Sarah E. Stuart

Tumor Recurrence 5 Years after Treatment of Cutaneous Basal Cell Carcinoma and Squamous Cell Carcinoma

For most cutaneous basal cell and squamous cell carcinomas (nonmelanoma skin cancers [NMSC]) data are insufficient to permit evidence-based choices among treatments. To compare tumor recurrence after treatments, we conducted a prospective cohort study of consecutive patients with primary NMSC treated with the most common treatments in two practices in 1999–2000. Recurrence was determined from medical records by observers blinded to treatment type. 24.3% of tumors (N=361) were treated with destruction with electrodessication / curettage, 38.3% (N=571) with excision, and 37.4% (N=556) with histologically-guided serial excision (Mohs surgery). Follow-up was available for 1174 patients with 1488 tumors (93.8%) at median 7.4 years; overall 5-year tumor recurrence rate [95% Confidence Interval] was 3.3% [2.3, 4.4]. Unadjusted recurrence rates did not differ after treatments: 4.9% [2.3, 7.4] after destruction, 3.5% [1.8, 5.2] after excision, and 2.1% [0.6, 3.5] after Mohs surgery (P=0.26), and no difference was seen after adjustment for risk factors. In tumors treated only with excision or Mohs surgery, the hazard of recurrence was not significantly different, even after adjustment for propensity for treatment with Mohs surgery. These data indicate that common treatments for NMSC were at least 95% effective, and further studies are needed to guide therapeutic choices for different clinical subgroups.

Recurrence After Treatment of Nonmelanoma Skin Cancer: A Prospective Cohort Study

OBJECTIVE To determine long-term tumor recurrence rates after treatment of primary nonmelanoma skin cancer (NMSC). Data are currently insufficient to permit evidence-based choices among treatments for NMSC. DESIGN Prospective study of an inception cohort observed for a median of 6.6 years after treatment. SETTING Dermatology clinic at a Veterans Affairs hospital. Care was provided by dermatology resident or attending physicians. PATIENTS Consecutive sample of all 495 patients with 616 primary NMSCs diagnosed in 1999 and 2000 and treated with electrodessication and curettage (ED&C), excision, or Mohs surgery. Follow-up was available for 608 tumors (99%). MAIN OUTCOME MEASURE Tumor recurrence, determined by medical record review, with validation by clinical examination. RESULTS The mean age at diagnosis was 71 years; 97% were men. Overall, 127 tumors were treated with ED&C (20.9%); 309 with excision (50.8%); and 172 with Mohs surgery (28.3%). Over the course of the study, 21 tumors recurred (3.5% [95% confidence interval (CI), 2.2%-5.2%]): 2 after ED&C (1.6% [95% CI, 0.2%-5.6%]), 13 after excision (4.2% [95% CI, 2.2%-7.1%]), and 6 after Mohs surgery (3.5% [95% CI, 1.3%-7.4%]). CONCLUSIONS Recurrence of primary NMSC after treatment occurred in less than 5% of tumors. The recurrence rate after ED&C was lower than expected, and the recurrence rate after Mohs surgery was higher than expected. These findings may be related to the risk for recurrence in the treatment groups.

Treatment of Nonfatal Conditions at the End of Life: Nonmelanoma Skin Cancer

IMPORTANCE Nonmelanoma skin cancer (NMSC) is the most common cancer and predominantly affects older patients. Because NMSCs do not typically affect survival or short-term quality of life, the decision about whether and how to treat patients with limited life expectancy (LLE) is challenging, especially for asymptomatic tumors. OBJECTIVE To compare treatment patterns and clinical outcomes of patients with NMSC with and without LLE. DESIGN, SETTING, AND PARTICIPANTS A prospective cohort study of 1536 consecutive patients diagnosed with NMSC at 2 dermatology clinics: a university-based private practice and a Veterans Affairs Medical Center in San Francisco, California. Patients were recruited in 1999 through 2000 and followed up for a median of 9 years. A total of 1360 patients with 1739 tumors (90%) were included in the final analysis. Limited life expectancy was defined as patients either 85 years or older at the time of diagnosis or patients with multiple comorbidities (Charlson Comorbidity Index of ≥ 3). Treatment options included no treatment, destruction, or 2 types of surgery-elliptical excision or Mohs surgery. MAIN OUTCOMES AND MEASURES Treatment type. RESULTS Most NMSCs (69%) were treated surgically, regardless of patient life expectancy. The choice of surgery was not influenced by patient prognosis in univariate or multivariable models adjusted for tumor and patient characteristics. Many patients with LLE (43%) died within 5 years, none of NMSC. Tumor recurrence was rare (3.7% at 5 years [95% CI, 2.6%-4.7%]) in all patients. Although serious complications were unusual, approximately 20% of patients with LLE reported complications of therapy, compared with 15% of other patients. CONCLUSIONS AND RELEVANCE Most NMSCs are treated surgically, regardless of the patients life expectancy. Given the very low tumor recurrence rates and high mortality from causes unrelated to NMSC in patients with LLE, clinicians should consider whether these patients would prefer less invasive treatment strategies.

