Opinion
EDITORIAL
How Likely Is Another Nonmelanoma Skin Cancer? Better Informing Patients and Clinicians Peggy A. Wu, MD, MPH; Robert S. Stern, MD
Among white non-Hispanics older than 50 years, nonmelanoma skin cancer (NMSC) incidence is likely to exceed 3.5 million annually in the United States.1 From a clinical and public health perspective, identifying the characteristics of those at the highest Related article page 382 risk would allow allocating limited resources to screen those most at need. Those with a prior NMSC are known to be at high risk, but data on the magnitude of and patient characteristics related to this risk are particularly important in deciding how these patients should be monitored. The United States Preventive Services Task Force (USPTF) and the National Cancer Institute (NCI) do not recommend skin cancer screening for all at-risk persons. The number of persons at risk for NMSC greatly exceeds the total number of visits each year to dermatologists. With a prevalence exceeding 13 million persons with a history of at least 1 NMSC,2 current annual screening of patients with a history of NMSC would alone account for more than one-third of visits to dermatologists.3,4 In this issue of JAMA Dermatology, Wehner et al5 provide data that help to identify patients at highest risk for subsequent NMSCs and highlight additional information needed to rationally direct resources for monitoring patients with this history. This study of 1284 immunocompetent patients with NMSC treated at a university academic practice and the San Francisco Veterans Administration assessed timing of subsequent basal cell cancer (BCC) or squamous cell cancer (SCC). Patients were followed up for an average of 5.7 years (0-12.3 years). Basal cell cancers (1234 [75.6%]) were more common than SCCs (399 [24.4%]). The authors found that the risk of a subsequent SCC or BCC occurring within 2 years of the first tumor was 41%, half as great as the risk after a non-first BCC or SCC (81%). For those who had a BCC at study entry and remained tumor free for 2 years, the incidence of BCC in subsequent years was relatively low, less than 5% per year. For comparable patients with SCC, the development of another SCC after year 2 was almost twice as high (data supporting this finding are reported by Wehner et al5 in their online supplemental materials). Subsequent tumors were usually of the same types: only 5.1% of the study cohort subsequently developed both BCCs and SCCs. These findings support those of prior studies indicating that patients tend to develop a single type of NMSC.6,7 Although the incidence of SCC is lower than that of BCC, the risk of developing a second tumor of the same type was higher in SCC: 69% of those with 1 SCC developed at least 1 adjamadermatology.com
ditional tumor. Over half of the patients who had multiple SCCs were likely to develop another SCC within 2 years (Wehner et al,5 online supplemental materials). Given the higher morbidity and the risk of mortality with SCCs, closely monitoring patients with SCCs is clearly indicated. According to the findings of this study, about 12 patients with SCC would have to be screened each year to detect another SCC. For persons with a single BCC, a second BCC will be detected for about every 20 patients screened annually.5 In a similar study of the Dutch population, slightly higher numbers of persons with a BCC would need to be screened to detect another BCC.8 These risk and incidence estimates are in line with results from previous publications on subsequent NMSCs in patients with a history of NMSC.7 Both Australian and Dutch data suggest fairly long median intervals between new tumors (1.5 to ≥2 years).8,9 Reflecting this observation, Dutch guidelines suggest yearly follow-up only for patients with an SCC, 2 or more BCCs, or a BCC in a high-risk zone.8 The National Comprehensive Cancer Network (NCCN) recommends that every patient with a history of low-risk BCC or SCC be screened with skin examinations every 6 to 12 months for life.10 The data from this and prior studies combined with the high incidence of BCC suggest that the wisdom and feasibility of such a recommendation is in doubt. With an increased number of screenings, a higher proportion of BCCs is likely to be detected in sites other than the head and neck, forearms, and hands—areas such as the trunk, where superficial BCCs are the most common histologic subtype.11 The magnitude of benefit of earlier detection of slowgrowing asymptomatic tumors in less cosmetically sensitive areas is not clear.12 The frequency with which screenings will allow clinicians to detect a subsequent BCC of the head and neck or hands sooner (or later, due to waiting for the annual appointment) than it would otherwise be detected by an educated patient with a prior BCC is also uncertain. Nor is it known the extent to which regular dermatologic examinations for patients who have gone 2 years without a subsequent BCC result in earlier detection and better outcomes. For patients who remain tumor free for 2 years after the first BCC and who are likely to recognize a subsequent tumor, further follow-up may not provide much value. About two-thirds of BCCs occur on the head and neck.5,8,13 The authors did not analyze the association of anatomic site or histologic subtype on the first and subsequent NMSCs. This information could be useful to practitioners and patients in targeting areas for surveillance and identifying suspect lesions that could be NMSC. (Reprinted) JAMA Dermatology April 2015 Volume 151, Number 4
Copyright 2015 American Medical Association. All rights reserved.
