Correspondence

References 1 Nannapaneni R, Behari S, Mendelow D, Gholkar A. Temporary alopecia after subarachnoid haemorrhage. J Clin Neurosci 2007; 14: 157–61. 2 Wen CS, Lin SM, Chen Y et al. Radiation-induced temporary alopecia after embolization of cerebral arteriovenous malformations. Clin Neurol Neurosurg 2003; 105: 215–17. 3 Tosti A, Piraccini BM, Alagna G. Temporary hair loss simulating alopecia areata after endovascular surgery of cerebral arteriovenous malformation: a report of three cases. Arch Dermatol 1999; 135: 1555–6. 4 Geleijns J, Wondergem J. X-ray imaging and the skin: radiation biology, patient dosimetry and observed effects. Radiat Prot Dosimetry 2005; 114: 121–5. 5 Gavagan L, Ti J, Thornton J. Is hair loss a reality in neuro-interventional radiology? Radiat Prot Dosimetry 2011; 147: 68–71.

The incidence of skin cancer in dermatology: comment doi: 10.1111/ced.12478 The recent publication by van der Geer et al.1 concludes that ‘the number of nonmelanoma skin cancers (NMSCs) differs substantially in practice from the number of first primary histologically confirmed NMSCs, as usually reported by population-based cancer registries such as the Eindhoven Cancer Registry (ECR)’. We fully agree with this unsurprising conclusion, as designation of ‘first primary’ implies that there may be more tumours, and it is well known that a substantial proportion of patients with basal cell carcinoma (BCC) develop one or more subsequent BCCs, depending on age at first diagnosis and intensity of surveillance.2–5 However, we disagree with the methodology and with the negative interpretation of work by population-based registries. The random sample of patients with skin cancer studied by van der Geer et al.1 was treated in a highly specialized dermatology clinic, as illustrated by the reported high proportion of patients treated with Mohs micrographic surgery. In such a population, the proportion of patients with high-risk BCC who develop multiple primaries is most likely much higher than in the general BCC population. The authors failed to adequately specify the characteristics of the population, and patient selection was unclear, and included first and subsequent skin cancers. In addition, the study combined all skin cancers for the estimation of the percentage of patients with multiple skin cancers over time, whereas risk of subsequent malignancies differs substantially for the different types of skin cancer.4 The conclusion by the authors that the numbers of NMSCs in the dermatology practice is higher than that

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reported by the ECR must refer to BCCs only, as the other invasive NMSCs, mainly SCC, are routinely collected. Contrary to what the authors imply, the ECR does collect information on all histologically confirmed skin cancers located at distinct localization, but usually only reports on the first primary BCCs, because it is known that complete registration of all BCCs is very difficult. In fact, the data of van der Geer et al.1 are also incomplete, as they do not have full information on all skin cancers diagnosed within their hospital before 2004, and neither do they have information on skin cancers diagnosed elsewhere. The authors failed to refer to elegantly performed research based on an audit of patient files of randomly selected patients with BCC in four different general dermatology departments, drawn from the ECR database.3 One-third of patients with a first primary BCC developed subsequent BCCs during 5 years of follow-up,5 most of them being histopathologically confirmed, very much in line with the literature. Moreover, a similar recent study in four different European cancer registries with an interest in BCC concluded that ‘Currently, routinely reported first BCC incidence rates of the included countries should be multiplied by a factor of 1.3 for an estimate of total number of patients’.2 We believe such conclusions are much more helpful for policymakers in healthcare than the conclusion that the number of patients with a first BCC is much lower than the total number of BCCs. E. de Vries1,2 and J. W. W. Coebergh1,2 1 Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands; and 2Research Section, Integraal Kankercentrum Nederland, Eindhoven, the Netherlands E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 2 May 2014

References 1 van der Geer S, Siemerink M, Reijers H et al. The incidence of skin cancer in dermatology. Clin Exp Dermatol 2013; 39: 724–9. 2 de Vries E, Micallef R, Brewster DH et al. Population-based estimates of the occurrence of multiple vs first primary basal cell carcinomas in 4 European regions. Arch Dermatol 2012; 148: 347–54. 3 Flohil SC, Koljenovic S, de Haas ER et al. Cumulative risks and rates of subsequent basal cell carcinomas in the Netherlands. Br J Dermatol 2011; 165: 874–81. 4 Flohil SC, van der Leest RJ, Arends LR et al. Risk of subsequent cutaneous malignancy in patients with prior keratinocyte carcinoma: a systematic review and meta-analysis. Eur J Cancer 2013; 49: 2365–75. 5 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: 1524–30.

ª 2014 British Association of Dermatologists

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The incidence of skin cancer in dermatology: comment.

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