- Email: [email protected]
203 Indoor tanning associations with substance use among Colorado high school students
ABSTRACTS | Clinical Research I: Epidemiology and Patient Outcomes Research 202
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Prescription variation of biologic therapies for psoriasis J Miller1, J Kirby1, D Leslie2, G Emily3 and G Liu2 1 Dermatology, Penn State Hershey, Hershey, PA, 2 Public Health Sciences, Penn State Hershey, Hershey, PA and 3 Penn State Coll of Med, Hershey, PA The objective of this study is to analyze and describe prescription variation of biologic medications for the treatment of psoriasis. A retrospective analysis of the MarketScanÒ medical claims database was performed to identify patients with claims for psoriasis, based on ICD-9 code, and pharmacy claims for biologic medications from January 2008 to December 2013. Prescription variation was described based on US census regions. Coefficients of variation were calculated for each biologic and logistic regression models were employed to identify patient demographics, geographic location, and provider types. The cohort includes 25,485 patients with 29,401 claims for biologics. There was equal distribution of patients across the all age groups ranging from 18 to 64 years. 56% of patients were male and 44% were female. The majority of biologics prescribed for psoriasis were adalimumab (43.5%) and etanercept (46.7%), together accounting for 90.1% of the total 29401 claims, while ustekinumab accounted for 9.6%. There is considerable variation in biologic prescriptions that was statistically significant (p <0.0001) by US census region. The South region had the fewest prescriptions for etanercept (44.1%), while the Northeast, Northcentral and West regions had 50.2%, 48.0% and 50.1%, respectively. In contrast, the Northeast region had the fewest prescriptions for adalimumab (38.8%), while the West and Northcentral regions had 40.8% and 43.2%, respectively. The South at 45.7% had the most prescriptions for adalimumab. Analysis of biologic prescription variation over the time period based on year of FDA approval is pending. This is the first study to demonstrate the variability in prescription patterns for the biologic agents used to treat psoriasis. Given the costs of biologics, dermatology as a specialty needs to understand the reasons behind the prescription patterns.
Indoor tanning associations with substance use among Colorado high school students M Sendelweck1, E Bell3, K Ashack4, T Pindyck1, A Anderson3, C Townley3 and R Dellavalle2 1 University of Colorado, Denver, CO, 2 Denver Veterans Affairs Medical Center, Denver, CO, 3 Colorado Department of Public Health and Environment, Denver, CO and 4 Michigan State University College of Human Medicine, Grand Rapids, MI The purpose of this study is to determine if there is an association between indoor tanning practices and substance use in Colorado high school students. Results from the Healthy Kids Colorado Survey reaching more than 40,000 Colorado youth were analyzed. Questionnaires included an item on the frequency of indoor tanning use as well as the utilization of various substances including alcohol, cigarettes, marijuana, non-prescription use of prescription drugs, steroids, ecstasy, cocaine and heroin. Logistic regression was performed to evaluate association. Univariate analysis showed that females were twice as likely to engage in indoor tanning as males (unadjusted odds ratio, 2.0; 95%CI, 1.6-2.5; P<0.001). The multivariate analysis identified any lifetime use of steroids as the variable most strongly associated with indoor tanning (adjusted OR, 5.5; 95% CI, 3.4-9.1; P<.001). In males, this potential association was even stronger (adjusted OR, 7.1; 95% CI, 3.6-14.0; P<.001). Any 30 day alcohol consumption, cigarette, and marijuana use were also associated with IT, as were select lifetime illicit drug use (heroin, glue sniffing and non-prescription prescription use). This study provides evidence for an association between substance use and indoor tanning practices in Colorado high school students. Identifying risky health behavior patterns can facilitate preventative health efforts to reduce indoor tanning among adolescents. These findings may be used in clinic settings to broaden patient risk assessments and tailor appropriate counseling.
