- Email: [email protected]
A systematic review of comorbidity indices used in the nonmelanoma skin cancer population
J AM ACAD DERMATOL
344 Research Letters
they performed TBSE in patients with no personal or family history of skin cancer and those with a high risk for skin cancer ( family history of skin cancer; personal history of sunburns, actinic damage, dysplastic nevi, and/or multiple nevi; or fair skin). Participant demographic data were collected including years in practice, location of practice (rural, suburban, urban, or combination), and practice environment (residency training, academic faculty practice, private practice, outpatient-based hospital clinic, or other). Data were analyzed using standard 2 and 95% confidence intervals. Of 6500 dermatologists surveyed, 9.6% (623) responded. The literature supports that our study sample size appears to be large enough to make accurate statistical inferences and representative of the surveyed population. In patients with no personal or family history of skin cancer, 86% of dermatologists reported performing TBSE either annually or every 2 to 3 years, 1% of dermatologists reported performing TBSE every 6 months, and 13% of dermatologists reported rarely/never performing TBSE routinely in this population.5 In comparison, in patients with high risk for skin cancer, 60% of dermatologists reported performing TBSE annually, with 34% performing TBSE every 6 months. In addition, in the high-risk population, 4% performed TBSE every 3 to 4 months, 2% performed TBSE every 2 to 3 years, and 1% of dermatologists reported rarely or never performing TBSE. The majority of dermatologists reported screening patients by TBSE at least every 2 to 3 years if not annually. In addition, those at increased risk of skin cancer were predominantly screened at least annually, if not every 6 months. Screening frequency was not associated with dermatologist gender, practice location, number of years in practice, or practice environment, with the exception of female practitioners and younger providers (with \5 years of practice experience) who screened those at normal risk for skin cancer more frequently (P ¼ .00004 and P ¼ .004, respectively). Limitations of this study include selection bias, as those who responded to this survey may have been more interested in this topic, recall bias, which may account for inaccuracy or incompleteness of participant’s responses, and finally systemic bias through which participants may have reported more screening than actually performed. There are no national guidelines regarding frequency of routine TBSE. This survey suggests that the majority of dermatologists routinely perform TBSE in patients at low risk every 2 to 3 years and more frequently in patients at high risk. These data suggest a uniform practice of skin cancer screening
FEBRUARY 2017
in the United States across the broad and diverse population of dermatologists. Mary L. Stevenson, MD,a Alex M. Glazer, MD,b David E. Cohen, MD, MPH,a Darrell S. Rigel, MD,a and Evan A. Rieder, MDa Ronald O. Perelman Department of Dermatology, New York University School of Medicine,a and National Society for Cutaneous Medicine,b New York, New York Funding sources: None. Conflicts of interest: None declared. Correspondence to: Mary L. Stevenson, MD, Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 240 E 38 St, 11th Floor, New York, NY 10016 E-mail: [email protected] REFERENCES 1. Little EG, Eide MJ. Update on the current state of melanoma incidence. Dermatol Clin. 2012;30(3):355-361. 2. Rogers HW, Coldiron BM. Analysis of skin cancer treatment and costs in the United States Medicare population, 1996-2008. Dermatol Surg. 2013;39(1 Pt 1):35-42. 3. Wernli KJ, Henrikson NB, Morrison CC, et al. Screening for skin cancer in adults: updated evidence report and systematic review for the US Preventative Services Task Force. JAMA. 2016;316(4):436-447. 4. Smith RA, Brooks D, Cokkinides V, et al. Cancer screening in the United States, 2013: a review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening. CA Cancer J Clin. 2013;63:88-105. 5. Survey research design. In: Phillips PP, Phillips JJ, Aaron B, eds. Survey basics. Alexandria (VA): ASTD Press; 2013. http://dx.doi.org/10.1016/j.jaad.2016.09.017