Timing of Subsequent New Tumors in Patients Who Present With Basal Cell Carcinoma or Cutaneous Squamous Cell Carcinoma

IMPORTANCE Patients with basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (SCC) (often termed nonmelanoma skin cancer or keratinocyte carcinoma [KC]) often develop new KCs, but information is limited on the frequency and timing of these subsequent tumors. This information is crucial to guide follow-up care. OBJECTIVE To determine the timing of subsequent new KCs in patients who present with KC. DESIGN, SETTING, AND PARTICIPANTS We enrolled a consecutive cohort of 1426 patients diagnosed as having biopsy-proven KC from January 1, 1999, through December 31, 2000, in a university dermatology practice and its affiliated Department of Veterans Affairs dermatology service. After exclusion of patients with basal cell nevus syndrome and immunocompromise, 1284 patients (90.0%) were followed up prospectively for a mean of 5.7 (range, 0-12.3) years. MAIN OUTCOMES AND MEASURES We assessed the risks for subsequent KCs over time using single-failure and multiple-failure models. We separately assessed outcomes after first lifetime KCs and after nonfirst lifetime KCs. We also performed secondary analyses of the risk for a subsequent BCC after a prior BCC diagnosis and the risk for a subsequent SCC after a prior SCC diagnosis. RESULTS The risk for a subsequent KC was substantially lower after the first lifetime KC diagnosis: 14.5% (95% CI, 11.9%-17.7%) at 1 year, 31.1% (95% CI, 27.3%-35.3%) at 3 years, and 40.7% (95% CI, 36.5%-45.2%) at 5 years, than after a nonfirst KC: 43.9% (95% CI, 42.0%-45.9%) at 1 year, 71.1% (95% CI, 69.1%-73.0%) at 3 years, and 82.0% (95% CI, 80.2%-83.7%) at 5 years. Secondary analyses of the risks for a subsequent BCC after a prior BCC diagnosis and of a subsequent SCC after a prior SCC diagnosis yielded results consistent with the analyses for the pooled KC sample. CONCLUSIONS AND RELEVANCE Although all patients with KC are assumed to be at high risk for subsequent tumors, a subset may not develop another KC after their first tumor. Whether these findings are related to biological or behavioral differences or to differences in health care services should be investigated further to inform and improve care. Ongoing routine screening for subsequent KC may not be indicated for all patients with KC. Skin cancer screening can be improved with a better understanding of the course and frequency of subsequent KC diagnoses.

Rerecurrence 5 Years After Treatment of Recurrent Cutaneous Basal Cell and Squamous Cell Carcinoma

Cutaneous basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) that have recurred after previous treatment are considered more difficult to cure compared with primary tumors, with overall 5-year re-recurrence rates reported as high as 15.4%1 for BCC and 5.9% for SCC.2 Few outcomes data exist from prospective studies, but a randomized controlled study in Europe of facial BCCs found that 5-year recurrence rates after excision or Mohs surgery for 397 primary tumors varied from 2.5% to 4.1%, compared with 2.4% to 12.1% for 202 recurrent tumors.3 The generalizability of these results to the United States, to other BCCs and SCCs, and after treatments delivered in the community is not clear. We sought to determine the 5-year recurrence rate after treatment of a consecutive cohort of BCCs and SCCs already recurrent at presentation.

Recurrence After Treatment of Cutaneous Basal Cell and Squamous Cell Carcinomas in Patients Infected With Human Immunodeficiency Virus

Cutaneous basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), collectively called nonmelanoma skin cancer (NMSC), are the most common primary malignant neoplasms, yet recurrence after treatment is unusual.1 With modern antiretroviral therapy, NMSC is also the most frequent cancer in persons infected with human immunodeficiency virus (HIV),2 but recurrence rates in this population are largely unknown.3 We followed a large prospective cohort of patients with NMSC to determine tumor recurrence rates and found unexpectedly high recurrence among the HIV-infected patients.

'What is it about your skin cancer that bothers you the most?': 700 patients respond.

20:698–700. 11 Irvine AD, Rugg EL, Lane EB et al. Molecular confirmation of the unique phenotype of epidermolysis bullosa simplex with mottled pigmentation. Br J Dermatol 2001; 144:40–5. 12 Uttam J, Hutton E, Coulombe PA et al. The genetic basis of epidermolysis bullosa simplex with mottled pigmentation. Proc Natl Acad Sci USA 1996; 93:9079–84. 13 Harel A, Bergman R, Indelman M, Sprecher E. Epidermolysis bullosa simplex with mottled pigmentation resulting from a recurrent mutation in KRT14. J Invest Dermatol 2006; 126:1654–7. 14 Betz RC, Planko L, Eigelshoven S et al. Loss-of-function mutations in the keratin 5 gene lead to Dowling-Degos disease. Am J Hum Genet 2006; 78:510–19. 15 McGowan KA, Aradhya S, Fuchs H et al. A mouse keratin 1 mutation causes dark skin and epidermolytic hyperkeratosis. J Invest Dermatol 2006; 126:1013–16.

