Howard W. Rogers

Incidence Estimate of Nonmelanoma Skin Cancer in the United States, 2006

OBJECTIVES To estimate the incidence of nonmelanoma skin cancer (NMSC) in the US population in 2006 and secondarily to indicate trends in numbers of procedures for skin cancer treatment. DESIGN A descriptive analysis of population-based claims and US Census Bureau data combined with a population-based cross-sectional survey using multiple US government data sets, including the Centers for Medicare and Medicaid Services Fee-for-Service Physicians Claims databases, to calculate totals of skin cancer procedures performed for Medicare beneficiaries in 1992 and from 1996 to 2006 and related parameters. The National Ambulatory Medical Care Service database was used to estimate NMSC-related office visits. We combined these to estimate totals of new skin cancer diagnoses and affected individuals in the overall US population. RESULTS The total number of procedures for skin cancer in the Medicare fee-for-service population increased by 76.9% from 1 158 298 in 1992 to 2 048 517 in 2006. The age-adjusted procedure rate per year per 100 000 beneficiaries increased from 3514 in 1992 to 6075 in 2006. From 2002 to 2006 (the years for which the databases allow procedure linkage to patient demographics and diagnoses), the number of procedures for NMSC in the Medicare population increased by 16.0%. In this period, the number of procedures per affected patient increased by 1.5%, and the number of persons with at least 1 procedure increased by 14.3%. We estimate the total number of NMSCs in the US population in 2006 at 3 507 693 and the total number of persons in the United States treated for NMSC at 2 152 500. CONCLUSIONS The number of skin cancers in Medicare beneficiaries increased dramatically over the years 1992 to 2006, due mainly to an increase in the number of affected individuals. Using nationally representative databases, we provide evidence of much higher overall totals of skin cancer diagnoses and patients in the US population than previous estimates. These data give the most complete evaluation to date of the underrecognized epidemic of skin cancer in the United States.

Incidence Estimate of Nonmelanoma Skin Cancer (Keratinocyte Carcinomas) in the US Population, 2012

IMPORTANCE Understanding skin cancer incidence is critical for planning prevention and treatment strategies and allocating medical resources. However, owing to lack of national reporting and previously nonspecific diagnosis classification, accurate measurement of the US incidence of nonmelanoma skin cancer (NMSC) has been difficult. OBJECTIVE To estimate the incidence of NMSC (keratinocyte carcinomas) in the US population in 2012 and the incidence of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) in the 2012 Medicare fee-for-service population. DESIGN, SETTING, AND PARTICIPANTS This study analyzes US government administrative data including the Centers for Medicare & Medicaid Services Physicians Claims databases to calculate totals of skin cancer procedures performed for Medicare beneficiaries from 2006 through 2012 and related parameters. The population-based National Ambulatory Medical Care Survey database was used to estimate NMSC-related office visits for 2012. We combined these analyses to estimate totals of new skin cancer diagnoses and affected individuals in the overall US population. MAIN OUTCOMES AND MEASURES Incidence of NMSC in the US population in 2012 and BCC and SCC in the 2012 Medicare fee-for-service population. RESULTS The total number of procedures for skin cancer in the Medicare fee-for-service population increased by 13% from 2,048,517 in 2006 to 2,321,058 in 2012. The age-adjusted skin cancer procedure rate per 100,000 beneficiaries increased from 6075 in 2006 to 7320 in 2012. The number of procedures in Medicare beneficiaries specific for NMSC increased by 14% from 1,918,340 in 2006 to 2,191,100 in 2012. The number of persons with at least 1 procedure for NMSC increased by 14% (from 1,177,618 to 1,336,800) from 2006 through 2012. In the 2012 Medicare fee-for-service population, the age-adjusted procedure rate for BCC and SCC were 3280 and 3278 per 100,000 beneficiaries, respectively. The ratio of BCC to SCC treated in Medicare beneficiaries was 1.0. We estimate the total number of NMSCs in the US population in 2012 at 5,434,193 and the total number of persons in the United States treated for NMSC at 3,315,554. CONCLUSIONS AND RELEVANCE This study is a thorough nationwide estimate of the incidence of NMSC and provides evidence of continued increases in numbers of skin cancer diagnoses and affected patients in the United States. This study also demonstrates equal incidence rates for BCC and SCC in the Medicare population.

Analysis of Skin Cancer Treatment and Costs in the United States Medicare Population, 1996–2008

BACKGROUND There is a skin cancer epidemic in the United States. OBJECTIVE To examine skin cancer treatment modality, location, and cost and physician specialty in the Medicare population from 1996 to 2008. METHODS Centers for Medicare and Medicaid Services databases were used to examine skin cancer treatment procedures performed for Medicare beneficiaries. RESULTS From 1996 to 2008, the total number of skin cancer treatment procedures [malignant excision, destruction, and Mohs micrographic surgery (MMS)] increased from 1,480,645 to 2,152,615 (53% increase). The numbers of skin cancers treated by excision and destruction increased modestly (20% and 39%, respectively), but the number of MMS procedures increased more rapidly (248% increase). Dermatologists treated an increasing percentage (75–82%) of skin cancers during these years, followed by plastic and general surgery. In 2008, more than 90% of all skin cancers were treated in the office, with the remainder being treated in facility‐based settings. Allowable charges paid to physicians by Medicare Part B for skin cancer treatments increased 137% from 1996 to 2008, from

Sentinel lymph node biopsy and completion lymph node dissection for malignant melanoma are not standard of care.