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369
Opinion Editorial
One potential benefit of regular dermatologic examination of patients with a history of NMSC is the detection of melanoma. In this study population, the standardized incidence ratio for invasive melanoma was 2.97 (95%, CI, 2.86-4.50; e-mail communication from Mary-Margaret Chren, MD, October 23, 2014). Whether this magnitude of increased risk justifies annual or more frequent screening for melanoma is not clear. In an ideal world, we would be able to identify patients with a history of NMSC who are at the highest risk for subsequent NMSC that are likely to result in substantial morbidity. With this information, we could more efficiently target counseling and screening efforts. The study by Wehner et al5 provides corroboration that subsequent NMSCs are likely to be of the same ARTICLE INFORMATION Author Affiliations: Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Corresponding Author: Peggy A. Wu, MD, MPH, Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, GZ522, Boston, MA 02215 ([email protected]). Published Online: January 14, 2015. doi:10.1001/jamadermatol.2014.3827. Conflict of Interest Disclosures: None reported. REFERENCES 1. American Cancer Society. What are the key statistics about basal and squamous cell skin cancer? http://www.cancer.org/cancer/skincancer -basalandsquamouscell/detailedguide/skin -cancer-basal-and-squamous-cell-key-statistics. Accessed October 20, 2014. 2. Stern RS. Prevalence of a history of skin cancer in 2007: results of an incidence-based model. Arch Dermatol. 2010;146(3):279-282. 3. Rogers HW, Weinstock MA, Harris AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol. 2010; 146(3):283-287.
370
type as the index NMSC and reassures us that those patients who have remained free of a subsequent tumor for 2 years following a BCC are at relatively low risk. Data from this study conducted in San Francisco5 and from others conducted in Australia9 and the Netherlands8 suggest that the risk of subsequent tumors is higher in geographic areas with higher overall NMSC incidence.8,9 Further studies are needed to more precisely define the risk, site, and type of subsequent tumors in relation to the location and characteristics of the index tumor, sun exposure history, and age, sex, phenotype, and other characteristics of the patient. Armed with this information, we can provide rational and efficient follow-up care for those with a history of NMSC.
4. Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey Factsheet: Dermatology. http://www.cdc.gov/nchs /data/ahcd/NAMCS_2010_factsheet_dermatology .pdf. Accessed October 1, 2014. 5. Wehner MR, Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Chren M-M. Timing of subsequent new tumors in patients who present with basal cell carcinoma or cutaneous squamous cell carcinoma [published online January 14, 2015]. JAMA Dermatol. doi:10.1001/jamadermatol.2014.3307. 6. Karagas MR, Stukel TA, Greenberg ER, Baron JA, Mott LA, Stern RS; Skin Cancer Prevention Study Group. Risk of subsequent basal cell carcinoma and squamous cell carcinoma of the skin among patients with prior skin cancer. JAMA. 1992;267 (24):3305-3310. 7. Marcil I, Stern RS. Risk of developing a subsequent nonmelanoma skin cancer in patients with a history of nonmelanoma skin cancer: a critical review of the literature and meta-analysis. Arch Dermatol. 2000;136(12):1524-1530. 8. Flohil SC, Koljenović S, de Haas ER, Overbeek LI, de Vries E, Nijsten T. Cumulative risks and rates of subsequent basal cell carcinomas in the Netherlands. Br J Dermatol. 2011;165(4):874-881.
Keratinocyte Skin Cancer: Evidence from an Australian Population-Based Cohort Study. J Invest Dermatol. 2014;(September). 10. Bichakjian CK, Olencki T, Alam M, et al. Basal Cell and Squamous Cell Skin Cancers, Version 2.2014: NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) [registration required]. http://www.nccn.org/professionals /physician_gls/PDF/nmsc.pdf. Accessed November 17, 2014. 11. Valery PC, Neale R, Williams G, Pandeya N, Siller G, Green A. The effect of skin examination surveys on the incidence of basal cell carcinoma in a Queensland community sample: a 10-year longitudinal study. J Investig Dermatol Symp Proc. 2004;9(2):148-151. 12. Linos E, Schroeder SA, Chren MM. Potential overdiagnosis of basal cell carcinoma in older patients with limited life expectancy. JAMA. 2014; 312(10):997-998. 13. Kiiski V, de Vries E, Flohil SC, et al. Risk factors for single and multiple basal cell carcinomas. Arch Dermatol. 2010;146(8):848-855.