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Association of non-melanoma skin cancer with second non-cutaneous malignancy in the Women’s Health Initiative K Ransohoff1, M Stefanick2, S Li1, A Kurian3, H Wakelee3, A Wang1, H Hedlin2, E Paskett4, J Han5 and J Tang1 1 Department of Dermatology, Stanford University School of Medicine, Stanford, CA, 2 Medicine; Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, 3 Oncology, Stanford University School of Medicine, Stanford, CA, 4 Department of Internal Medicine, College of Medicine Epidemiology, Ohio State University, Columbus, OH and 5 School of Public Health, Indiana University, Indianapolis, IN Non-melanoma skin cancer (NMSC) is the most prevalent cancer in the United States and adults with NMSC have been reported to have higher rates of non-cutaneous malignancies. We examined the rates of development of non-cutaneous cancers in those with and without history of NMSC in the Women’s Health Initiative Observational Study, a large prospective cohort which collected important cancer-related covariates and has long-term follow up data. Looking at WHI participants who had history of NMSC at baseline (N ¼ 11,692) and without NMSC history (N ¼ 109,927), using cox proportional hazards modeling, we found a significant association between NMSC and risk of total cancers (hazard ratio (HR) ¼ 1.25, 95% confidence intervals (CI) ¼ 1.20-1.31). In cancer-specific adjusted models, we also observed an increase in risk of breast cancer (HR ¼ 1.24, 95% CI ¼ 1.14-1.34), lung cancer (HR ¼ 1.21, 95% CI ¼ 1.08-1.37), NHL (HR ¼ 1.40, CI ¼ 1.18-1.65), leukemia (HR ¼ 1.28, CI ¼ 1.02-1.60) and melanoma (HR ¼ 2.1, 95% CI ¼ 1.78-2.48); whereas, we observed no increased risk of colon, ovarian, endometrial, or pancreatic cancers. Our finding that NMSC diagnosis is associated with increased risk of all cancers, lung cancer, breast cancer, NonHodgkin lymphoma/leukemia and melanoma, even adjusting for known risk factors for these cancers, supports prior studies investigating this relationship. Observation of the types of cancers associated with NMSC may inform studies of tumor etiology, and ultimately guide targeted screening strategies for survivors of NMSC.
Decreasing pediatric skin biopsy rates of lesions that were pigmented in a large health system MA Levoska4, R Jansen1, G Jacobsen3, M Jahnke1, D Hekman2 and M Eide1,3 1 Dermatology, Henry Ford Hospital, Detroit, MI, 2 Medical College of Wisconsin, Milwaukee, WI, 3 Public Health Sciences, Henry Ford Hospital, Detroit, MI and 4 Wayne State University School of Medicine, Detroit, MI Pediatric melanoma is difficult to clinically detect, which can delay diagnosis. Diagnostic tools, such as dermatoscopes, have evolved, improving evaluation and management of pigmented lesions. We sought to quantify biopsy rates of pigmented lesions and assess clinical suspicion in pediatric patients in a large US health system to assess changes over time. We identified a cohort of patients ages 0-18 years who underwent biopsies of skin lesions in 2004, 2007 and 2010. Using electronic data from a large health plan, biopsy rates for incident pigmented lesions and confidence intervals were calculated. Differential diagnoses recorded by clinicians at time of biopsy were used to classify lesions into categories of low, intermediate, high or unknown clinical suspicion. Kappa coefficients were calculated to compare histology with clinical suspicion. We identified 251 health plan pediatric patients for biopsy rate calculation. Biopsy rates of lesions that were pigmented declined by 44% from 2004 (182.9/100,000) to 2010 (102.0/100,000). Rates declined more in older children, with a 52.9% decline in preadolescents aged 10-14 years old and 53.3% in adolescents aged 15-18 years old. Biopsies of intermediate clinical suspicion declined by 64.3% during the study period with concurrent improvement in the kappa coefficients between clinical suspicion and histology: 0.04, 0.06 and 0.10 respectfully. Pediatric biopsy rates of lesions that were pigmented declined between 2004 and 2010, especially among preadolescents and adolescents. We theorize that clinicians may be more confident in their differential diagnoses due to improved diagnostic ability or patient reassurance related to the use of dermatoscopes. Findings may refute concerns of an increase in medically unnecessary skin biopsies, at least in the pediatric population.
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The influence of health insurance status on stage at diagnosis of cutaneous melanoma O Trofymenko University of Arizona College of Medicine - Tucson, Tucson, AZ The incidence of cutaneous melanoma has increased worldwide and in the United States over the last several decades. Later stage of melanoma diagnosis is associated with increased mortality. Retrospective review of Surveillance, Epidemiology, and End Results (SEER) database was conducted to evaluate the relationship between health insurance status of the patient diagnosed with melanoma of the skin and the stage of melanoma at diagnosis. The query of 2007-2012 data for Medicare-ineligible patients resulted in 20,305 records. 51.43% of patients were male. Interquartile age range was 52-59 years old. 3.50% were uninsured, 3.59% were on Medicaid, and 92.91% of patients had private insurance. On univariate analysis, significantly fewer patients with private insurance (8.85%), relative to those on Medicaid (28.53%) and uninsured (19.69%), presented with late stage of melanoma (p<0.001). When patient demographic characteristics and county socioeconomic factors were accounted for, the differences remained significant for both uninsured (odds ratio (OR) 2.20; 95% confidence interval [CI]: 1.81 e 2.68) and Medicaid (OR 3.87; 95% CI: 3.25 e 4.61) cohorts. The results suggest the existence of potential barriers to preventative care and surveillance that delay detection and treatment of cutaneous melanoma in both uninsured and Medicaid populations.
