Assessment of therapeutic efficacy in seven cases of basal cell carcinoma in the ear and nose region treated with new surgical excision and immediate photodynamic therapy.

BACKGROUND: Basal cell carcinoma (BCC) is the most prevalent non-melanoma skin tumor. It commonly affects exposed areas. Currently, surgical resection is considered the primary approach for BCC treatment. However, BCC frequently affects exposed facial areas, leading to visible scars after surgery. PDT has garnered increasing recent attention, demonstrating superior efficacy and favorable cosmetic outcomes for superficial BCCs. However, it shows limited treatment effectiveness for deep-seated tumors. Most of the current literature focuses on the combination of surgery and postoperative PDT, while no studies have reported on the use of standard surgical excision with intraoperative margin pathological monitoring and immediate PDT. Therefore, we implemented a treatment protocol combining surgery and immediate PDT. Accordingly, this paper aimed to explore the effectiveness, cosmetic outcomes, and other relevant advantages of this therapeutic approach. METHODS: We aimed to evaluate this approach in seven patients with BCC on the nose and ears. Standard surgical excision of skin lesions was performed, with intraoperative frozen section examination of the margins, followed by immediate postoperative PDT for the wounds, and continued periodic PDT during the second phase of wound healing. RESULTS: All seven cases demonstrated significant improvement. The cosmetic rating was 100 % and no cases of recurrence existed among the seven patients. CONCLUSIONS: This approach effectively minimized the surgical wound, improved tumor clearance, achieved precise therapeutic effects, and reduced the recurrence rate. Moreover, it produced favorable cosmetic outcomes.

Years of dermatology experience and geographic region are associated with outlier performance of excision or destruction for nonmelanoma skin cancer.

INTRODUCTION: Treatments for nonmelanoma skin cancer (NMSC) include excision (surgical removal) and destruction (cryotherapy or curettage with or without electrodesiccation) in addition to other methods. Although cure rates are similar between excision and destruction for low-risk NMSCs, excision is substantially more expensive. Performing destruction when appropriate can reduce costs while providing comparable cure rate and cosmesis. OBJECTIVE: To identify characteristics associated with exclusive (outlier) performance of excision or destruction for NMSC. METHODS: The study consisted of malignant excision and destruction procedures submitted by dermatologists to Medicare in 2019. Proportions of services for each method were analyzed with respect to geographic region, years of dermatology experience, median income of the practice zip code, and rural-urban commuting area (RUCA) code. RESULTS: Fewer years of experience predicted a higher proportion of excisions (R2 = 0.7, p < .001) and higher odds of outlier excision performance. Outlier performance of excision was associated with practicing in the South, Midwest, and West, whereas outlier performance of destruction was associated with practicing in the Northeast and Midwest. CONCLUSIONS: Dermatologists with less experience or in certain geographic regions performed more malignant excision relative to destruction. As the older population of dermatologists retires, the cost of care for NMSC may increase.

The Prevalence and Treatment Costs of Non-Melanoma Skin Cancer in Cluj-Napoca Maxillofacial Center.

Background and Objectives: An increasing incidence of non-melanoma skin cancer (NMSC) is noted, as well as an increasing cost of the treatment, with NMSC becoming a public health problem. We aimed to investigate the prevalence and treatment costs of surgically treated NMSC from the Oral and Maxillofacial Surgery Department of Cluj-Napoca County Hospital. Materials and Methods: We retrospectively analyzed the clinical data and the charge data of hospitalization from the informatic system of Cluj-Napoca County Hospital. All patients benefited from standard surgical excision with the reconstruction of the post-excisional defect. A statistical analysis of the costs related to the patients' features, period and conditions of hospitalization, materials, medication, and paraclinical investigations was performed. Results: Between 2015 and 2019, 133 patients with NMSC were addressed to our department, with basal cell carcinoma (BCC) being four-fold higher than squamous cell carcinoma (SCC). Most NMSC cases were diagnosed in stage I or II, and they benefited from local reconstruction. The treatment costs progressively increased in the last five years, reaching a total cost of EUR ~13.000 in 2019. The treatment cost per episode was higher for SCC compared to BCC, while the total cost of treatment in 5 years was higher for BCC. Low income, immunosuppression, comorbidities, flap reconstruction option, long-lasting surgery, and prolonged hospitalization were associated with an increased cost of the treatment. Conclusion: The prevalence and treatment cost of surgically treated NMSC of the head and neck region increased in the last five years, with high-cost drivers being related to patients and treatment options.

