasive SCC increased risk of the same cancers to be diagnosed as SPC (RRF_H = 1·48, 95% CI 1·35-1·61 vs. RR_{no FH} = 1·40, 95% CI 1·32-1·48); significant increases were observed for seven different nonskin cancers. Most results were replicated for in situ SCC. SPC was deleterious for survival irrespective of family history; HR for patients with SPC was 4·28 (95% CI 3·83-4·72) vs. those without SPC (1·04).

CONCLUSIONS

Family history of nonskin cancer was associated with approximately a doubling of risk for SPCs in patients with SCC. SPC increases the death rate in patients with SCC 3-4 times, irrespective of family history. Taking family history into account at SCC diagnosis may help prevention or early detection of SPCs. What's already known about this topic? Second primary cancers (SPCs) are frequently diagnosed in patients with invasive and in situ squamous cell carcinoma (SCC); some epidemiological studies suggest a link to immune dysfunction. Family history of cancer is a risk factor for practically all first primary cancers but whether it also influences risk of SPCs in patients with SCC is not known. The possible influence of family history on survival in patients with SCC remains to be established. Linked Comment: Youlden and Baade. Br J Dermatol 2020; 183:414-415.

Viruses in Skin Cancer (VIRUSCAN): Study Design and Baseline Characteristics of a Prospective Clinic-Based Cohort Study

BACKGROUND

Accumulating evidence suggests that cutaneous viral infections are risk factors for the development of keratinocyte carcinomas. The Viruses in Skin Cancer (VIRUSCAN) Study, a prospective cohort study, was established in 2014 to investigate the risk of keratinocyte carcinoma associated with cutaneous human papillomavirus and polyomavirus infection and the possible interaction with ultraviolet radiation exposure (UVR).

METHODS/RESULTS

VIRUSCAN incorporates repeated measures of viral infection using multiple markers of infection and quantitative measures of UVR using a spectrophotometer. Participants were recruited between July 14, 2014 and August 31, 2017 at the University of South Florida Dermatology Clinic in Tampa, FL. After excluding 124 individuals with prevalent keratinocyte carcinomas at baseline, 1,179 participants (53.2% women, 46.8% men, all ages 60 years and older) were followed for up to 4 years with routine skin exams occurring every 6 to 12 months. Here, we present the VIRUSCAN Study design, methods, and baseline characteristics, including demographics, sun exposure behavior, quantitative UVR exposure measurements, and cutaneous viral prevalence, for the full study cohort.

CONCLUSIONS

The VIRUSCAN Study will provide critical temporal evidence needed to assess the causality of the role cutaneous viral infections play in the development of keratinocyte carcinomas, as well as the potential interaction between cutaneous viral infections and UVR exposure.

IMPACT

Study findings will be valuable in future development of novel keratinocyte carcinoma prevention strategies.

A cohort study of personal and family history of skin cancer in relation to future risk of non-cutaneous malignancies

PURPOSE

Skin cancer has repeatedly been observed to be a marker of increased risk for developing an internal malignancy. The purpose of our study was to further investigate this association while also characterizing the potential role of family history of skin cancer in relation to risk for non-cutaneous malignancies.

METHODS

Our study used data from 8,408 participants from the NHANES I epidemiological follow-up study. Cox-proportional hazards models were used to estimate the risk for developing an internal cancer associated with a personal history and family history of skin cancer during follow-up.

RESULTS

A personal history of skin cancer was associated with significantly increased risk of developing an internal cancer in adjusted models [hazard ratio (HR) 1.33, 95% confidence interval (CI) 1.09-1.61] but a family history of skin cancer was not associated with increased risk (HR 0.80, 95% CI 0.58-1.11).

CONCLUSIONS

Consistent with prior reports, a personal history of skin cancer was associated with increase of developing internal malignancies, but this did not hold true for a family history of skin cancer. Further research is needed to understand why a personal history of skin cancer acts as a marker for increased risk for internal cancer.

Food insecurity among adult cancer survivors in the United States

PURPOSE

The purpose of this study was to examine the prevalence of food insecurity among US adults with a history of a cancer diagnosis and to understand if socio-demographic factors and cancer characteristics (i.e., time since diagnosis, cancer type) relate to food insecurity.

METHODS

This was a secondary analysis of cancer survivors drawn from the National Health and Nutrition Examination Surveys (NHANES) 2011-2014. Weighted analyses included descriptive, bivariate, and multinomial logistic regression.

