Adam Sutton

Redefinition of Skin Cancer as a Chronic Disease.

Chronic diseases have profoundassociated morbidity and mortality. In addition to having a significant effect on a patient’s quality of life (QOL), they have substantial direct costs to our health care system and indirect costs to society. At present, all types of cancer except nonmelanoma skin cancer (NMSC) are considered chronic diseases. The exclusion of NMSC as a chronic disease limits our ability to characterize NMSC and to optimize its management for patients. Nonmelanoma skin cancer has become an epidemic in the United States. The incidence and total cost of treating basal cell and squamous cell carcinoma are increasing annually. In the 18-year period from 1994 to 2012, the estimated incidence of NMSC increased from 1 200 000 to 5 434 193.1 This figure makes the annual incidence of NMSC more than 3 times as common as all other forms of cancer combined.2 The rapid rise in incidence has been closely mirrored by an increase in treatments as dermatologists have devoted more resources and training to the treatment of basal cell and squamous cell carcinoma. From 2007 to 2011, approximately 5 million individuals were treated for skin cancer annually with an estimated annual cost of

Teledermatology as a tool to improve access to care for medically underserved populations: A retrospective descriptive study

8.1 billion. The cost of treating skin cancer just 5 years earlier was

SLNB in cutaneous SCC: A review of the current state of literature and the direction for the future

3.6 billion, representing a 126.2% increase.3 In addition to the economic burden that NMSC places on our health care system, it has a substantial effect on the QOL of individual patients. The Global Burden of Disease Study4 reports that patients with NMSC have disability-adjusted life-years (expressed as the number of years lost owing to ill health, disability, or early death) similar to those of patients with thyroid cancer and substantially higher than those of patients with testicular cancer. Health-related QOL instruments for general dermatology and specific to skin cancer have highlighted the significant effect that NMSC has on several domains of an individual’s health. The combination of increasing costs to our health care system and significant associated morbidity has led to the allocation of more resources to studying the pathogenesis and characteristics of NMSC and to identifying risk factors for the development of multiple tumors. Wehner and colleagues5 found that after an initial diagnosis of NMSC, an individual’s risk for developing a subsequent NMSC at 10 years was 59.6%. Furthermore, individuals who develop a nonfirst NMSC have a 61.5% risk for developing an additional NMSC in just 2 years. This finding suggests that certain high-risk individuals are predisposed to the development of multiple NMSCs and highlights the importance of early identification, routine screening, and long-term treatment plans. Despite the well-documented financial and healthrelated consequences of NMSC, these cancers are not reported to cancer registries. The lack of reporting has significance when NMSC is compared with other types of cancer because it hinders the development of accurate, reproducible, and understandable measures to define the true impact of the disease and to develop consensus recommendations on screening and treatment plans. This situation also leads others to hold the false belief that NMSC is a diagnosis of limited significance. Under current definitions, all cancers except NMSC are considered chronic diseases or illnesses. Redefining how NMSC is classified has the potential to alter the perception of the disease by the public and by other specialties. We propose that NMSC be defined as a chronic disease in a subset of high-risk individuals. This reclassification would promote several shortand long-term goals, including developing meaningful outcome and quality measures, proposing longterm treatment strategies, appropriately stratifying patients by risk, and improving delivery system processes and coordination of care. In a subset of patients who develop multiple NMSCs, looking at each occurrence as an isolated incident is shortsighted and harmful to the patient. Patients who develop their first NMSC ideally should be stratified on the basis of risk factors to determine those with the highest likelihood of developing a subsequent NMSC. Limited stratification already occurs but identifies only some of the highest-risk patients, including transplant recipients and other immunocompromised patients. Dermatologists are aware of and have cared for other subsets of high-risk patients, but their characteristics, along with the associated morbidity and mortality of their disease, are not well described. In addition, the presence of high-risk patients is less well appreciated by our other medical colleagues. Based on a more detailed risk stratification of patients with NMSC, recommendations could be made for the appropriate surveillance plan and secondary and tertiary prevention strategies for the patient. A recommended and regular follow-up period would aim for early diagnosis, treatment of precancerous lesions, and promotion of sun-safety education. In addition, a personalized plan for high-risk individuals would give patients and physicians the opportunity to discuss long-term treatment goals and to coordinate care across specialties. One of the challenges of our proposal is the lack of agreement on the criteria for a condition to be considered a chronic disease. Although no consensus definition for chronic diseases or chronic conditions exists, common themes can be extracted when reading through proposed definitions. The US Department of Health & Human Services defines chronic illnesses as “conditions that last a year or more and require ongoing medical treatment and/or limit activities of daily living.”6(p9) This definition can be broken down into the following 3 components: duration, need for ongoing medical care, VIEWPOINT

Vancomycin and DRESS: A retrospective chart review of 32 cases in Los Angeles, California

Photo included at any point No 1976 (21%) Yes 7523 (79%) Photo included initially Yes 7337 (98%) No 186 (2%) Photo adequate Yes 7160 (95%) No 363 (5%) Length of dialogue exchange #1000 characters 5902 (62%) [1000 characters 3596 (38%) PCP suspects malignancy Yes 2072 (22%) No 7427 (78%) Dermatologist suspects malignancy Yes 860 (9%) No 8639 (91%) PCP suspects melanoma Yes 663 (7%) No 8836 (93%) Dermatologist suspects melanoma Yes 182 (2%) No 9317 (98%)

Management of Skin Cancer in the High-Risk Patient

The concept of the sentinel lymph node biopsy (SLNB) has been universally accepted for melanoma, however, remains controversial for squamous cell carcinoma (SCC). We performed a quantitative review on 260 cases of SCC that had a SLNB. The positivity rate was found to be 14.6%. Literature was qualitatively reviewed to determine whether a positive SLNB has any bearing on prognosis in SCC cases, finding a significant relationship between poor prognosis and a positive SLN (P = 0.0082).

Chronic Non-Melanoma Skin Cancers and Health Related Impairment: A Case-Control Study

Dermatologists should be aware of the increased risk for mental health issues among patients with acne, particularly sexual minorities with acne. Validated screening tools to assess sexual orientation and depression among patients with acne may identify at-risk individuals and expedite referral for psychological care. Prospective studies are needed to further explore the relationship between acne, sexual orientation, and mental health.