Factors influencing current low-value follow-up care after basal cell carcinoma and suggested strategies for de-adoption: a qualitative study.

BACKGROUND: Providing follow-up to patients with low-risk basal cell carcinoma (BCC) can be considered as low-value care. However, dermatologists still provide substantial follow-up care to this patient group, for reasons not well understood. OBJECTIVES: To identify factors influencing current BCC follow-up practices among dermatologists and suggested strategies to de-adopt this low-value care. In addition, views of patients regarding follow-up care were explored. METHODS: A qualitative study was conducted consisting of 18 semistructured interviews with dermatologists and three focus groups with a total of 17 patients with low-risk BCC who had received dermatological care. The interviews focused on current follow-up practices, influencing factors and suggested strategies to de-adopt the follow-up care. The focus groups discussed preferred follow-up schedules and providers, as well as the content of follow-up. All (group) interviews were transcribed verbatim and analysed by two researchers using ATLAS.ti software. RESULTS: Factors influencing current follow-up care practices among dermatologists included complying with patients' preferences, lack of trust in general practitioners (GPs), financial incentives and force of habit. Patients reported varying needs regarding periodic follow-up visits, preferred to be seen by a dermatologist and indicated a need for improved information provision. Suggested strategies by dermatologists to de-adopt the low-value care encompassed educating patients with improved information, educating GPs to increase trust of dermatologists, realizing appropriate financial reimbursement and informing dermatologists about the low value of care. CONCLUSIONS: A mixture of factors appear to contribute to current follow-up practices after low-risk BCC. In order to de-adopt this low-value care, strategies should be aimed at dermatologists and GPs, and also patients.

Needs and preferences of patients regarding basal cell carcinoma and cutaneous squamous cell carcinoma care: a qualitative focus group study.

BACKGROUND: Despite the high and rising incidence rate of keratinocyte cancer (KC) and the importance of incorporating patient values into evidence-based care, few studies have focused on the perspectives of patients with KC. OBJECTIVES: To identify the needs and preferences of patients with basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) regarding care. METHODS: A qualitative study was conducted consisting of three focus groups with patients with BCC and three focus groups with patients with SCC. In total 42 patients participated. In each focus group, the patients' needs and preferences regarding treatment and follow-up were discussed, using a predefined topic list. All sessions were transcribed verbatim and analysed by two researchers. RESULTS: The following needs and preferences were identified: (i) the need to receive all relevant, tailored information; (ii) a physician who takes you seriously and communicates well; (iii) a short waiting period and the best treatment with direct results; (iv) to be seen by the same physician; a preference for a dermatologist during (v) treatment and (vi) follow-up; (vii) a general need for structured follow-up care and (viii) a full-body skin examination during follow-up. Patients with BCC additionally expressed the need for openness and transparency and wanting to participate in shared decision making. CONCLUSIONS: It is advocated to organize skin cancer care that is better tailored to the needs of patients with KC, providing patient-centred care. This should include investing in the patient-physician relationship, and personalizing the type and form of information and the follow-up schedules. Adding the patient's perspective to current guidelines could facilitate this process.

[Complete treatment of basal cell carcinoma; cost effectiveness of Mohs micrographic surgery versus conventional excision]. / Radicale behandeling van basaalcelcarcinoom.

OBJECTIVE: To investigate whether Mohs micrographic surgery (MMS) in accordance with the indications in the revised guideline on basal cell carcinoma (BCC) more often leads to complete treatment than conventional excision (CE) and whether the costs are comparable, and to analyse whether this also applies to all primary BCC of the face. DESIGN: Retrospective analysis. METHOD: We gathered data on 3374 MMS procedures and calculated per localisation, subtype and size: the percentage of CE that would have been incomplete after applying the recommended surgical margin; the surgical margin necessary to achieve complete excision in > 90% of cases; the final defect after CE and after MMS; the cost of MMS and the cost of CE with postponed reconstruction or, in the case of incomplete CE, subsequent MMS. RESULTS: For the new MMS indications we can show that using MMS seems to prevent incomplete CE in 12-45% of cases. CE will also lead to incomplete excision in ≥ 10% of cases in most subgroups of primary facial BCC, with the exception of some small superficial or nodular BCCs in the H-zone. The final defect was always smaller after MMS than after CE. MMS can be used with comparable costs for primary BCCs > 5 mm in the H-zone and > 20 mm elsewhere in the face. CONCLUSION: The surgical margins recommended in the guidelines are inadequate to achieve complete excision rates in > 90% of facial CEs. MMS is an efficient alternative for CE for primary BCCs > 5 mm in the H-zone and > 20 mm elsewhere in the face.

An epidemic of occupational contact dermatitis from an immersion oil for microscopy in laboratory personnel.

Since November 1997, 14 successive cases of occupational contact dermatitis were observed in 13 laboratory technicians and 1 physician, working in a genetics laboratory in Leuven (Belgium) in 3 laboratories of bacteriology in Strasbourg, Montbeliard and Angers, and in the laboratory of hematology in Bordeaux (France). The dermatitis, located on the hands, forearms and face, relapsed after each exposure to an immersion oil for microscopy. Patch tests performed in 10 patients were positive to epoxy resin (ER) in the European standard series (10/10 patients) and to newly formulated Leica immersion oil (7/7), 1 patient testing negatively with the former oil. A breakdown performed in 2 patients with the oil's ingredients confirmed sensitization to liquid modified ER components, contained at >80% concentration in the oil. The presence of DGEBA was demonstrated by HPLC analysis at a +/-30% rate. Although the safety data sheet indicated a revision of the formula, nobody was alerted to the risk of sensitization and the need for skin protection. ERs, as a source of occupational allergy, can provoke epidemics of contact dermatitis in industry. This report of epidemic contact dermatitis from ERs, used for their optical properties in an immersion oil for microscopy, emphasizes the need for perpetual vigilance in occupational medicine and the usefulness of multicentre contacts in dermato-allergology.

Epidermolysis bullosa dystrophica of Hallopeau-Siemens and squamous-cell carcinoma: a case report.

A 46-year-old patient suffering from Hallopeau-Siemens type epidermolysis bullosa dystrophica presented a large squamous-cell carcinoma of the left hand. No metastases were observed. The tumour was resected and the phalanxes were amputated. The wound was covered with autologous skin grafts. Squamous-cell carcinoma is extremely aggressive in these patients and surgery is the only effective therapy. This life-threatening complication should always be kept in mind and a biopsy taken of every chronic, non-healing ulceration and of each atypical lesion.