RESULTS

Of the cancer survivors identified in the sample (n = 1,022), 8.36% were food insecure. In bivariate analysis, several factors were significantly associated with food insecurity among cancer survivors, including female gender, younger age, non-Hispanic black or Hispanic race/ethnicity, lower income, no insurance coverage, lower education, single relationship status, having children at home, having poor health or diet, and cancer characteristics (i.e., non-melanoma skin cancer, female reproductive cancer). In logistic regression analyses, odds of food insecurity decreased with older age and higher income and increased with poor health, although cancer type was no longer significant.

CONCLUSIONS

Though a low proportion of cancer survivors indicated being food insecure, food insecurity was evident, and this study identified socio-demographic factors related to food insecurity which may be important to consider in clinical and community health settings serving cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Nutrition is essential throughout the cancer care trajectory, including survivorship. Clinicians should consider processes for screening patients, especially younger and lower income patients, for food insecurity through all stages of treatment and particularly as part of survivorship planning. Furthermore, availability and referral to community partners for nutrition and food support is essential.

Second Primary Cancers in Patients with Invasive and In Situ Squamous Cell Skin Carcinoma, Kaposi Sarcoma, and Merkel Cell Carcinoma: Role for Immune Mechanisms?

Second primary cancers (SPCs) are becoming a common cancer entity, which may interfere with survival in relatively benign first primary cancers. We examined the hypothesis that immune dysfunction may contribute to SPCs by assessing SPCs associated with known immune responsive skin cancers, invasive and in situ squamous cell carcinoma, Kaposi sarcoma, and Merkel cell carcinoma. Cancers were identified from the Swedish Cancer Registry from the year 1958 to 2015. Standardized relative risks were calculated bidirectionally for any SPC after skin cancer and for skin cancer as SPC. Over 80,000 first primary cancers were identified for each invasive and in situ squamous cell carcinoma of the skin. Bidirectional increased risks were observed for 26 cancers associated with invasive skin cancer; the Spearman rank correlation was 0.72 (P = 4.6 × 10^-5). The highest bidirectional relative risks were for invasive and in situ skin cancer as SPCs (14.59 and 16.71, respectively). Remarkably high risks for second in situ squamous cell carcinoma of the skin were found after Kaposi sarcoma (685.68) and Merkel cell carcinoma (117.23). The high systematic bidirectional risks between immune responsive skin cancers and most other cancers suggest that immune suppression is a key mechanism contributing to an increased risk of SPCs.

High melanoma risk in non-melanoma skin cancer patients under age 40: a large retrospective cohort study

BACKGROUND

Patients with a history of non-melanoma skin cancer (NMSC) are at increased risk for other primary cancers, in particular for cutaneous melanoma. However, rarely such studies are able to identify age-specific risks due to the lack of statistical power. The aim of this study was to compare the risk of melanoma development within age groups in a large cohort of NMSC patients and in a control group of non-dermatological patients.

METHODS

A retrospective linkage analysis was performed between records of hospitalizations and the occurrence of melanoma was compared within 10-year age group by computing the relative risk (RR) and modeled using multiple logistic regression.

RESULTS

The linkage procedures identified 30,929 individuals with NMSC and 25,956 control patients. Overall, NMSC patients had RR for melanoma of 6.2 compared to controls. Patients with NMSC and less than 40 years of age have a RR of melanoma of 25.1 compared to controls. Our study is a retrospective analysis, and our ICD-9 codes do not distinguish between basal cell carcinoma and squamous cell carcinoma, nor between subtypes of melanoma.

CONCLUSIONS

Our large study suggests that prevention of melanoma in NMSC patients is mandatory, especially for patients which develop a NMSC under 40 years of age.

A panel of biomarkers for skin squamous cell carcinoma: various functional entities and differential responses to resveratrol

In contrast to the highly malignant melanoma, skin squamous cell carcinoma (SCC) usually presents with lower morbidity. However, its incidence has been alarmingly rising worldwide and is a public health burden, let alone the current SCC cancer classification scheme is inadequate. Due to its features of progressing along different pathologic stages, early detection of precancerous lesions with accurate molecular markers would be desirable for cancer prevention and treatment. In the present study, using immunohistochemical staining of 85 clinical samples, we profiled the expression of a panel of ten proteins from five functional divisions implicated in SCC development, i.e. cytokeratins, intercellular molecules, chaperone proteins, transcription factors, and mitochondrial redox enzymes. The differential alterations of the proteins in SCC cell lines SCL12 and COLO16, upon resveratrol therapy, were also examined by immunocytochemistry (ICC). Our data reveal that, while all these proteins show significant correlation with cancer initiation and/or progression, a comprehensive panel encompassing a range of biologic functions, instead of a single marker, will provide prognostic value in SCC diagnosis and management. Additionally, the strong correlation among the proteins with cancer stages implies their distinct roles in SCC pathogenesis and contributions to the therapeutic effects of resveratrol, which is demonstrated in the resveratrol-sensitive COLO16 cells, but not in the resveratrol-resistant SCL12 cells.