Imaging technologies for presurgical margin assessment of basal cell carcinoma.

Basal cell carcinoma is the most common cancer worldwide, necessitating the development of techniques to decrease treatment costs through efficiency and efficacy. Mohs micrographic surgery, a specialized surgical technique involving staged resection of the tumor with complete histologic evaluation of the peripheral margins, is highly utilized. Reducing stages by even 5% to 10% would result in significant improvement in care and economic benefits. Noninvasive imaging could aid in both establishing the diagnosis of suspicious skin lesions and streamlining the surgical management of skin cancers by improving presurgical estimates of tumor sizes. Herein, we review the current state of imaging techniques in dermatology and their applications for diagnosis and tumor margin assessment of basal cell carcinoma prior to Mohs micrographic surgery.

Association of Tumor Characteristics With Insurance Type Among Patients Undergoing Mohs Micrographic Surgery for Nonmelanoma Skin Cancer.

Importance: Little is known about the association between insurance type and tumor or treatment characteristics among patients undergoing Mohs micrographic surgery (MMS) for nonmelanoma skin cancer (NMSC). Objective: To investigate whether there are differences in tumor and treatment characteristics among patients undergoing MMS for NMSC by insurance type. Design, Setting, and Participants: This retrospective cohort study included patients with NMSC who presented for surgery at an academic MMS practice between May 2017 and May 2019. Main Outcomes and Measures: Preoperative and postoperative tumor diameters, number of MMS stages, type of closure, and number of high-risk tumors were compared based on insurance type among uninsured and underinsured patients and those with private insurance, Medicare, and Veterans Affairs (VA) insurance. Results: A total of 1397 patients with NMSC (978 [70%] male; mean [SD] age, 68.5 [12.4] years) underwent 1916 MMS procedures. Of these patients, 868 (45%) had Medicare, 570 (30%) had private insurance, 299 (16%) had VA insurance, and 179 (9%) were treated at a safety net clinic or were uninsured. Compared with patients with private insurance, uninsured and underinsured patients had significantly larger preoperative tumor bed diameters (difference, 28%; 95% CI, 14%-43%; P < .001) and postoperative defect sizes (difference, 28%, 95% CI, 16%-41%; P < .001). Patients with Medicare and VA insurance did not have significantly different preoperative tumor bed diameters compared with patients with private insurance. Patients with VA insurance had larger postoperative defect sizes than patients with private insurance (difference, 12%; 95% CI, 2%-23%; P = .02). The number of MMS stages and type of closure did not significantly differ based on insurance type. Conclusions and Relevance: In this cohort study of patients undergoing MMS for NMSC, larger preoperative tumor and postoperative defect sizes were associated with being uninsured or underinsured compared with privately insured. Future studies are required to determine why these differences exist to deliver optimal care to all patients.

Disparities in nonmelanoma skin cancer in Hispanic/Latino patients based on Mohs micrographic surgery defect size: A multicenter retrospective study.

BACKGROUND: There is limited literature regarding potential disparities in nonmelanoma skin cancer for patients with skin of color. OBJECTIVE: Use the sizes of Mohs micrographic surgery defects to examine disparities in nonmelanoma skin cancer among Hispanic/Latino patients with a secondary aim to examine the effect of insurance type. METHODS: We conducted a multicenter retrospective study using data from 3 major institutions in Los Angeles County. A total of 3486 Mohs micrographic surgeries of basal cell, squamous cell, and basosquamous cell carcinomas were analyzed. RESULTS: Mohs micrographic surgery defect sizes were 17% larger among Hispanic/Latino patients compared with non-Hispanic White patients. More notably, when comparing defect sizes of squamous cell carcinomas to those of basal cell carcinomas, defects were 80% larger among Hispanic/Latino patients compared to non-Hispanic White patients who had 25% larger defect sizes. Compared to patients with Medicare, patients with health maintenance organization and Medicaid/health maintenance organization had 22% and 52% larger defect sizes, respectively, whereas patients with preferred provider organization, had 10% smaller defect sizes. LIMITATIONS: The data included were from a single county population. CONCLUSION: Disparities regarding nonmelanoma skin cancer exist between patients with skin of color and White patients. Patients and the medical community need to be cognizant that skin cancer can develop in patients regardless of their race and ethnicity.

