Studies reveal substantial increases in non-melanoma skin cancers

The article is one of several in the issue focusing on skin cancers, and is being published in conjunction with a JAMA theme issue on cancer. The March issues of Archives of Pediatrics & Adolescent Medicine, Archives of Neurology, Archives of Internal Medicine, Archives of Ophthalmology, Archives of Surgery, Archives of Facial Plastic Surgery and Archives of Otolaryngology-Head & Neck Surgery will also publish articles on this topic.

Non-melanoma skin cancer is the most common malignant disease in the United States, according to background information in one of the articles. The disease is associated with substantial illness and cost, and a death rate that is lower than other cancers but still significant. However, non-melanoma skin cancer is not typically reported to cancer registries, and the most recent peer-reviewed, published national estimates date back to 1994. "Understanding skin cancer incidence and treatment is important for planning prevention strategies and allocating resources for treatment," the authors write.

In one article, Robert S. Stern, M.D., of Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, developed a mathematical model to estimate the prevalence of non-melanoma skin cancer in 2007. "This model used age-specific incidence data adjusted to reflect changes in incidence from 1957 to 2006, the age distribution of the population from 1957 to 2006 and the likelihood that an incident tumor was the first ever for that person," Dr. Stern writes.

Based on the model, Dr. Stern estimates that approximately 13 million white, non-Hispanic Americans had had at least one non-melanoma skin cancer by 2007. About one in five 70-year-olds have had non-melanoma skin cancers, and most who were affected have had more than one. "The prevalence of a history of skin cancer is far higher than that of any other cancer and exceeds that of all other cancers diagnosed since 1975," and is about five times higher than that of breast or prostate cancer, he writes.

In another article, Howard W. Rogers, M.D., Ph.D., of Advanced Dermatology, Norwich, Conn., and colleagues analyzed data from two Medicare databases and national surveys to estimate the incidence and treatment rates of non-melanoma skin cancer in 2006.

The total number of procedures to treat skin cancer in the Medicare population increased 76.9 percent from an estimated approximately 1.6 million procedures in 1992 to approximately 2 million procedures in 2006. Between 2002 and 2006, when database linkages allowed more detailed analyses, procedures to treat non-melanoma skin cancer increased 16 percent, the number of procedures per affected person increased 1.5 percent and the number of individuals undergoing at least one procedure increased by 14.3 percent.

Based on the results, the researchers estimate that in 2006 there were more than 3.5 million non-melanoma skin cancers in the United States and that approximately 2.1 million patients were treated for the disease.

"There is an epidemic of non-melanoma skin cancer in the United States, as illustrated by comparison with the previously published estimates and the 4.2 percent yearly average increase in cases in the Medicare population from 1992 to 2006," the authors conclude. "To date, educational programs emphasizing sun protection have mainly been disappointing in slowing skin cancer rates. In the face of ongoing increases in skin cancer incidence, continued national research and programs on treatment, education and prevention are critical."

Other articles featured in this issue include the following:

Melanoma Survivors Appear to Be at Increased Risk for Another Melanoma

Survivors of one melanoma appear approximately nine times as likely as the general population to develop a second melanoma. Porcia T. Bradford, M.D., and colleagues at the National Cancer Institute, Bethesda, Md., used nine cancer registries to identify 89,515 patients who survived at least two months after an initial melanoma diagnosis between 1973 and 2006.

Of these, 10,857 (12.1 percent) developed one or more additional primary cancers, such that their overall risk of another cancer increased by 28 percent. One-fourth of these subsequent cancers were primary melanomas. Women with head and neck melanoma and patients younger than 30 had additionally increased risks of a subsequent melanoma.

"The risk remains elevated more than 20 years after the initial melanoma diagnosis. This increased risk may be owing to behavioral factors, genetic susceptibility or medical surveillance," the authors conclude. "Melanoma survivors should remain under surveillance not only for recurrence but also for future primary melanomas and other cancers."

Older Adults With Melanoma Incur Significant Costs

Treating melanoma in older adults is estimated to cost approximately $249 million annually. Anne M. Seidler, M.D., M.B.A., Emory University School of Medicine, Atlanta, and colleagues used national databases to assess health care resource consumption by a total of 1,858 patients age 65 and older with melanoma during fiscal years 1991 to 1996.

Melanoma-related charges for older patients totaled an estimated $2,200 per month during the first four months of treatment, close to $4,000 monthly during the last six months and about $900 per month in the interim phase. Per patient, lifetime disease-related costs totaled up to $28,210 from the time of diagnosis to the time of death.

"Although relatively few patients actually die of this condition, the per-patient expenditures have particular significance in late-stage disease," the authors write. "The majority of consumption is attributable to advanced-stage disease and the terminal phase of treatment. If all patients were diagnosed and effectively treated in stage 0 or 1, we estimate that the annual direct costs for the population 65 years or older would be between $99 million and $161 million, or 40 percent to 65 percent of their current value of $249 million. Policy guidelines for melanoma screening should consider that patients 65 years or older represent an increased risk, and thus, economic burden, for later-stage melanoma."

Study Identifies Factors Associated With Early Detection of Melanoma

Early detection of melanoma appears more common among younger patients, those living in areas with high concentrations of dermatologists and those whose cancer is detected by dermatologists. Frédérique Durbec, M.D., of Hôpital Robert Debré, France, and colleagues studied new cases of cutaneous melanoma in five regions of northeastern France in 2004.

Of the 652 patients who had cancers detected, 45.1 percent were diagnosed among those who consulted dermatologists directly, 26.1 percent were referred to dermatologists by general practitioners, 14.1 percent were diagnosed when consulting a dermatologist for another disease and 8.4 percent were diagnosed during a follow-up visit for skin lesions. Patients who were referred to dermatologists were older and had the highest frequency of thick, or more advanced, melanomas, whereas those diagnosed on a follow-up visit had no thick or ulcerated melanomas.

"Easy access of patients to dermatologists, information campaigns targeting elderly people and education of general practitioners are complementary approaches to improving early detection," the authors write.

Special Article: Skin Cancer Should Be Treated as a Chronic Disease

"To manage the future costs and quality of care for patients with skin cancer, a revised health strategy is needed," write Simone van der Geer, M.D., of Erasmus University Medical Center, Rotterdam, and colleagues in a special article. "These new strategies should be combined into a disease management system that organizes health care for one well-documented health care problem using a systematic approach."

"By applying the disease management systems approach, multiple opportunities for chronic skin cancer care become apparent in prevention, education, multidisciplinary care, information technology and management," they continue. "The disease management system is embedded within a supportive overall organization structure, which is based on firm financial support that must be available for all aspects of the system, including prevention-based efforts."

"Skin cancer needs to be regarded as a chronic disease and should not be considered a solitary event requiring the treatment of one tumor," they conclude. "Combining these strategies in a disease management system will lead to efficient, evidence-based, high-quality care to help dermatologists deal proactively with chronic diseases such as skin cancer."