Risk factors for development of new skin neoplasms in patients with past history of skin cancer: A survival analysis

We conducted a retrospective study aiming to assess the risk, and associated risk factors, of developing subsequent skin cancers after having a first diagnosis of skin cancer. We included all patients with biopsy-proven skin cancer attending a dermatology clinic between July 2007 and July 2017. We assessed the frequency of new skin cancers, as well as potential demographic and clinical factors significantly associated with occurrence of such neoplasms, that were identified by means of a survival analysis. We analyzed 969 patients with a total of 1584 skin neoplasms (1122 basal cell carcinomas (BCC), 310 squamous cell carcinomas (SCC), 143 melanomas and 9 other neoplasms). 165 patients (17.0%) developed subsequent skin neoplasms. Factors identified in multivariable models to be significantly associated with development of new skin cancers included older age (adjusted HR = 1.04 per year; 95%CI = 1.02-1.05; p < 0.001), and presence of synchronous neoplasms (adjusted HR = 2.25; 95%CI = 1.61-3.14; p < 0.001). Having a history of a BCC was significantly associated with development of new BCC (adjusted HR = 1.63; 95%CI = 1.05-2.54; p = 0.030), while having a previous SCC was associated with occurrence of subsequent SCC (adjusted HR = 3.60; 95%CI = 1.93-6.72; p < 0.001). These findings point to the importance of careful follow-up (e.g., skin self-examination and full body examination) of skin cancer patients.

Clinically amelanotic or hypomelanotic melanoma: Anatomic distribution, risk factors, and survival

BACKGROUND

The recognition and diagnosis of clinically amelanotic or hypomelanotic melanoma is a challenge.

OBJECTIVE

This study aimed to examine the anatomic distribution and risk factors associated with clinically amelanotic or hypomelanotic melanoma and compare the survival of patients with clinically amelanotic or hypomelanotic melanoma with that of patients with pigmented melanoma.

METHODS

A prospective cohort study of all cases of primary invasive melanoma managed at a tertiary referral center was performed.

RESULTS

There were a total of 3913 invasive melanomas, and 384 (9.8%) were clinically amelanotic or hypomelanotic. Skin phototype I; red as well as blonde hair color; actinic keratoses; nodular, desmoplastic, and lentigo maligna subtype; increased Breslow thickness; and mitoses were independently associated with amelanotic or hypomelanotic melanoma (P < .05). After adjustment for subtype and thickness, the face, ears, lateral aspect of the neck, upper portion of the arm, posterior aspect of the forearm, dorsal aspect of the hand, and anterior aspect of the lower portion of the leg were associated with increased odds of amelanotic or hypomelanotic melanoma when compared with the upper portion of the back (P < .05). Mortality risk from melanoma appeared greater for amelanotic or hypomelanotic melanoma than for pigmented melanoma (hazard ratio, 1.5; 95% confidence interval, 1.1-2.1) but was similar once Breslow thickness was taken into account.

LIMITATIONS

Single tertiary referral center.

CONCLUSION

Although clinically amelanotic or hypomelanotic melanoma can occur on all body sites, it is more common on chronically sun-exposed areas. Clinicians should have an increased index of suspicion in patients with a sun-sensitive skin phenotype, red hair, and associated actinic keratoses.

Red meat and processed meat intake and risk for cutaneous melanoma in white women and men: Two prospective cohort studies

BACKGROUND

Red and processed meat consumption has been associated with increased risk for several cancers, but the association with cutaneous melanoma risk has been inconclusive.

OBJECTIVE

To investigate the association between red and processed meat intake and melanoma risk.

METHODS

Dietary information was assessed by using food frequency questionnaires in 2 prospective cohorts: 75,263 women from the Nurses' Health Study (1984-2010) and 48,523 men from the Health Professionals Follow-up Study (1986-2010). Melanoma cases were confirmed by reviewing pathology records. Pooled multivariable hazard ratios and 95% confidence intervals were estimated by using Cox proportional hazards models.

RESULTS

A total of 679 female and 639 male melanoma cases were documented during follow-up. Red and processed meat intake was inversely associated with melanoma risk (P = .002 for trend); the pooled hazard ratios (95% confidence intervals) of the 2 cohorts were 1.00 (reference), 1.00 (0.87-1.14), 0.98 (0.86-1.13), 0.89 (0.77-1.02), and 0.81 (0.70-0.95) for increasing quintiles of intake.

LIMITATIONS

Findings might have limited generalizability, considering that the cohorts were limited to white health professionals.