A systematic review of comorbidity indices used in the nonmelanoma skin cancer population To the Editor: Nonmelanoma skin cancer (NMSC) is more common than all other cancers combined in the United States, and despite low mortality, their management is associated with significant cost. Questions have been raised regarding appropriate treatment in patients with limited life expectancy, and the best way to determine which patients fall into this category.1 Prioritizing comorbidity rather than age may be preferred for informing treatment decisions in the very elderly. A systematic review of the literature was conducted to identify comorbidity instruments used in the NMSC population. Squamous and basal cell carcinoma were included, whereas Merkel cell
J AM ACAD DERMATOL
Research Letters 345
VOLUME 76, NUMBER 2
Table I. Characteristics of comorbidity indices Charlson Comorbidity Index
Categories Conditions and organ systems included
19 Conditions Myocardial infarct, congestive heart failure, peripheral vascular disease, cerebrovascular disease, dementia, chronic pulmonary disease, connective tissue disease, peptic ulcer disease, liver disease, diabetes, hemiplegia, renal disease, any tumor, leukemia, lymphoma, AIDS
Weighted conditions Formal comorbidity index Advantages
Disadvantages
Prior use(s) in the skin cancer population
American Society of Anesthesiologists
Adult Comorbidity Evaluation-27
6 Categories of operative risk No specific condition; categories include: I: Healthy patient II: Patient with mild systemic disease III: Patient with severe systemic disease IV: Patient with severe systemic disease that is a constant threat to life V: Moribund patient who is not expected to survive without the operation VI: Patient declared brain-dead whose organs are being removed for donor purposes
Yes
27 Conditions Myocardial infarct, angina, coronary artery disease, congestive heart failure, arrhythmias, hypertension, venous disease, peripheral artery disease, respiratory disease, hepatic disease, stomach/intestinal disease pancreatic disease, end-stage renal disease, diabetes, stroke, dementia, paralysis, neuromuscular disease, psychiatric disease, rheumatologic disease, immunologic system disease (AIDS), solid tumor, leukemia/ myeloma, lymphoma, alcohol abuse, illicit drug use, obesity Yes
Yes
Yes
No
Most extensively used in the localized skin cancer population Assumes ‘‘additive impact’’ of all conditions
More inclusive of conditions Designed specifically for a cancer population Limited use in skin cancer population
Evaluation of surgical and nonsurgical skin cancer population
Evaluation of surgical and nonsurgical skin cancer population
Widespread availability in medical records of surgical patients Not formally developed as comorbidity index Data available only for surgical patients Limited use in skin cancer population Preoperative screening for patients undergoing surgery for skin cancer
carcinoma or adnexal tumors were excluded, given the inherently different natural history of these lesions. A total of 2608 titles and 1407 abstracts were identified, of which 22 studies used a comorbidity assessment tool. Three comorbidity assessment tools in the localized NMSC population were identified: the Charlson Comorbidity Index (CCI), the American Society of Anesthesiologists (ASA) risk classification system, and the Adult Comorbidity Evaluation (ACE)-27 (Table I). The CCI was the most commonly used in 18 studies involving the NMSC population, and offers the advantages of extensive use and validation in additional cancer populations (Supplemental Table I; available at http://www.jaad.org). The CCI was
No
shown to predict life expectancy in nonagenarians who had NMSC treated by Mohs micrographic surgery.2 An additional study in a Department of Veterans Affairs population showed an association between increased CCI score and death.3 Dhiwakar and colleagues4 showed a significantly higher CCI score in a group of patients older than 80 years with head and neck skin tumors, compared with patients younger age 80 years. However, a separate study of patients aged 90 years and older undergoing Mohs micrographic surgery did not show a correlation between CCI score and life expectancy after Mohs micrographic surgery.5 The ASA risk classification was developed in an attempt to define operative risk, and was used
346 Research Letters