Patient-reported outcomes of electrodessication and curettage for treatment of nonmelanoma skin cancer.

We have shown that electrodessication and curettage (ED&C) cures most (>95%) basal cell and cutaneous squamous cell carcinomas (nonmelanoma skin cancers, NMSCs) for which it is used,(1) but skin-related quality of life after ED&C does not improve as much as after excision or Mohs surgery.(2) Our goal was to determine other patient-reported outcomes (PROs) after treatment of NMSC with ED&C. We studied all patients with primary NMSCs treated with ED&C, excision, or Mohs surgery in 1999–2000 at a university hospital or its affiliated Veterans Affairs clinic, and who responded to a survey before treatment. The final sample consisted of 149 patients treated with ED&C and 568 treated with excision or Mohs surgery. Three months after treatment, we used an adapted version of the Patient Satisfaction Questionnaire (PSQ-18) to measure satisfaction with care, including its technical quality, interpersonal manner, communication, financial aspects, time with clinician, and accessibility.(4) Responses vary from 1 to 5, with higher scores indicating greater satisfaction. One year after treatment, we used global items to measure patients’ description of cosmetic appearance, bother from appearance, bother from scar, judgment of treatment worth, and overall satisfaction with treatment. The response rate for PROs varied from 65% to 92%. We used the chi-squared test for categorical variables and the Wilcoxon rank sum test for continuous variables. We used multivariable logistic regression models to determine if treatment independently predicted PROs better or worse than the median; these models adjusted for patient characteristics (age, gender, number of tumors at enrollment), tumor characteristics (histological type, diameter, invasiveness, location on the head and neck), practice site, and clinician training level. Tumors treated with ED&C were less likely than those treated with excision or Mohs surgery to be located on the head and neck, to be invasive, to have histological risk factors for recurrence, and to have been treated by an attending physician (Table 1). Table 1 Characteristics of study sample of patients with nonmelanoma skin cancera Three months after treatment, both groups were similarly satisfied with all domains of care except that patients treated with ED&C were somewhat less satisfied with the time spent with the clinician and the accessibility and convenience of their care. A year after treatment, patients treated with ED&C described worse cosmetic appearance and were more bothered by the appearance (Table 2). In adjusted analyses, patients treated with ED&C remained twice as likely to report more frequent bother from appearance (p=.002), but did not differ in any other PRO. Table 2 Patient reported outcomes that differed in treatment groups after treatment of non-melanoma skin cancera,b Patients treated with ED&C for NMSC were as satisfied as those treated with excision or Mohs surgery with much of their care, but they were more frequently bothered by the appearance even in adjusted analyses that controlled for patient and tumor characteristics and training level of clinician. Interviews would be required to understand patients’ responses fully, but the results support the clinical impressions of many dermatologists: although overall outcomes are good, patients treated with ED&C may be more bothered by the treatment site. The findings highlight the importance of PROs after NMSC, and the need for thoughtful decision making for this most common cancer.

Tumor recurrence of keratinocyte carcinomas judged appropriate for Mohs micrographic surgery using Appropriate Use Criteria

Background The use of Mohs micrographic surgery (MMS) has increased greatly to treat basal cell and cutaneous squamous cell carcinomas (keratinocyte carcinoma [KC]), and consensus‐based Appropriate Use Criteria (AUC) were developed to identify tumors for which MMS is appropriate. Objective We sought to compare recurrence rates after different treatments in tumors judged appropriate for MMS. Methods We used data from an observational prospective cohort study and retrospectively categorized consecutive tumors as appropriate for MMS according to the AUC. Among appropriate tumors, we used survival analyses to compare 5‐year recurrence rates after treatments. Results Among tumors appropriate for MMS (N = 1483), adjusted 5‐year recurrence rates were 2.9% (range, 1.4‐4.3%) after MMS, 5.5% (range, 3.1‐7.9%) after excision, 4.0% (range, 0.6‐7.2%) after destruction, and 5.9% (range, 1.5‐10.2%) after other treatments. In tumors treated only with MMS or excision (the most similar subgroups), the adjusted hazard ratio of 5‐year recurrence after MMS was 0.6 (95% confidence interval, 0.3‐1.0; P = .06). Limitations This study is limited by its uncertain generalizability, lack of randomization, and unmeasured characteristics. Conclusion The AUC identified tumors for which recurrence would be less common after MMS than after excision, but the absolute difference in recurrence rates was small.