CONCLUSION

Red and processed meat intake was inversely associated with melanoma risk in these 2 cohorts.

Personal history of keratinocyte carcinoma is associated with reduced risk of death from invasive melanoma in men

BACKGROUND

Previous studies have found an increased risk for invasive cutaneous melanoma (CM) among those with a history of keratinocyte carcinoma (KC).

OBJECTIVE

The aim of this study was to evaluate the risk of CM death after KC.

METHODS

The study was based on the Health Professionals Follow-up Study. A Cox proportional hazards model was used to examine the hazard ratio (HR) of death due to CM associated with personal history of KC among the entire study population (primary analysis) and among participants with invasive CM (secondary analysis), respectively.

RESULTS

We documented a total of 908 participants with invasive CM over a total of 0.7 million person-years of follow-up. Among all participants, the risk for development of either lethal or nonlethal invasive CM increased for those with a history of KC. The risk for death due to melanoma based on KC history was not significantly increased, with an HR of 1.53 (95% confidence interval, 0.95-2.46). In the case-only analysis, those with a history of KC had a significantly lower risk for death due to melanoma than those with no such history (HR, 0.60; 95% confidence interval, 0.35-0.94).

LIMITATIONS

Because the population covered by the Health Professionals Follow-up Study consists exclusively of male health professionals, the results of this study may not be extended to the entire population.

CONCLUSION

Personal history of KC is associated with a decreased risk for melanoma-specific death among male patients with invasive CM.

All-cause mortality in patients with basal and squamous cell carcinoma: A systematic review and meta-analysis

BACKGROUND

There are varying reports of the association of basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (SCC) with mortality.

OBJECTIVE

To synthesize the available information on all-cause mortality after a diagnosis of BCC or SCC in the general population.

METHODS

We searched PubMed (1966-present), Web of Science (1898-present), and Embase (1947-present) and hand-searched to identify additional records. All English articles that reported all-cause mortality in patients with BCC or SCC were eligible. We excluded case reports, case series, and studies in subpopulations of patients. Random effects model meta-analyses were performed separately for BCC and SCC.

RESULTS

The searches yielded 6538 articles, and 156 were assessed in a full-text review. Twelve studies met the inclusion criteria, and 4 were included in the meta-analysis (encompassing 464,230 patients with BCC and with 175,849 SCC), yielding summary relative mortalities of 0.92 (95% confidence interval, 0.83-1.02) in BCC and 1.25 (95% confidence interval, 1.17-1.32) in SCC.

LIMITATIONS

Only a minority of studies controlled for comorbidities. There was significant heterogeneity in meta-analysis (χ2P < .001, I2 > 98%), but studies of SCC were qualitatively concordant: all showed statistically significant increased relative mortality.

CONCLUSIONS

We found that patients with SCC are at higher risk for death from any cause compared with the general population.

Guidelines of care for the management of cutaneous squamous cell carcinoma

Cutaneous squamous cell carcinoma (cSCC) is the second most common form of human cancer and has an increasing annual incidence. Although most cSCC is cured with office-based therapy, advanced cSCC poses a significant risk for morbidity, impact on quality of life, and death. This document provides evidence-based recommendations for the management of patients with cSCC. Topics addressed include biopsy techniques and histopathologic assessment, tumor staging, surgical and nonsurgical management, follow-up and prevention of recurrence, and management of advanced disease. The primary focus of these recommendations is on evaluation and management of primary cSCC and localized disease, but where relevant, applicability to recurrent cSCC is noted, as is general information on the management of patients with metastatic disease.

Carcinoembryonic Antigen Serum Levels in Nonmelanoma Skin Cancer

Background: Carcinoembryonic antigen (CEA) is a glycoprotein, which is present in the foetal colon, some benign conditions and different malignancies, particularly in colon adenocarcinoma. We focused this study on non-melanoma skin cancer (NMSC). NMSC is a common malignancy and it is an important source of morbidity and death in the world. In this study we evaluated whether CEA level increases in NMSC. Patients and Methods: A total of 566 patients with non-melanoma skin cancer (NMSC) were enrolled; 286 patients with NMSC showed CEA levels above normal values, and 280 showed CEA levels below normal values. Patients with high levels of CEA underwent abdominal ultrasound, gastro endoscopy, colonoscopy, and abdominal CT scans. Results: We studied 566 patients, 286 were positive to CEA and 280 were negative. Of the 286 patients positive to CEA, 132 had basal cell carcinoma (64 patients had an associated cancer) and 154 had squamous cell carcinoma (75 patients were affected by cancer). Of the 280 patients negative to CEA, 130 had basal cell carcinoma (12 were associated with cancer), and 150 had squamous cell carcinoma (18 were associated with cancer). The mean age of the 566 case control subjects were 65–81 years. Of the 10 subjects that were the positive control for CEA, two had cancer. Of the 556 subjects that were the negative control for CEA, three had cancer. Conclusions: In patients that present high serum levels of CEA, we give attention to adenocarcinoma tumour first. The pattern of association may be attributable to bias because the group with NMSC were frequently evaluated than those with no history of NMSC. Our results showed that out of 286 patients that were CEA-positive, 139 had cancer, and of the 280 that were CEA-negative, 30 had cancer. Therefore, 20% of patients do not follow the trend. Other markers should be investigated.