Willingness to Pay for Surgical Treatments for Basal Cell Carcinoma: A Population-Based Cross-Sectional Study.

BACKGROUND: Keratinocyte carcinoma (KC) treatment accounts for approximately $5 billion in spending per year, yet no studies have evaluated the US general public's willingness to pay (WTP) for these procedures. OBJECTIVE: To determine the monetary value of surgical KC treatments, as perceived by society, as a measure of preference. PARTICIPANTS, METHODS AND MATERIALS: We performed an internet-based age-, sex-, and race-stratified cross-sectional survey of 425 subjects representative of the US general population. Stated WTP and desirability of electrodesiccation and curettage (EDC), excision, and Mohs micrographic surgery (MMS) for facial and extrafacial basal cell carcinoma (BCC) were assessed. A discrete choice experiment was performed using maximum likelihood estimation, and a secondary analysis was performed to determine the influence of framing MMS as the best treatment option. RESULTS: A total of 425 subjects finished their questionnaires, yielding a completion rate of 97%. Median (interquartile range) stated WTP for EDC, excision, and MMS were $1,000 (421-2,079), $1,503 (562-3,062), and $3,006 (1,250-5,084), respectively, when MMS was framed in a standard fashion. Stated WTP for MMS increased to $3,989 (2,015-5,801) when it was framed as the best option. For BCC on the back, WTP for MMS dropped by 12%. CONCLUSION: There is markedly higher societal WTP for MMS on both the face and trunk, regardless of whether MMS is framed as the best option. Gold-standard bias may affect WTP and desirability in medical decision-making under uncertainty, inflating the WTP of options framed as the best while decreasing the desirability of alternatives.

Outpatient surgical management of non-melanoma skin cancers of the head and neck in a regional centre: an analysis of costs and outcomes.

BACKGROUND: Non-melanoma skin cancer is the most commonly diagnosed malignancy in Australia. Lesions of the head and neck are often outside the scope of primary care providers. The challenges of cancer care in regional Australia necessitate careful resource planning. This study presents an outpatient model that minimizes health service cost with local general practitioner follow-up. METHODS: A retrospective review of 105 patients with 122 skin lesions in a dedicated Facial Lesion Assessment Management and Excision clinic was performed from July 2018 to 2019. Clinical outcomes, patient travel and cost analysis/comparison were recorded. RESULTS: There were 85 malignant cases with 59 basal cell carcinomas and 25 squamous cell carcinomas. For basal cell carcinoma, clear margins (≥3 mm), close margins (<3 mm) and positive margins were achieved in 24 (48%), 23 (46%) and three (6%) cases, respectively. For squamous cell carcinoma, clear margins (≥5 mm), close margins (<5 mm) and positive margins were achieved in seven (38.8%), 11 (61.1%) and none (0%) of the cases, respectively. Complications included one haematoma and two wound infections. For 37% of patients living >100 km from the department, 72.3% had local general practitioner follow-up. Inpatient cost was $2870, $5697 and $9300 for primary closure, local flap and full-thickness skin graft, respectively, and outpatient cost was $746 for a single facial lesion. CONCLUSION: This study presents a cost-effective model for the management of non-melanoma skin cancers with improved departmental efficiency and streamlined patient care in an outpatient skin cancer management model in a regional centre.

Assessment of Incidence Rate and Risk Factors for Keratoacanthoma Among Residents of Queensland, Australia.

