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MM Chren, Dermatology Service, San Francisco Veterans Affairs Medical Center and Department of Dermatology, University of California at San Francisco; AP Sahay, Department of Medicine, University of California at San Francisco; LP Sands, Department of Medicine, University of California at San Francisco

Objectives: Nonmelanoma skin cancer is the most frequent malignancy. Prevention of tumor recurrence has been the traditional goal of therapy. There have been no prospective controlled studies comparing outcomes of therapy with different therapies and, for most tumors, many therapies are believed to be effective in preventing recurrence. The most common therapies are electrodessication / curettage (which requires minimal technical resources), surgical excision, and histologically-guided Mohs surgery (which requires intensive technical support). The objective of this work was to compare performance rates of therapies for nonmelanoma skin cancer in different settings.

Methods: We performed a prospective cohort study of consecutive patients with non-recurrent nonmelanoma skin cancer (NMSC) that was diagnosed and treated over 18 months in two sites, a private dermatology faculty practice (PRIVATE), and the dermatology clinic at the affiliated VA hospital (VA). Most VA physicians also practiced in the PRIVATE site, and all therapies for NMSC were available at both sites. Patients were identified by daily review of pathology records at both sites. Data were collected from medical records, and included tumor type (basal cell carcinoma vs. squamous cell carcinoma), diameter, body location, presence in the ‘H-zone’ of the face (a cosmetically important location in which tumors may also be more likely to recur after therapy), and description in the histopathological report of microscopic features conventionally believed to increase the risk of recurrence.

Results: Overall, 828 patients were diagnosed with 1028 NMSCs. Compared with patients in the PRIVATE setting, the 354 VA patients (43%) were older (73 vs. 64 years, p<0.01) and poorer (proportion with annual income less than $30,000, 33% vs. 79%, p<0.01). Tumors of VA patients were somewhat smaller (10 vs 11 mm, p=0.06) and more likely to be located on the head and neck (69% vs 59%, p<0.01). Treatments varied widely (p<0.01) between the VA and PRIVATE sites. The proportions of tumors treated in the VA and PRIVATE sites, respectively, were 22% and 26% for electrodessication and curettage; 50% and 25% for excisional surgery; and 23% and 41% for Mohs surgery. Mohs surgery was much more likely to be performed at the PRIVATE site compared with the VA site in multiple clinically important subgroups, including small and larger tumors, tumors on the head and neck, and in tumors with and without histological risk factors for recurrence. In multivariable analyses controlling for patient age and gender, and tumor type, size, body location, presence in the ‘H-zone’ of the face, and histological features associated with risk for recurrence, tumors treated in the PRIVATE site were significantly more likely to be treated with Mohs surgery (OR 3.3 [2.0-5.5], P=0.01).

Conclusions: We conclude that nonmelanoma skin cancers are treated differently at PRIVATE and VA sites, and that these differences cannot be explained by features of the patients or their tumors.

Impact: These results may indicate deficiencies in access to or in the quality of care in different sites. To ensure that patients in all settings are receiving quality care for this most common malignancy, the outcomes of treatment for nonmelanoma skin cancer should be evaluated.