Use of antihypertensive drugs and risk of keratinocyte carcinoma: A meta-analysis of observational studies

PURPOSE

Current epidemiologic evidence on the association between antihypertensive drugs and keratinocyte carcinoma (KC) risk is inconsistent. We sought to quantify this association by meta-analysis of observational studies.

METHODS

We systematically reviewed observational studies published through August 2016 and reported the KC risk (basal cell carcinoma [BCC] and squamous cell carcinoma [SCC]) associated with antihypertensive drugs, including diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-adrenergic blocking agents (β-blockers), and calcium channel blockers (CCBs). Random-effects meta-analysis was used to estimate the odds ratio (OR) with 95% confidence interval (CI).

RESULTS

Ten eligible studies were included. Compared with nonuse, diuretic use was significantly associated with increased risk of both BCC (OR, 1.10; 95% CI, 1.01-1.20) and SCC (OR, 1.40; 95% CI, 1.19-1.66). Use of β-blockers or CCBs was associated with increased risk of BCC (but not SCC); the OR with β-blockers was 1.09 (95% CI, 1.04-1.15) and with CCBs was 1.15 (95% CI, 1.09-1.21). Use of ACE inhibitors or ARBs was associated with decreased risk of both BCC (OR, 0.53; 95% CI, 0.39-0.71) and SCC (OR, 0.58; 95% CI, 0.42-0.80) in high-risk individuals.

CONCLUSIONS

Current evidence indicates that use of diuretics might be associated with increased risk of KC, while ACE inhibitors or ARBs might be associated with decreased risk in high-risk individuals. β-blockers or CCBs might be positively associated with BCC risk. Further postmarketing surveillance studies and investigations to clarify the possible underlying mechanisms are warranted.

Skin diseases in indigenous population: retrospective epidemiological study at Xingu Indigenous Park (XIP) and review of the literature

BACKGROUND

Skin diseases among indigenous populations have been poorly described in the literature. Risk factors linked to habits, cultural practices, genetics, and environmental characteristics can influence the frequency and clinical presentation of these diseases.

METHODS

This was a cross-sectional study conducted through a review of dermatological medical records. Data were obtained over three visits to Xingu Indigenous Park (XIP). Main dermatoses were compared by gender, age, ethnicity, and village. Diseases were classified into four groups: infectious, inflammatory, neoplastic, and other.

RESULTS

Of the 398 patients included in the study, 54.2% were female. The participants ranged in age from 1 to 75 years (median, 10 years). The predominant ethnic group was Caiabi (49.7%), followed by Ikpeng (14.3%) and Kamaiurá (10.0%). The primary village studied was Diauarum, followed by Moigú and Morena. Infectious dermatoses were the most frequent (43.8%), followed by inflammatory (33.7%), neoplastic (15.5%), and other skin diseases (7.0%). Infectious diseases were predominant in Caiabi and Kamaiurá Indians, whereas inflammatory skin diseases were more frequent in Ikpeng and Juruna populations. We also observed a high frequency of malignancy in the Ikpeng and Trumai ethnic groups. Infectious skin diseases, except for fungal infections, were frequent in younger age groups. This trend was not replicated for neoplastic skin diseases. Uncommon dermatoses such as Heck's disease, lichen striatus, and aquagenic urticaria were also observed. Jorge Lobo's disease was not included in this analysis.

CONCLUSION

Improved knowledge of the distribution of common dermatoses among different ethnic groups and villages in XIP will aid in the prevention of skin infections and skin cancer. This improved knowledge will also allow the development of skin disease guidelines that can help local indigenous health professionals.