9. Keim U, van der Pols JC, Williams GM, Green AC. Exclusive Development of a Single Type of
JAMA Dermatology April 2015 Volume 151, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a The University of Manchester Library User on 06/02/2015
jamadermatology.com
EDITORIAL
How Likely Is Another Nonmelanoma Skin Cancer? Better Informing Patients and Clinicians Peggy A. Wu, MD, MPH; Robert S. Stern, MD
Among white non-Hispanics older than 50 years, nonmelanoma skin cancer (NMSC) incidence is likely to exceed 3.5 million annually in the United States.1 From a clinical and public health perspective, identifying the characteristics of those at the highest Related article page 382 risk would allow allocating limited resources to screen those most at need. Those with a prior NMSC are known to be at high risk, but data on the magnitude of and patient characteristics related to this risk are particularly important in deciding how these patients should be monitored. The United States Preventive Services Task Force (USPTF) and the National Cancer Institute (NCI) do not recommend skin cancer screening for all at-risk persons. The number of persons at risk for NMSC greatly exceeds the total number of visits each year to dermatologists. With a prevalence exceeding 13 million persons with a history of at least 1 NMSC,2 current annual screening of patients with a history of NMSC would alone account for more than one-third of visits to dermatologists.3,4 In this issue of JAMA Dermatology, Wehner et al5 provide data that help to identify patients at highest risk for subsequent NMSCs and highlight additional information needed to rationally direct resources for monitoring patients with this history. This study of 1284 immunocompetent patients with NMSC treated at a university academic practice and the San Francisco Veterans Administration assessed timing of subsequent basal cell cancer (BCC) or squamous cell cancer (SCC). Patients were followed up for an average of 5.7 years (0-12.3 years). Basal cell cancers (1234 [75.6%]) were more common than SCCs (399 [24.4%]). The authors found that the risk of a subsequent SCC or BCC occurring within 2 years of the first tumor was 41%, half as great as the risk after a non-first BCC or SCC (81%). For those who had a BCC at study entry and remained tumor free for 2 years, the incidence of BCC in subsequent years was relatively low, less than 5% per year. For comparable patients with SCC, the development of another SCC after year 2 was almost twice as high (data supporting this finding are reported by Wehner et al5 in their online supplemental materials). Subsequent tumors were usually of the same types: only 5.1% of the study cohort subsequently developed both BCCs and SCCs. These findings support those of prior studies indicating that patients tend to develop a single type of NMSC.6,7 Although the incidence of SCC is lower than that of BCC, the risk of developing a second tumor of the same type was higher in SCC: 69% of those with 1 SCC developed at least 1 adjamadermatology.com
ditional tumor. Over half of the patients who had multiple SCCs were likely to develop another SCC within 2 years (Wehner et al,5 online supplemental materials). Given the higher morbidity and the risk of mortality with SCCs, closely monitoring patients with SCCs is clearly indicated. According to the findings of this study, about 12 patients with SCC would have to be screened each year to detect another SCC. For persons with a single BCC, a second BCC will be detected for about every 20 patients screened annually.5 In a similar study of the Dutch population, slightly higher numbers of persons with a BCC would need to be screened to detect another BCC.8 These risk and incidence estimates are in line with results from previous publications on subsequent NMSCs in patients with a history of NMSC.7 Both Australian and Dutch data suggest fairly long median intervals between new tumors (1.5 to ≥2 years).8,9 Reflecting this observation, Dutch guidelines suggest yearly follow-up only for patients with an SCC, 2 or more BCCs, or a BCC in a high-risk zone.8 The National Comprehensive Cancer Network (NCCN) recommends that every patient with a history of low-risk BCC or SCC be screened with skin examinations every 6 to 12 months for life.10 The data from this and prior studies combined with the high incidence of BCC suggest that the wisdom and feasibility of such a recommendation is in doubt. With an increased number of screenings, a higher proportion of BCCs is likely to be detected in sites other than the head and neck, forearms, and hands—areas such as the trunk, where superficial BCCs are the most common histologic subtype.11 The magnitude of benefit of earlier detection of slowgrowing asymptomatic tumors in less cosmetically sensitive areas is not clear.12 The frequency with which screenings will allow clinicians to detect a subsequent BCC of the head and neck or hands sooner (or later, due to waiting for the annual appointment) than it would otherwise be detected by an educated patient with a prior BCC is also uncertain. Nor is it known the extent to which regular dermatologic examinations for patients who have gone 2 years without a subsequent BCC result in earlier detection and better outcomes. For patients who remain tumor free for 2 years after the first BCC and who are likely to recognize a subsequent tumor, further follow-up may not provide much value. About two-thirds of BCCs occur on the head and neck.5,8,13 The authors did not analyze the association of anatomic site or histologic subtype on the first and subsequent NMSCs. This information could be useful to practitioners and patients in targeting areas for surveillance and identifying suspect lesions that could be NMSC. (Reprinted) JAMA Dermatology April 2015 Volume 151, Number 4