preoperatively in 3 NMSC studies (Supplemental Table I). The ASA, although not formally developed as a comorbidity index, was used for decades preoperatively to predict risk in patients undergoing general anesthesia, and performed comparably with formal indices as a comorbidity measure.6 An advantage of the ASA is its widespread use in patients who have undergone general anesthesia, many of whom may have this information documented in presurgical paperwork. The ACE-27 is a modification of the KaplanFeinstein Index and was used in 2 studies in the localized skin cancer population, showing superior performance to a standard medical interview in identifying comorbidity, and a correlation between more severe comorbidity and lower survival7,8 (Supplemental Table I). The ACE-27 includes more comorbid conditions than the CCI and was designed specifically for a cancer population. Both the CCI and the ACE-27 allow investigators to calculate scores retrospectively through medical chart review. They have also been adapted into the form of patientreported questionnaires for ease of data collection. Although 3 comorbidity measures were identified for the NMSC population, studies are small and limited by significant heterogeneity. The ACE-27 captures more conditions and allows for comorbidity grading, which is not possible with the CCI. Perhaps the ACE-27 will be more accurate in comorbidity assessment, however, larger studies are needed. As demographics shift to an older population over the next 2 decades, an evidence-based approach to management will depend on better understanding the impact of comorbidity and age on patient outcomes. Comorbidity tools may facilitate the decision-making process for physicians and patients, however, further studies are needed to better define their role. Karen L. Connolly, MD,a Jiyeon M. Jeong, MD,d Christopher A. Barker, MD,b Marisol Hernandez, MLS, MA,c and Erica H. Lee, MDa Dermatology Service,a Department of Radiation Oncology,b and Medical Library,c Memorial Sloan Kettering Cancer Center, and Weill Cornell Medical College,d New York, New York Funded in part through the National Institutes of Health/National Cancer Institute Cancer Center Support Grant 2P30CA008748-48. Conflicts of interest: None declared. Correspondence to: Karen L. Connolly, MD, Dermatology Service, Memorial Sloan Kettering Cancer Center, 16 E 60 St, New York, NY 10022. E-mail: [email protected]
J AM ACAD DERMATOL
FEBRUARY 2017
REFERENCES 1. Linos E, Berger T, Chren MM. Point: care of potential low-risk basal cell carcinomas (BCCs) at the end of life: the key role of the dermatologist. J Am Acad Dermatol. 2015;73:158-161. 2. Charles AJ Jr, Otley CC, Pond GR. Prognostic factors for life expectancy in nonagenarians with nonmelanoma skin cancer: implications for selecting surgical candidates. J Am Acad Dermatol. 2002;47:419-422. 3. Weinstock MA, Bingham SF, Lew RA, et al. Topical tretinoin therapy and all-cause mortality. Arch Dermatol. 2009; 145:18-24. 4. Dhiwakar M, Khan NA, McClymont LG. Surgery for head and neck skin tumors in the elderly. Head Neck. 2007;29: 851-856. 5. Delaney A, Shimizu I, Goldberg LH, MacFarlane DF. Life expectancy after Mohs micrographic surgery in patients aged 90 years and older. J Am Acad Dermatol. 2013;68:296-300. 6. Reid BC, Alberg AJ, Klassen AC, Koch WM, Samet JM. The American Society of Anesthesiologists’ class as a comorbidity index in a cohort of head and neck cancer surgical patients. Head Neck. 2001;23:985-994. 7. Lee EH, Nijhawan RI, Nehal KS, et al. Comorbidity assessment in skin cancer patients: a pilot study comparing medical interview with a patient-reported questionnaire. J Skin Cancer. 2015;2015:953479. 8. Samstein RM, Ho AL, Lee NY, Barker CA. Locally advanced and unresectable cutaneous squamous cell carcinoma: outcomes of concurrent cetuximab and radiotherapy. J Skin Cancer. 2014;2014:284582. http://dx.doi.org/10.1016/j.jaad.2016.10.007
Predictors of actinic keratosis count in patients with multiple keratinocyte carcinomas: A cross-sectional study To the Editor: Actinic keratoses (AKs) are common, are costly, and have the potential for malignant transformation to keratinocyte carcinoma (KC),1 ie, cutaneous basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). We sought to determine predictors of AK in patients with a history of multiple KCs, as AKs are more likely to progress to KC in this high-risk population.1 Predictors of AK count were explored crosssectionally using prerandomization baseline data from 2 trials of veterans with 2 or more KCs in the past 5 years (Department of Veterans Affairs [VA] KC Chemoprevention Trial, n ¼ 9322; and VA Topical Tretinoin Chemoprevention Trial, n ¼ 1131).3 Univariable and multivariable analyses using Stata software (StataCorp LP, College Station, TX) were performed to elucidate associations between AK count on the face/ears (assessed by study dermatologists) and demographic/health-related factors (selfreported) and KCs in the past 5 years ( from medical records). Baseline AKs and prior KCs were analyzed in quintiles to minimize impact of extreme values. VA Institutional Review Boards approved both trials, participants gave written consent, and Declaration of Helsinki protocols were followed.