Risk of Second Malignancies in Solid Organ Transplant Recipients Who Develop Keratinocyte Cancers

Solid organ transplant recipients have increased risk for developing keratinocyte cancers, including cutaneous squamous cell carcinoma (SCC) and basal cell carcinoma (BCC), in part as a result of immunosuppressive medications administered to prevent graft rejection. In the general population, keratinocyte cancers are associated with increased risks of subsequent malignancy, however, the risk in organ transplant populations has not been evaluated. We addressed this question by linking the U.S. Scientific Registry of Transplant Recipients, which includes data on keratinocyte cancer occurrence, with 15 state cancer registries. Risk of developing malignancies after keratinocyte cancer was assessed among 118,440 Caucasian solid organ transplant recipients using multivariate Cox regression models. Cutaneous SCC occurrence (n = 6,169) was associated with 1.44-fold increased risk [95% confidence interval (CI), 1.31-1.59] for developing later malignancies. Risks were particularly elevated for non-cutaneous SCC, including those of the oral cavity/pharynx (HR, 5.60; 95% CI, 4.18-7.50) and lung (HR, 1.66; 95% CI, 1.16-2.31). Cutaneous SCC was also associated with increased risk of human papillomavirus-related cancers, including anal cancer (HR, 2.77; 95% CI, 1.29-5.96) and female genital cancers (HR, 3.43; 95% CI, 1.44-8.19). In contrast, BCC (n = 3,669) was not associated with overall risk of later malignancy (HR, 0.98; 95% CI, 0.87-1.12), including any SCC. Our results suggest that transplant recipients with cutaneous SCC, but not BCC, have an increased risk of developing other SCC. These findings somewhat differ from those for the general population and suggest a shared etiology for cutaneous SCC and other SCC in the setting of immunosuppression. Cutaneous SCC occurrence after transplantation could serve as a marker for elevated malignancy risk. Cancer Res; 77(15); 4196-203. ©2017 AACR.

History of Keratinocyte Carcinoma and Risk of Melanoma: A Prospective Cohort Study

Background

The association between history of keratinocyte carcinoma (KC, also known as nonmelanoma skin cancer) and risk of developing invasive melanoma has not been assessed comprehensively using prospective data.

Methods

We followed 91 846 women in the Nurses' Health Study (NHS; 1984-2010), 114 918 women in the NHSII (1989-2011), and 48 946 men in the Health Professionals Follow-up Study (1986-2010) for diagnoses of KC and melanoma biennially. Cox proportional hazards models were used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) of melanoma associated with history of KC, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC). All statistical tests were two-sided.

Results

We documented 1949 melanomas, 38 842 BCCs, and 7462 SCCs over 6.4 million person-years of follow-up. After adjustment for other risk factors, a personal history of KC was associated with an increased risk of melanoma (meta-analysis HR = 2.22, 95% CI = 1.73 to 2.85). The association was more apparent among participants with a history of both BCC and SCC (HR = 3.40, 95% CI = 1.60 to 7.19) than among participants with a history of BCC only (HR = 2.20, 95% CI = 1.80 to 2.70) or SCC only (HR = 1.56, 95% CI = 0.98 to 2.46), and there was a strong risk-increasing trend associated with a higher number of reported KCs removed by surgery ( P trend < .001). In women, KC history was more strongly associated with head/neck melanomas (HR = 4.17, 95% CI = 2.77 to 6.27) than with trunk or limb melanomas (both HRs < 2.50, P heterogeneity = .04).

Conclusions

Our results provide novel insights for the relationship between KC history and risk of developing melanoma, which may be important for melanoma prevention.

The association between ambient fine particulate matter and incident adenocarcinoma subtype of lung cancer

BACKGROUND

Adenocarcinoma (AC) is the most common lung cancer among non-smokers, but few studies have assessed the effect of PM_2.5 on AC among never smokers. The purpose of this study was to assess the association between ambient PM_2.5 and incident lung AC in the Adventist Health and Smog Study-2 (AHSMOG-2), a cohort of 80,044 non-smokers (81% never smokers) followed for 7.5 years (597,177 person-years) (2002-2011).

METHODS

Incident lung AC was identified through linkage with U.S. state cancer registries. Ambient PM_2.5 levels at subjects' residences were estimated for the years 2000 and 2001, immediately prior to study start.

RESULTS

A total of 164 incident lung AC occurred during follow-up. Each 10 μg/m³ increment in PM_2.5 was associated with an increase in the hazard rate of lung AC [HR = 1.31 (95% confidence interval (CI) 0.87-1.97)] in the single-pollutant model. Excluding those with prevalent non-melanoma skin cancer (NMSC) strengthened the association with lung AC (HR = 1.62 (95% CI, 1.11-2.36) for each 10 μg/m³ PM_2.5 increment. Also, limiting the analyses to subjects who spent more than 1 h/day outdoors, increased the estimate (HR = 1.55, 95% CI: 1.05, 2.30).

CONCLUSIONS

Increased risk of AC was observed for each 10 μg/m³ increment in ambient PM_2.5 concentrations. The risk was higher among those without prevalent NMSC and those who spent more than 1 h/day outdoors.