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a The University of Manchester Library User on 06/02/2015
369
Opinion Editorial
One potential benefit of regular dermatologic examination of patients with a history of NMSC is the detection of melanoma. In this study population, the standardized incidence ratio for invasive melanoma was 2.97 (95%, CI, 2.86-4.50; e-mail communication from Mary-Margaret Chren, MD, October 23, 2014). Whether this magnitude of increased risk justifies annual or more frequent screening for melanoma is not clear. In an ideal world, we would be able to identify patients with a history of NMSC who are at the highest risk for subsequent NMSC that are likely to result in substantial morbidity. With this information, we could more efficiently target counseling and screening efforts. The study by Wehner et al5 provides corroboration that subsequent NMSCs are likely to be of the same ARTICLE INFORMATION Author Affiliations: Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Corresponding Author: Peggy A. Wu, MD, MPH, Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, GZ522, Boston, MA 02215 ([email protected]). Published Online: January 14, 2015. doi:10.1001/jamadermatol.2014.3827. Conflict of Interest Disclosures: None reported. REFERENCES 1. American Cancer Society. What are the key statistics about basal and squamous cell skin cancer? http://www.cancer.org/cancer/skincancer -basalandsquamouscell/detailedguide/skin -cancer-basal-and-squamous-cell-key-statistics. Accessed October 20, 2014. 2. Stern RS. Prevalence of a history of skin cancer in 2007: results of an incidence-based model. Arch Dermatol. 2010;146(3):279-282. 3. Rogers HW, Weinstock MA, Harris AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol. 2010; 146(3):283-287.
370
type as the index NMSC and reassures us that those patients who have remained free of a subsequent tumor for 2 years following a BCC are at relatively low risk. Data from this study conducted in San Francisco5 and from others conducted in Australia9 and the Netherlands8 suggest that the risk of subsequent tumors is higher in geographic areas with higher overall NMSC incidence.8,9 Further studies are needed to more precisely define the risk, site, and type of subsequent tumors in relation to the location and characteristics of the index tumor, sun exposure history, and age, sex, phenotype, and other characteristics of the patient. Armed with this information, we can provide rational and efficient follow-up care for those with a history of NMSC.
4. Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey Factsheet: Dermatology. http://www.cdc.gov/nchs /data/ahcd/NAMCS_2010_factsheet_dermatology .pdf. Accessed October 1, 2014. 5. Wehner MR, Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Chren M-M. Timing of subsequent new tumors in patients who present with basal cell carcinoma or cutaneous squamous cell carcinoma [published online January 14, 2015]. JAMA Dermatol. doi:10.1001/jamadermatol.2014.3307. 6. Karagas MR, Stukel TA, Greenberg ER, Baron JA, Mott LA, Stern RS; Skin Cancer Prevention Study Group. Risk of subsequent basal cell carcinoma and squamous cell carcinoma of the skin among patients with prior skin cancer. JAMA. 1992;267 (24):3305-3310. 7. Marcil I, Stern RS. Risk of developing a subsequent nonmelanoma skin cancer in patients with a history of nonmelanoma skin cancer: a critical review of the literature and meta-analysis. Arch Dermatol. 2000;136(12):1524-1530. 8. Flohil SC, Koljenović S, de Haas ER, Overbeek LI, de Vries E, Nijsten T. Cumulative risks and rates of subsequent basal cell carcinomas in the Netherlands. Br J Dermatol. 2011;165(4):874-881.
Keratinocyte Skin Cancer: Evidence from an Australian Population-Based Cohort Study. J Invest Dermatol. 2014;(September). 10. Bichakjian CK, Olencki T, Alam M, et al. Basal Cell and Squamous Cell Skin Cancers, Version 2.2014: NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) [registration required]. http://www.nccn.org/professionals /physician_gls/PDF/nmsc.pdf. Accessed November 17, 2014. 11. Valery PC, Neale R, Williams G, Pandeya N, Siller G, Green A. The effect of skin examination surveys on the incidence of basal cell carcinoma in a Queensland community sample: a 10-year longitudinal study. J Investig Dermatol Symp Proc. 2004;9(2):148-151. 12. Linos E, Schroeder SA, Chren MM. Potential overdiagnosis of basal cell carcinoma in older patients with limited life expectancy. JAMA. 2014; 312(10):997-998. 13. Kiiski V, de Vries E, Flohil SC, et al. Risk factors for single and multiple basal cell carcinomas. Arch Dermatol. 2010;146(8):848-855.
9. Keim U, van der Pols JC, Williams GM, Green AC. Exclusive Development of a Single Type of
JAMA Dermatology April 2015 Volume 151, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a The University of Manchester Library User on 06/02/2015
jamadermatology.com