Research Letters 346.e1
Continued
J AM ACAD DERMATOL
Charlson Comorbidity Index Johannesdottir SA, Chang ET, Mehnert F, Schmidt M, Olesen AB, Sorensen HT. Nonsteroidal anti-inflammatory drugs and the risk of skin cancer: a population-based casecontrol study. Cancer 2012;118:4768-76. Asgari MM, Bertenthal D, Sen S, Sahay A, Chren MM. Patient satisfaction after treatment of nonmelanoma skin cancer. Dermatol Surg 2009;35:1041-9. 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. Arch Dermatol 2007;143:1386-92. Chren MM, Linos E, Torres JS, Stuart SE, Parvataneni R, Boscardin WJ. Tumor recurrence 5 years after treatment of cutaneous basal cell carcinoma and squamous cell carcinoma. J Invest Dermatol 2013;133:1188-96. Chren MM, Torres JS, Stuart SE, Bertenthal D, Labrador RJ, Boscardin WJ. Recurrence after treatment of nonmelanoma skin cancer: a prospective cohort study. Arch Dermatol 2011;147:540-6. Christian JB, Lapane KL, Hume AL, Eaton CB, Weinstock MA. Association of ACE inhibitors and angiotensin receptor blockers with keratinocyte cancer prevention in the randomized VATTC trial. J Natl Cancer Inst 2008;100:1223-32. Dore DD, Lapane KL, Trivedi AN, Mor V, Weinstock MA. Association between statin use and risk for keratinocyte carcinoma in the Veterans Affairs topical tretinoin chemoprevention trial. Ann Intern Med 2009;150:9-18. Weinstock MA, Bingham SF, Lew RA, et al. Topical tretinoin therapy and all-cause mortality. Arch Dermatol 2009;145:18-24. Dhiwakar M, Khan NA, McClymont LG. Surgery for head and neck skin tumors in the elderly. Head Neck 2007;29:851-6. Weinstock MA, Lee KC, Chren MM, Marcolivio K. Quality of life in the actinic neoplasia syndrome: the VA Topical Tretinoin Chemoprevention (VATTC) trial. J Am Acad Dermatol 2009;61:207-15. Charles AJ Jr, Otley CC, Pond GR. Prognostic factors for life expectancy in nonagenarians with nonmelanoma skin cancer: implications for selecting surgical candidates. J Am Acad Dermatol 2002;47:419-22. Delaney A, Shimizu I, Goldberg LH, MacFarlane DF. Life expectancy after Mohs micrographic surgery in patients aged 90 years and older. J Am Acad Dermatol 2013;68:296300. Clark FL, Sahay A, Bertenthal D, et al. Variation in care for recurrent nonmelanoma skin cancer in a university-based practice and a Veterans Affairs clinic. Arch Dermatol 2008;144:1148-52. Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Landefeld CS, Chren MM. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer. JAMA Intern Med 2013;173:1006-12. Pascual JC, Belinchon I, Ramos JM. Mortality after dermatologic surgery for nonmelanoma skin cancer in patients aged 80 years and older. J Am Acad Dermatol 2013;69:1051-2. Jensen AO, Lamberg AL, Jacobsen JB, Braae Olesen A, Sorensen HT. Non-melanoma skin cancer and ten-year all-cause mortality: a population-based cohort study. Acta Derm Venereol 2010;90:362-7. Jensen V, Prasad AR, Smith A, et al. Prognostic criteria for squamous cell cancer of the skin. J Surg Res 2010;159:509-16. Chren MM, Sahay AP, Bertenthal DS, Sen S, Landefeld CS. Quality-of-life outcomes of treatments for cutaneous basal cell carcinoma and squamous cell carcinoma. J Invest Dermatol 2007;127:1351-7. American Society of Anesthesiologists Dhiwakar M, Khan NA, McClymont LG. Surgery for head and neck skin tumors in the elderly. Head Neck 2007;29:851-6. Nassab RS, Thomas SS, Murray D. Orbital exenteration for advanced periorbital skin cancers: 20 years experience. J Plast Reconstr Aesthet Surg 2007;60:1103-9. Wollina U, Bayyoud Y, Kronert C, Nowak A. Giant epithelial malignancies (basal cell carcinoma, squamous cell carcinoma): a series of 20 tumors from a single center. J Cutan Aesthet Surg 2012;5:12-9.
VOLUME 76, NUMBER 2
Supplemental Table I. Bibliography of studies using comorbidity indices in the nonmelanoma skin cancer population
Adult Comorbidity Evaluation-27 Lee EH, Nijhawan RI, Nehal KS, et al. Comorbidity assessment in skin cancer patients: a pilot study comparing medical interview with a patient-reported questionnaire. J Skin Cancer 2015;2015:953479. Samstein RM, Ho AL, Lee NY, Barker CA. Locally advanced and unresectable cutaneous squamous cell carcinoma: outcomes of concurrent cetuximab and radiotherapy. J Skin Cancer 2014;2014:284582.