Risk of second primary cancer associated with pre-diagnostic smoking, alcohol, and obesity in women with keratinocyte carcinoma

Keratinocyte carcinoma (KC), which includes basal-cell carcinoma (BCC) and squamous-cell cancer (SCC), has been associated with an increased risk of second primary cancers (SPCs), although the reason for this increase is unknown. We assessed the effects of smoking, alcohol, and obesity prior to the diagnosis of KC on the development of SPCs, as these are well-established risk factors for multiple cancers and may also contribute to the increased risk of SPCs among those with KC. A total of 15,628 women with self-reported KC were identified in the Nurses' Health Study. Incident SPCs were assessed throughout the follow-up until June 2012. Cox proportional hazards models were used to calculate the hazard ratios (HRs) of SPC associated with pre-diagnostic smoking, alcohol and body mass index (BMI). We also compared these risk estimates to those for first cancers in all cohort participants. During 193,695 person-years of follow-up, we recorded 2839 SPC cases. Compared with never smokers, current smokers had a significantly elevated risk for SPC overall and specifically for lung, colorectal, and bladder cancers. We also found a positive association between higher BMI and risk for SPC overall as well as for endometrial and bladder SPCs. Women with KC who consumed alcohol ≥30g/day had a marginally higher risk of SPC compared to non-drinkers. The associations between incident SPC risk among KC cases and smoking, alcohol, and obesity appeared similar to the associations between these risk factors and the incident first primary cancers in the whole cohort. Only in the heavy smoking (≥25 cigarettes/day) category was the HR for SPC after KC (2.34; 95% CI 1.98-2.76) slightly higher than that for the first cancer in the overall cohort (HR 1.86; 95% CI 1.75-1.98, P_{heterogeneity}=0.01). In conclusion, pre-diagnostic smoking, alcohol and obesity prior to KC diagnosis were associated with risk of SPCs.

Noncardiovascular deaths are more common than cardiovascular deaths in patients with cardiovascular disease or cardiovascular risk factors and impaired glucose tolerance: Insights from the Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research (NAVIGATOR) trial

BACKGROUND

Patients with impaired glucose tolerance have an elevated risk of cardiovascular (CV) death; however, the causes and risk factors associated with non-CV deaths are poorly understood.

METHODS

The NAVIGATOR trial enrolled 9,306 participants with impaired glucose tolerance and CV disease or at high CV risk, with a median follow-up of 6.4years. Using this population, we identified (1) the proportion of deaths attributed to CV, non-CV, and unknown causes, and (2) the risk factors associated with non-CV death.

RESULTS

During the NAVIGATOR trial follow-up, 622 patients died. Investigators reported 244 (39.2%) CV deaths, 313 (50.3%) non-CV deaths, and 65 (10.5%) deaths of unknown cause. Myocardial infarction was the leading cause of investigator-reported death (57/622 [9.2%]). Among non-CV deaths, the most commonly identified cause related to malignancy (177/313 [56.5%]). Using adjudicated causes of death, Cox proportional hazard models identified 3 independent prognostic markers that increased the risk of non-CV death: history of non-melanoma skin cancer (hazard ratio 2.67 [95% CI 1.65-4.33]; P<.0001), white blood cell count (1 unit >5000/mm³; 1.10 [1.02-1.18]; P=.011), and serum potassium levels (per 1mmol/L above any value; 1.67 [1.302.15]; P<.0001).

CONCLUSIONS

Despite the high baseline CV risk among patients in the NAVIGATOR trial, the most common cause of death was non-CV. The high burden of non-CV death in this population has potential implications for future CV event-driven trials.

Sunburn and sun-protective behaviors among adults with and without previous nonmelanoma skin cancer (NMSC): A population-based study

BACKGROUND

Individuals with previous nonmelanoma skin cancer (NMSC) are at increased risk for subsequent skin cancer, and should therefore limit ultraviolet exposure.

OBJECTIVE

We sought to determine whether individuals with previous NMSC engage in better sun protection than those with no skin cancer history.

METHODS

We pooled self-reported data (2005 and 2010 National Health Interview Surveys) from US non-Hispanic white adults (758 with and 34,161 without previous NMSC). We calculated adjusted prevalence odds ratios (aPOR) and 95% confidence intervals (CI), taking into account the complex survey design.