266,960,673 to

Understanding Mohs Micrographic Surgery: A Review and Practical Guide for the Nondermatologist

633,448,103. CONCLUSIONS The number of skin cancer treatment procedures increased substantially from 1996 to 2008, as did overall costs to Medicare. Dermatologists treated the vast majority of skin cancers in the Medicare population, using a mix of treatment modalities, almost exclusively in the office setting.

Properly Selected Skin Cancer Treatments Are Very Effective

Malignant melanoma is a cutaneous malignancy characterized by high metastatic potential and an unpredictable course. Enormous amounts of research have been done into surgical and adjunctive therapies for melanoma. Given the regularity with which sentinel lymph node biopsy and completion lymph node dissection are performed at private and academic hospitals, it would seem that evidence supporting these procedures is not controversial. A growing body of studies, however, points to sentinel lymph node biopsy and completion lymph node dissection as ineffective treatment for malignant melanoma and necessitates a discussion of what constitutes standard of care.

Sentinel node biopsy not standard of care for melanoma

&NA; The incidence and diagnosis of cutaneous malignancies are steadily rising. In addition, with the aging population and increasing use of organ transplant and immunosuppressive medications, subsets of patients are now more susceptible to skin cancer. Mohs micrographic surgery (MMS) has become the standard of care for the treatment of high‐risk nonmelanoma skin cancers and is increasingly used to treat melanoma. Mohs micrographic surgery has the highest cure rates, spares the maximal amount of normal tissue, and is cost‐effective for the treatment of cutaneous malignancies. As in other medical fields, appropriate use criteria were developed for MMS and have become an evolving guideline for determining which patients and tumors are appropriate for referral to MMS. Patients with cutaneous malignancies often require multidisciplinary care. With the changing landscape of medicine and the rapidly increasing incidence of skin cancer, primary care providers and specialists who do not commonly manage cutaneous malignancies will need to have an understanding of MMS and its role in patient care. This review better familiarizes the medical community with the practice of MMS, its utilization and capabilities, differences from wide excision and vertical section pathology, and cost‐effectiveness, and it guides practitioners in the process of appropriately evaluating and determining when patients with skin cancer might be appropriate candidates for MMS.

Commentary on Trends in Mohs surgery from 1995 to 2010.

The lower amounts of Ki-67 staining when p16INK4A expression is high suggests that downregulation of proliferation is occurring. This decrease is likely a consequence of its increased inhibitory effects on CDK4/6 and the retinoblastoma pathway, resulting in cell cycle arrest (Ortega et al., 2002) and increased senescence (Alcorta et al., 1996). Unexpectedly, we observed that the level of endogenous p16INK4A expression appeared higher in the p16INK4A overexpression model. We speculate that the presence of recombinant p16INK4A protein might indirectly upregulate endogenous p16INK4A protein through various detrimental factors excreted from an increased number of senescent cells. On the basis of these observations, we decided to explore the biological consequences of silencing p16INK4A in the aged donor LSE model. Here, we saw a dramatic improvement in the morphology of the aged donor LSE, which now resembled that of a much younger donor (Figure 2c and d). A striking difference between these LSEs and the atrophic, non–silenced controls was the substantial increase of Ki-67positive cells in the p16INK4A-silenced cultures with a consequent normalization of terminal differentiation, as detected by the restoration of filaggrin, loricrin, and caspase expression. This was repeated in at least three other aged donor models with similar results. In accordance with the conditional knockout model of Baker et al. (2011), in which senescent p16INK4A-expressing cells were selectively eliminated, and as evidenced by this model’s morphology and biomarkers, our results indicate that the atrophic phenotype can be significantly improved in vitro by selectively silencing the expression of p16INK4A. Collectively, these results further substantiate p16INK4A as a major regulator of aging in the epidermis, thus lending strong support for furthering our knowledge on the function and appearance of aged skin. For human cells obtained from donors, the Declaration of Helsinki protocols were followed; donors gave written, informed consent; and the Stony Brook University IRB approved of the study.

Letter: Skin cancer treatment fee comparisons inaccurate.

REFERENCES 1. Ortega-Loayza AG, Diamantis SA, Gilligan P, Morrell DS. Characterization of Staphylococcus aureus cutaneous infections in a pediatric dermatology tertiary health care outpatient facility. J Am Acad Dermatol 2010;62:804-11. 2. K€ orber A, Schmid EN, Buer J, Klode J, Schadendorf D, Dissemond J. Bacterial colonization of chronic leg ulcers: current results compared with data 5 years ago in a specialized dermatology department. J Eur Acad Dermatol Venereol 2010;24:1017-25.

Seventy Seconds Inadequate for a Complete Skin Examination

I commend the authors of Trends in Mohs Surgery from 1995 to 2010: An Analysis of Nationally Representative Data on their examination of Mohs surgery utilization for the US population. Skin cancer is a major public health concern in the United States and has been described as an epidemic. Skin cancer incidence has increased by 86% in the Medicare population from 1992 to 2008 with over 3.5 million new cases of nonmelanoma skin cancer each year affecting over 2.2 million people in the United States. Trends in the usage of surgical skin cancer treatments (excisions, destructions, and Mohs surgery) have been well characterized in the Medicare system, and increases in the utilization of Mohs surgery have been reported. In 1996, 1 in 10 skin cancers in the Medicare population was treated by Mohs surgery, increasing to 1 in 4 by 2008. Despite numerous advantages over other treatment modalities, Mohs surgery has drawn significant attention from insurers and regulators as a possibly overutilized and misvalued procedure, and Mohs surgery’s costeffectiveness has been questioned. Because of the multiple insurers in the US healthcare system and the lack of an encompassing database or registry, it has been difficult to evaluate skin cancer treatment trends for the population as a whole.