346.e2 Research Letters
Supplemental Table I. Cont’d
FEBRUARY 2017
J AM ACAD DERMATOL
344 Research Letters
they performed TBSE in patients with no personal or family history of skin cancer and those with a high risk for skin cancer ( family history of skin cancer; personal history of sunburns, actinic damage, dysplastic nevi, and/or multiple nevi; or fair skin). Participant demographic data were collected including years in practice, location of practice (rural, suburban, urban, or combination), and practice environment (residency training, academic faculty practice, private practice, outpatient-based hospital clinic, or other). Data were analyzed using standard 2 and 95% confidence intervals. Of 6500 dermatologists surveyed, 9.6% (623) responded. The literature supports that our study sample size appears to be large enough to make accurate statistical inferences and representative of the surveyed population. In patients with no personal or family history of skin cancer, 86% of dermatologists reported performing TBSE either annually or every 2 to 3 years, 1% of dermatologists reported performing TBSE every 6 months, and 13% of dermatologists reported rarely/never performing TBSE routinely in this population.5 In comparison, in patients with high risk for skin cancer, 60% of dermatologists reported performing TBSE annually, with 34% performing TBSE every 6 months. In addition, in the high-risk population, 4% performed TBSE every 3 to 4 months, 2% performed TBSE every 2 to 3 years, and 1% of dermatologists reported rarely or never performing TBSE. The majority of dermatologists reported screening patients by TBSE at least every 2 to 3 years if not annually. In addition, those at increased risk of skin cancer were predominantly screened at least annually, if not every 6 months. Screening frequency was not associated with dermatologist gender, practice location, number of years in practice, or practice environment, with the exception of female practitioners and younger providers (with \5 years of practice experience) who screened those at normal risk for skin cancer more frequently (P ¼ .00004 and P ¼ .004, respectively). Limitations of this study include selection bias, as those who responded to this survey may have been more interested in this topic, recall bias, which may account for inaccuracy or incompleteness of participant’s responses, and finally systemic bias through which participants may have reported more screening than actually performed. There are no national guidelines regarding frequency of routine TBSE. This survey suggests that the majority of dermatologists routinely perform TBSE in patients at low risk every 2 to 3 years and more frequently in patients at high risk. These data suggest a uniform practice of skin cancer screening
FEBRUARY 2017
in the United States across the broad and diverse population of dermatologists. Mary L. Stevenson, MD,a Alex M. Glazer, MD,b David E. Cohen, MD, MPH,a Darrell S. Rigel, MD,a and Evan A. Rieder, MDa Ronald O. Perelman Department of Dermatology, New York University School of Medicine,a and National Society for Cutaneous Medicine,b New York, New York Funding sources: None. Conflicts of interest: None declared. Correspondence to: Mary L. Stevenson, MD, Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 240 E 38 St, 11th Floor, New York, NY 10016 E-mail: [email protected] REFERENCES 1. Little EG, Eide MJ. Update on the current state of melanoma incidence. Dermatol Clin. 2012;30(3):355-361. 2. Rogers HW, Coldiron BM. Analysis of skin cancer treatment and costs in the United States Medicare population, 1996-2008. Dermatol Surg. 2013;39(1 Pt 1):35-42. 3. Wernli KJ, Henrikson NB, Morrison CC, et al. Screening for skin cancer in adults: updated evidence report and systematic review for the US Preventative Services Task Force. JAMA. 2016;316(4):436-447. 4. Smith RA, Brooks D, Cokkinides V, et al. Cancer screening in the United States, 2013: a review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening. CA Cancer J Clin. 2013;63:88-105. 5. Survey research design. In: Phillips PP, Phillips JJ, Aaron B, eds. Survey basics. Alexandria (VA): ASTD Press; 2013. http://dx.doi.org/10.1016/j.jaad.2016.09.017
A systematic review of comorbidity indices used in the nonmelanoma skin cancer population To the Editor: Nonmelanoma skin cancer (NMSC) is more common than all other cancers combined in the United States, and despite low mortality, their management is associated with significant cost. Questions have been raised regarding appropriate treatment in patients with limited life expectancy, and the best way to determine which patients fall into this category.1 Prioritizing comorbidity rather than age may be preferred for informing treatment decisions in the very elderly. A systematic review of the literature was conducted to identify comorbidity instruments used in the NMSC population. Squamous and basal cell carcinoma were included, whereas Merkel cell
