Case Studies

A Growing Epidemic
Brian Moore

These days it seems that if you have not been treated for skin cancer yourself, you certainly know someone who has. The actual incidence of skin cancer is somewhat difficult to track, because most cancer registries do not record squamous cell carcinoma and basal cell carcinoma, even though they are the two most common forms of skin cancer. Recent publications estimate that over 2.1 million people were treated for nonmelanoma skin cancers in 2006, reflecting a significant increase over the preceding decade. When you consider that roughly 69,000 Americans are diagnosed with malignant melanoma each year, skin cancer begins to take on epidemic proportions. Because most skin cancers are related to sun exposure, most nonmelanoma skin cancers, and a significant proportion of melanoma, develop on the head and neck. Our love of sunbathing, tanning beds, and outdoor activities under a depleted ozone layer suggest that these numbers will continue to rise for the foreseeable future.

As the largest organ in the body, it is not surprising that skin cancer is by far the most common malignancy, with the prevalence of a skin cancer history recently noted to be five times higher than breast or prostate cancer and greater than the 31-year prevalence of all other cancers combined. Although this prevalence estimate underscores how the vast majority of skin cancers are successfully treated (since you have to still be alive from your cancer to have a history of cancer), it provides further evidence as to the wide reach of this epidemic. Often lost in discussions of skin cancer is the fact that dozens of cancer types can arise in the skin, and, although uncommon, the rare malignancies—Merkel cell carcinoma, sebaceous carcinoma, angiosarcoma, and many others—tend to be aggressive.
Thankfully, the incidence of skin cancer of all types greatly exceeds the mortality rate, but this leads to the false perception of skin cancer as a non-lethal entity. In fact, the American Cancer Society estimates that almost 12,000 people died from skin cancer in the United States in 2010. Melanoma accounts for 75% of these skin cancer-related deaths, and this rate has remained stable, at least in part attributable to early diagnosis and a treatment approach that incorporates a multidisciplinary approach. While the ratio of incidence to mortality for skin cancer seems favorable, it comes at significant cost—the direct and indirect costs of treatment are mind-boggling, and this does not even consider the effects on the individual patient, particularly in cosmetically “sensitive” areas such as the face, scalp, and neck.

Because it is so common, skin cancer is treated by a heterogeneous array of providers, depending on where the cancer arises. Dermatologists/dermatologic surgeons, Mohs surgeons, general surgeons, plastic surgeons, otolaryngologists, surgical oncologists, family physicians, and primary care providers, among others, all manage skin cancer in daily practice. Respect for the aggressiveness and metastatic potential of melanoma triggers referrals to experts and multidisciplinary treatment teams at higher levels of care, but a diagnosis of squamous cell carcinoma, basal cell carcinoma, or other nonmelanoma skin cancer often does not. Many of these cancers can be treated successfully with a variety of surgical and non-surgical measures, but there are some that require Mohs surgery or even a multidisciplinary approach with surgical oncologists/head and neck surgeons, plastic and reconstructive surgeons, radiation oncologists, and medical oncologists. The challenge is to identify those lesions with aggressive features so that the initial treatment can be appropriate and, ultimately, successful.

Improved awareness, prevention, and public health efforts designed to change behaviors with regard to sun exposure are required to truly impact the rising rates of skin cancer. However, these measures take time and money—two things that are not in abundance these days. In the meantime, early detection and an appreciation of the features of aggressive nonmelanoma skin cancer should prompt referrals to experts and multidisciplinary skin cancer treatment teams when appropriate. We are all at risk—see your health care professional soon for a comprehensive skin exam.

References:

  1. Rogers HW, Weinstock MA, Harris AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 2010;146:283-287.
  2. http://www.cancer.org/Cancer/CancerCauses/SunandUVExposure/skin-cancer-facts. Accessed May 23, 2011.
  3. Stern RS. Prevalence of a history of skin cancer in 2007: results of an incidence-based model. Arch Dermatol 2010;146:279-282.

About The Author:

Brian Moore, MD, FACS is an emerging national leader in head and neck surgery and a recognized expert in head and neck surgical oncology and reconstructive microsurgery. After serving in the United States Air Force as Chief of Surgical Services at Eglin AFB in Florida, Dr. Moore joined Ochsner Medical Center in New Orleans as Chief of Head and Neck Surgery and Vice-Chairman of the Department of Otolaryngology.

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