Nonmelanoma skin cancer (NMSC) is the most frequent malignancy in older men. Its incidence is increasing dramatically, making aging veterans at very high risk. The most common treatments for NMSC are excisional surgery, surgical destruction by electrodessication/curettage, and histologically-guided serial excision (Mohs surgery). Comprehensive outcomes of NMSC and its therapy (including patient-reported outcomes such as quality of life) have not been measured. In fact, although the cost of these treatments and opinions about their relative efficacy vary considerably, no single treatment has been shown to be superior for most tumors. Furthermore, there is wide variation in the frequency with which various therapies are used.
The objective of this project is to compare comprehensive outcomes of different treatments of nonmelanoma skin cancer.
This project is a prospective longitudinal observational study of a consecutive cohort of patients newly-diagnosed with NMSC. Over two years this study enrolled approximately 1500 patients with NMSC recruited from two clinical sites: the Dermatology Clinic of the San Francisco Veterans Affairs Medical Center, and the private practice of faculty in the Dermatology Department of the University of California at San Francisco. Patients were surveyed at the time the diagnosis of NMSC was initially considered (before it was established by skin biopsy), and are being followed for at least a year thereafter. The principal sources of data are patient survey and medical record review. Data pertaining to cost of the treatment have been accessed from the UCSF and VA databases.
Overall, 1777 non-recurrent nonmelanoma skin cancers were diagnosed in 1375 patients. Compared with the VA site, patients at the private site were younger, more likely to be female, and less likely to be poor, and their tumors were smaller, and less likely to be on visible areas of the body. Treatments varied between the two sites (p<0.001). The proportions of tumors treated at the private and VA sites, respectively, were 23% and 19% for destruction, 25% and 48% for excision, and 37% and 25% for Mohs surgery. In multiple clinical subgroups, Mohs surgery was more likely to be performed at the private site than at the VA. Moreover, in a multivariable model controlling for clinical features that may have affected treatment choice, tumors at the private site were more likely than tumors at the VA to be treated with Mohs surgery (OR 2.01 [95% confidence interval 1.03 – 3.95]).
This project is significant to the health care of veterans because of the high prevalence of NMSC, the costs of its care, and the lack of information about patient outcomes--including quality of life--with different therapies. The study will inform clinical decisions and facilitate patients' participation in those decisions by providing comprehensive information about the outcomes of treatment. The results will also help define the need for prospective controlled trials of different treatments of NMSC.
- Clark FL, Sahay A, Bertenthal D, Maddock L, Lindquist K, Grekin R, Chren MM. Variation in care for recurrent nonmelanoma skin cancer in a university-based practice and a veterans affairs clinic. Archives of dermatology. 2008 Sep 1; 144(9):1148-52.
- Chen T, Bertenthal D, Sahay A, Sen S, Chren MM. Predictors of skin-related quality of life after treatment of cutaneous basal cell carcinoma and squamous cell carcinoma. Archives of dermatology. 2007 Nov 1; 143(11):1386-92.
- Chren MM, Sahay AP, Sands LP, Maddock L, Lindquist K, Bertenthal D, Bacchetti P. Variation in care for nonmelanoma skin cancer in a private practice and a veterans affairs clinic. Medical care. 2004 Oct 1; 42(10):1019-26.
- Wilson LS, Pregenzer MW, Bertenthal D, Koplowicz YB, Chren MM. Comparison of surgical treatment costs of nonmelanoma skin cancer patients in a university-affiliated practice. Paper presented at: International Society for Pharmacoeconomics and Outcomes Research Annual Meeting; 2008 May 3; Toronto, Canada.
Aging, Older Veterans' Health and Care
Treatment - Observational