J AM ACAD DERMATOL
Research Letters 345
VOLUME 76, NUMBER 2
Table I. Characteristics of comorbidity indices Charlson Comorbidity Index
Categories Conditions and organ systems included
19 Conditions Myocardial infarct, congestive heart failure, peripheral vascular disease, cerebrovascular disease, dementia, chronic pulmonary disease, connective tissue disease, peptic ulcer disease, liver disease, diabetes, hemiplegia, renal disease, any tumor, leukemia, lymphoma, AIDS
Weighted conditions Formal comorbidity index Advantages
Disadvantages
Prior use(s) in the skin cancer population
American Society of Anesthesiologists
Adult Comorbidity Evaluation-27
6 Categories of operative risk No specific condition; categories include: I: Healthy patient II: Patient with mild systemic disease III: Patient with severe systemic disease IV: Patient with severe systemic disease that is a constant threat to life V: Moribund patient who is not expected to survive without the operation VI: Patient declared brain-dead whose organs are being removed for donor purposes
Yes
27 Conditions Myocardial infarct, angina, coronary artery disease, congestive heart failure, arrhythmias, hypertension, venous disease, peripheral artery disease, respiratory disease, hepatic disease, stomach/intestinal disease pancreatic disease, end-stage renal disease, diabetes, stroke, dementia, paralysis, neuromuscular disease, psychiatric disease, rheumatologic disease, immunologic system disease (AIDS), solid tumor, leukemia/ myeloma, lymphoma, alcohol abuse, illicit drug use, obesity Yes
Yes
Yes
No
Most extensively used in the localized skin cancer population Assumes ‘‘additive impact’’ of all conditions
More inclusive of conditions Designed specifically for a cancer population Limited use in skin cancer population
Evaluation of surgical and nonsurgical skin cancer population
Evaluation of surgical and nonsurgical skin cancer population
Widespread availability in medical records of surgical patients Not formally developed as comorbidity index Data available only for surgical patients Limited use in skin cancer population Preoperative screening for patients undergoing surgery for skin cancer
carcinoma or adnexal tumors were excluded, given the inherently different natural history of these lesions. A total of 2608 titles and 1407 abstracts were identified, of which 22 studies used a comorbidity assessment tool. Three comorbidity assessment tools in the localized NMSC population were identified: the Charlson Comorbidity Index (CCI), the American Society of Anesthesiologists (ASA) risk classification system, and the Adult Comorbidity Evaluation (ACE)-27 (Table I). The CCI was the most commonly used in 18 studies involving the NMSC population, and offers the advantages of extensive use and validation in additional cancer populations (Supplemental Table I; available at http://www.jaad.org). The CCI was
No
shown to predict life expectancy in nonagenarians who had NMSC treated by Mohs micrographic surgery.2 An additional study in a Department of Veterans Affairs population showed an association between increased CCI score and death.3 Dhiwakar and colleagues4 showed a significantly higher CCI score in a group of patients older than 80 years with head and neck skin tumors, compared with patients younger age 80 years. However, a separate study of patients aged 90 years and older undergoing Mohs micrographic surgery did not show a correlation between CCI score and life expectancy after Mohs micrographic surgery.5 The ASA risk classification was developed in an attempt to define operative risk, and was used
346 Research Letters