RESULTS

Individuals with previous NMSC versus no history of NMSC had higher rates of frequent use of shade (44.3% vs 27.0%; aPOR 1.41; 95% CI 1.16-1.71), long sleeves (20.5% vs 7.7%; aPOR 1.55; 95% CI 1.21-1.98), a wide-brimmed hat (26.1% vs 10.5%; aPOR 1.52; 95% CI 1.24-1.87), and sunscreen (53.7% vs 33.1%; aPOR 2.11; 95% CI 1.73-2.59), but did not have significantly lower odds of recent sunburn (29.7% vs 40.7%; aPOR 0.95; 95% CI 0.77-1.17). Among those with previous NMSC, recent sunburn was inversely associated with age, sun avoidance, and shade but not sunscreen.

LIMITATIONS

Self-reported cross-sectional data and unavailable information quantifying regular sun exposure are limitations.

CONCLUSION

Physicians should emphasize sunburn prevention when counseling patients with previous NMSC, especially younger adults, focusing on shade and sun avoidance over sunscreen.

Incidence of eyelid basal cell carcinoma in England: 2000-2010

INTRODUCTION

Basal cell carcinomas (BCCs) are the most frequently diagnosed type of skin cancer, with eyelid (including canthus) BCCs accounting for a notable proportion of these. Using population-based data from the English Cancer Registries, we report here the incidence of eyelid BCCs in England, for the period 2000-2010.

METHODS

ICD-10 and histology codes for eyelid BCCs (including canthus) from the English National Cancer Data Repository were used to identify incident events. Crude incidence rates by age and sex, together with directly standardised incidence rates for eyelid BCCs in England in 3-year cohorts, are presented, in keeping with the reporting practice of the English Cancer Registries.

RESULTS

Over the 11-year study period, there were a total of 33 610 recorded eyelid BCCs; 18 146 in females and 15 464 in males. There were regional variations in registrations. Incidence of eyelid BCCs increased with age. No major change in the age-standardised incidence of BCC was observed during the period 2000-2010. Overall, the age-standardised incidence of BCCs during 2008-2010 was similar for males and females (4.51 per 100 000 (95% CI 4.37 to 4.65) and 4.53 per 100 000 (95% CI 4.40 to 4.67), respectively). However, females under 50 years of age had higher incidence rates, and males over 75 years of age had higher rates.

CONCLUSIONS

The findings provide the current frequency and distribution of eyelid BCCs in England, highlighting opportunities for health education and improving reporting and registration of events, and for informing service planning.

Keratinocyte Carcinoma as a Marker of a High Cancer-Risk Phenotype

Keratinocyte carcinoma (KC) (also referred to as nonmelanoma skin cancer) is by far the most common form of human cancer. A personal history of KC is well established to be associated with increased risk of recurrent KC and malignant melanoma, a less common yet more fatal form of skin cancer. More surprising is that a substantial body of epidemiologic evidence now indicates that a personal history of KC is significantly associated with an overall elevated risk of noncutaneous malignancies. This association is not limited to one or a few types of cancer but applies across many different types of malignancy. This association has been consistently observed in prospective studies across genders for both major histologic types of KC, basal cell carcinoma and squamous cell carcinoma. The risk of other cancers has been even stronger in those with younger compared with older age of onset of KC. A robust body of evidence lends support to the notion that KC may be a marker of a high cancer-risk phenotype. The underlying mechanisms for this association remain to be elucidated, but the cross-cutting nature of this association across numerous malignancies suggests that research to uncover these mechanisms is a promising line of inquiry that could potentially yield valuable insight into human carcinogenesis.

An Evaluation of Root Phytochemicals Derived from Althea officinalis (Marshmallow) and Astragalus membranaceus as Potential Natural Components of UV Protecting Dermatological Formulations

As lifetime exposure to ultraviolet (UV) radiation has risen, the deleterious effects have also become more apparent. Numerous sunscreen and skincare products have therefore been developed to help reduce the occurrence of sunburn, photoageing, and skin carcinogenesis. This has stimulated research into identifying new natural sources of effective skin protecting compounds. Alkaline single-cell gel electrophoresis (comet assay) was employed to assess aqueous extracts derived from soil or hydroponically glasshouse-grown roots of Althea officinalis (Marshmallow) and Astragalus membranaceus, compared with commercial, field-grown roots. Hydroponically grown root extracts from both plant species were found to significantly reduce UVA-induced DNA damage in cultured human lung and skin fibroblasts, although initial Astragalus experimentation detected some genotoxic effects, indicating that Althea root extracts may be better suited as potential constituents of dermatological formulations. Glasshouse-grown soil and hydroponic Althea root extracts afforded lung fibroblasts with statistically significant protection against UVA irradiation for a greater period of time than the commercial field-grown roots. No significant reduction in DNA damage was observed when total ultraviolet irradiation (including UVB) was employed (data not shown), indicating that the extracted phytochemicals predominantly protected against indirect UVA-induced oxidative stress. Althea phytochemical root extracts may therefore be useful components in dermatological formulations.