Importance: Keratoacanthoma (KA) is a common and generally benign keratinocyte skin tumor. Reports of the incidence rates of KA are scant. In addition, the risk factors for KA are not well understood, although associations with UV radiation exposure and older age have been described. Objective: To investigate the incidence rate of KA and the risk factors for developing KA. Design, Setting, and Participants: The study included data from 40 438 of 193 344 randomly selected residents of Queensland, Australia, who participated in the QSkin Sun and Health (QSkin) prospective population-based cohort study. All participants completed a baseline survey between 2010 and 2011 and were ages 40 to 69 years at baseline. Histopathologic reports of KA were prospectively collected until June 30, 2014, through data linkage with pathologic records. Cox proportional hazards models were used to identify risk factors associated with KA while controlling for potential confounding variables. Data were analyzed from January 2 to April 8, 2020. Exposures: Demographic characteristics, phenotypes, UV radiation exposure, medical history, and lifestyle. Results: Among 40 438 participants (mean [SD] age, 56 [8] years; 18 240 men [45.1%]), 596 individuals (mean [SD] age, 62 [6] years; 349 men [58.6%]) developed 776 KA tumors during a median follow-up period of 3.0 years (interquartile range, 2.8-3.3 years). The person-based age-standardized incidence rate for KA in the age-restricted cohort was 409 individuals per 100 000 person-years (based on the 2001 Australian population). Risk factors after adjustment for potential confounders were older age (age ≥60 years vs age <50 years; hazard ratio [HR], 6.38; 95% CI, 4.65-8.75), male sex (HR, 1.56; 95% CI, 1.33-1.84), fair skin (vs olive, dark, or black skin; HR, 3.42; 95% CI, 1.66-7.04), inability to tan (vs ability to tan deeply; HR, 1.69; 95% CI, 1.19-2.40), previous excisions of keratinocyte cancers (ever had an excision vs never had an excision; HR, 6.28; 95% CI, 5.03-7.83), current smoking (vs never smoking, HR, 2.02; 95% CI, 1.59-2.57), and high alcohol use (≥14 alcoholic drinks per week vs no alcoholic drinks per week; HR, 1.42; 95% CI, 1.09-1.86). Conclusions and Relevance: This is, to date, the first large prospective population-based study to report the incidence rate and risk factors for KA. The high person-based incidence rate (409 individuals per 100 000 person-years) highlights the substantial burden of KA in Queensland, Australia. Furthermore, the study's findings suggest that older age (≥60 years), male sex, UV radiation-sensitive phenotypes, indications of high sun exposure (eg, previous keratinocyte cancer excisions), smoking, and high alcohol use are independent risk factors for the development of KA.

Adherence to the National Comprehensive Cancer Network Criteria of Complete Circumferential Peripheral and Deep Margin Assessment in Treatment of High-Risk Basal and Squamous Cell Carcinoma.

BACKGROUND: The National Comprehensive Cancer Network (NCCN) has established guidelines for the treatment of keratinocyte carcinomas (KCs). Complete circumferential peripheral and deep margin assessment (CCPDMA) is recommended for "high-risk" tumors that cannot be closed primarily. If flap or grafts are needed and CCPDMA was not used, it is recommended that reconstruction be delayed until achieving clear margins. OBJECTIVE: To measure provider utilization rates of the NCCN guidelines for high-risk KCs and assess barriers that are limiting adherence. MATERIALS AND METHODS: A ten-item questionnaire was distributed to NCCN nonmelanoma skin cancer panel members and physicians participating in KC treatment at academic institutions. RESULTS: Response rate was 49% (57/116). Responses were categorized by practice area: Mohs surgery, pathology, and other specialties: General Dermatology, Otolaryngology, Plastic Surgery, Surgical Oncology, Radiation Oncology, and Oral and Maxillofacial Surgery. Mohs surgeons were most likely to use CCPDMA for tumors meeting NCCN criteria with 14/15 using this technique in a majority of their cases, versus 2/6 pathologists and 10/16 specialists from other fields. Reasons cited for not using CCPDMA included deference to pathologists to determine the appropriate method for margin assessment and logistical difficulty. CONCLUSION: Further efforts are needed to increase adherence to NCCN's guidelines regarding CCPDMA in KCs.