preoperatively in 3 NMSC studies (Supplemental Table I). The ASA, although not formally developed as a comorbidity index, was used for decades preoperatively to predict risk in patients undergoing general anesthesia, and performed comparably with formal indices as a comorbidity measure.6 An advantage of the ASA is its widespread use in patients who have undergone general anesthesia, many of whom may have this information documented in presurgical paperwork. The ACE-27 is a modification of the KaplanFeinstein Index and was used in 2 studies in the localized skin cancer population, showing superior performance to a standard medical interview in identifying comorbidity, and a correlation between more severe comorbidity and lower survival7,8 (Supplemental Table I). The ACE-27 includes more comorbid conditions than the CCI and was designed specifically for a cancer population. Both the CCI and the ACE-27 allow investigators to calculate scores retrospectively through medical chart review. They have also been adapted into the form of patientreported questionnaires for ease of data collection. Although 3 comorbidity measures were identified for the NMSC population, studies are small and limited by significant heterogeneity. The ACE-27 captures more conditions and allows for comorbidity grading, which is not possible with the CCI. Perhaps the ACE-27 will be more accurate in comorbidity assessment, however, larger studies are needed. As demographics shift to an older population over the next 2 decades, an evidence-based approach to management will depend on better understanding the impact of comorbidity and age on patient outcomes. Comorbidity tools may facilitate the decision-making process for physicians and patients, however, further studies are needed to better define their role. Karen L. Connolly, MD,a Jiyeon M. Jeong, MD,d Christopher A. Barker, MD,b Marisol Hernandez, MLS, MA,c and Erica H. Lee, MDa Dermatology Service,a Department of Radiation Oncology,b and Medical Library,c Memorial Sloan Kettering Cancer Center, and Weill Cornell Medical College,d New York, New York Funded in part through the National Institutes of Health/National Cancer Institute Cancer Center Support Grant 2P30CA008748-48. Conflicts of interest: None declared. Correspondence to: Karen L. Connolly, MD, Dermatology Service, Memorial Sloan Kettering Cancer Center, 16 E 60 St, New York, NY 10022. E-mail: [email protected]
J AM ACAD DERMATOL
FEBRUARY 2017
REFERENCES 1. Linos E, Berger T, Chren MM. Point: care of potential low-risk basal cell carcinomas (BCCs) at the end of life: the key role of the dermatologist. J Am Acad Dermatol. 2015;73:158-161. 2. Charles AJ Jr, Otley CC, Pond GR. Prognostic factors for life expectancy in nonagenarians with nonmelanoma skin cancer: implications for selecting surgical candidates. J Am Acad Dermatol. 2002;47:419-422. 3. Weinstock MA, Bingham SF, Lew RA, et al. Topical tretinoin therapy and all-cause mortality. Arch Dermatol. 2009; 145:18-24. 4. Dhiwakar M, Khan NA, McClymont LG. Surgery for head and neck skin tumors in the elderly. Head Neck. 2007;29: 851-856. 5. Delaney A, Shimizu I, Goldberg LH, MacFarlane DF. Life expectancy after Mohs micrographic surgery in patients aged 90 years and older. J Am Acad Dermatol. 2013;68:296-300. 6. Reid BC, Alberg AJ, Klassen AC, Koch WM, Samet JM. The American Society of Anesthesiologists’ class as a comorbidity index in a cohort of head and neck cancer surgical patients. Head Neck. 2001;23:985-994. 7. Lee EH, Nijhawan RI, Nehal KS, et al. Comorbidity assessment in skin cancer patients: a pilot study comparing medical interview with a patient-reported questionnaire. J Skin Cancer. 2015;2015:953479. 8. Samstein RM, Ho AL, Lee NY, Barker CA. Locally advanced and unresectable cutaneous squamous cell carcinoma: outcomes of concurrent cetuximab and radiotherapy. J Skin Cancer. 2014;2014:284582. http://dx.doi.org/10.1016/j.jaad.2016.10.007
Predictors of actinic keratosis count in patients with multiple keratinocyte carcinomas: A cross-sectional study To the Editor: Actinic keratoses (AKs) are common, are costly, and have the potential for malignant transformation to keratinocyte carcinoma (KC),1 ie, cutaneous basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). We sought to determine predictors of AK in patients with a history of multiple KCs, as AKs are more likely to progress to KC in this high-risk population.1 Predictors of AK count were explored crosssectionally using prerandomization baseline data from 2 trials of veterans with 2 or more KCs in the past 5 years (Department of Veterans Affairs [VA] KC Chemoprevention Trial, n ¼ 9322; and VA Topical Tretinoin Chemoprevention Trial, n ¼ 1131).3 Univariable and multivariable analyses using Stata software (StataCorp LP, College Station, TX) were performed to elucidate associations between AK count on the face/ears (assessed by study dermatologists) and demographic/health-related factors (selfreported) and KCs in the past 5 years ( from medical records). Baseline AKs and prior KCs were analyzed in quintiles to minimize impact of extreme values. VA Institutional Review Boards approved both trials, participants gave written consent, and Declaration of Helsinki protocols were followed.
Research Letters 346.e1
Continued
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Charlson Comorbidity Index Johannesdottir SA, Chang ET, Mehnert F, Schmidt M, Olesen AB, Sorensen HT. Nonsteroidal anti-inflammatory drugs and the risk of skin cancer: a population-based casecontrol study. Cancer 2012;118:4768-76. Asgari MM, Bertenthal D, Sen S, Sahay A, Chren MM. Patient satisfaction after treatment of nonmelanoma skin cancer. Dermatol Surg 2009;35:1041-9. 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. Arch Dermatol 2007;143:1386-92. Chren MM, Linos E, Torres JS, Stuart SE, Parvataneni R, Boscardin WJ. Tumor recurrence 5 years after treatment of cutaneous basal cell carcinoma and squamous cell carcinoma. J Invest Dermatol 2013;133:1188-96. Chren MM, Torres JS, Stuart SE, Bertenthal D, Labrador RJ, Boscardin WJ. Recurrence after treatment of nonmelanoma skin cancer: a prospective cohort study. Arch Dermatol 2011;147:540-6. Christian JB, Lapane KL, Hume AL, Eaton CB, Weinstock MA. Association of ACE inhibitors and angiotensin receptor blockers with keratinocyte cancer prevention in the randomized VATTC trial. J Natl Cancer Inst 2008;100:1223-32. Dore DD, Lapane KL, Trivedi AN, Mor V, Weinstock MA. Association between statin use and risk for keratinocyte carcinoma in the Veterans Affairs topical tretinoin chemoprevention trial. Ann Intern Med 2009;150:9-18. Weinstock MA, Bingham SF, Lew RA, et al. Topical tretinoin therapy and all-cause mortality. Arch Dermatol 2009;145:18-24. Dhiwakar M, Khan NA, McClymont LG. Surgery for head and neck skin tumors in the elderly. Head Neck 2007;29:851-6. Weinstock MA, Lee KC, Chren MM, Marcolivio K. Quality of life in the actinic neoplasia syndrome: the VA Topical Tretinoin Chemoprevention (VATTC) trial. J Am Acad Dermatol 2009;61:207-15. Charles AJ Jr, Otley CC, Pond GR. Prognostic factors for life expectancy in nonagenarians with nonmelanoma skin cancer: implications for selecting surgical candidates. J Am Acad Dermatol 2002;47:419-22. Delaney A, Shimizu I, Goldberg LH, MacFarlane DF. Life expectancy after Mohs micrographic surgery in patients aged 90 years and older. J Am Acad Dermatol 2013;68:296300. Clark FL, Sahay A, Bertenthal D, et al. Variation in care for recurrent nonmelanoma skin cancer in a university-based practice and a Veterans Affairs clinic. Arch Dermatol 2008;144:1148-52. Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Landefeld CS, Chren MM. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer. JAMA Intern Med 2013;173:1006-12. Pascual JC, Belinchon I, Ramos JM. Mortality after dermatologic surgery for nonmelanoma skin cancer in patients aged 80 years and older. J Am Acad Dermatol 2013;69:1051-2. Jensen AO, Lamberg AL, Jacobsen JB, Braae Olesen A, Sorensen HT. Non-melanoma skin cancer and ten-year all-cause mortality: a population-based cohort study. Acta Derm Venereol 2010;90:362-7. Jensen V, Prasad AR, Smith A, et al. Prognostic criteria for squamous cell cancer of the skin. J Surg Res 2010;159:509-16. Chren MM, Sahay AP, Bertenthal DS, Sen S, Landefeld CS. Quality-of-life outcomes of treatments for cutaneous basal cell carcinoma and squamous cell carcinoma. J Invest Dermatol 2007;127:1351-7. American Society of Anesthesiologists Dhiwakar M, Khan NA, McClymont LG. Surgery for head and neck skin tumors in the elderly. Head Neck 2007;29:851-6. Nassab RS, Thomas SS, Murray D. Orbital exenteration for advanced periorbital skin cancers: 20 years experience. J Plast Reconstr Aesthet Surg 2007;60:1103-9. Wollina U, Bayyoud Y, Kronert C, Nowak A. Giant epithelial malignancies (basal cell carcinoma, squamous cell carcinoma): a series of 20 tumors from a single center. J Cutan Aesthet Surg 2012;5:12-9.
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Supplemental Table I. Bibliography of studies using comorbidity indices in the nonmelanoma skin cancer population
Adult Comorbidity Evaluation-27 Lee EH, Nijhawan RI, Nehal KS, et al. Comorbidity assessment in skin cancer patients: a pilot study comparing medical interview with a patient-reported questionnaire. J Skin Cancer 2015;2015:953479. Samstein RM, Ho AL, Lee NY, Barker CA. Locally advanced and unresectable cutaneous squamous cell carcinoma: outcomes of concurrent cetuximab and radiotherapy. J Skin Cancer 2014;2014:284582.
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Supplemental Table I. Cont’d
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