S36 Journal of Investigative Dermatology (2016), Volume 136
Outcomes and tumor characteristics of melanoma in patients with hypothyroidism K Hrynewycz and LA Mark Dermatology, Indiana University School of Medicine, Indianapolis, IN The incidence of malignant melanoma is on the rise, though the etiology and behavior remains complex and multifactorial. There is evidence that melanoma cells express functional thyroid stimulating hormone (TSH) receptors and TSH acts as a growth factor for melanomas, stimulating the mitogen-activated protein kinase pathway. An increased prevalence of hypothyroidism has been demonstrated in those with cutaneous melanoma and to date there are no clinical studies that evaluate tumor characteristics in patients with hypothyroidism and melanoma, or outcomes of such patients with or without levothyroxine therapy. The purpose of this study was to assess if patients with hypothyroidism diagnosed with melanoma fair worse than those without hypothyroidism. We performed a retrospective review of patients with melanoma seen at Indiana University multidisciplinary melanoma program from 20102015 and 2,551 patients were identified. Those with hypothyroidism found prior to or at the time of diagnosis of melanoma were included. Characteristics such as tumor site, depth, BRAF status and progression free and overall survival were delineated and compared to the 7th Edition American Joint Commission on Cancer Melanoma Staging and Classification data. The prevalence of hypothyroidism for both males and females was 14.1%, significantly higher than that of the general population. Of these patients with hypothyroidism, initial melanoma staging ranged from melanoma in situ to stage IIIC, only one patient harbored a BRAF mutation and all survived beyond 5 years from diagnosis. Our research suggests the prognosis for this cohort may, in fact, be better than those without hypothyroidism. Further studies are needed in both the clinic and laboratory settings such as assessing outcomes with and without hormone supplementation and evaluating the cellular response of a melanoma cell to treatment with levothyroxine. Additionally, our research supports the concept that hormonal regulation of melanoma may be present, which has the potential to open a previously uncharted approach to the treatment of melanoma.
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Prescription variation of biologic therapies for psoriasis J Miller1, J Kirby1, D Leslie2, G Emily3 and G Liu2 1 Dermatology, Penn State Hershey, Hershey, PA, 2 Public Health Sciences, Penn State Hershey, Hershey, PA and 3 Penn State Coll of Med, Hershey, PA The objective of this study is to analyze and describe prescription variation of biologic medications for the treatment of psoriasis. A retrospective analysis of the MarketScanÒ medical claims database was performed to identify patients with claims for psoriasis, based on ICD-9 code, and pharmacy claims for biologic medications from January 2008 to December 2013. Prescription variation was described based on US census regions. Coefficients of variation were calculated for each biologic and logistic regression models were employed to identify patient demographics, geographic location, and provider types. The cohort includes 25,485 patients with 29,401 claims for biologics. There was equal distribution of patients across the all age groups ranging from 18 to 64 years. 56% of patients were male and 44% were female. The majority of biologics prescribed for psoriasis were adalimumab (43.5%) and etanercept (46.7%), together accounting for 90.1% of the total 29401 claims, while ustekinumab accounted for 9.6%. There is considerable variation in biologic prescriptions that was statistically significant (p <0.0001) by US census region. The South region had the fewest prescriptions for etanercept (44.1%), while the Northeast, Northcentral and West regions had 50.2%, 48.0% and 50.1%, respectively. In contrast, the Northeast region had the fewest prescriptions for adalimumab (38.8%), while the West and Northcentral regions had 40.8% and 43.2%, respectively. The South at 45.7% had the most prescriptions for adalimumab. Analysis of biologic prescription variation over the time period based on year of FDA approval is pending. This is the first study to demonstrate the variability in prescription patterns for the biologic agents used to treat psoriasis. Given the costs of biologics, dermatology as a specialty needs to understand the reasons behind the prescription patterns.
Indoor tanning associations with substance use among Colorado high school students M Sendelweck1, E Bell3, K Ashack4, T Pindyck1, A Anderson3, C Townley3 and R Dellavalle2 1 University of Colorado, Denver, CO, 2 Denver Veterans Affairs Medical Center, Denver, CO, 3 Colorado Department of Public Health and Environment, Denver, CO and 4 Michigan State University College of Human Medicine, Grand Rapids, MI The purpose of this study is to determine if there is an association between indoor tanning practices and substance use in Colorado high school students. Results from the Healthy Kids Colorado Survey reaching more than 40,000 Colorado youth were analyzed. Questionnaires included an item on the frequency of indoor tanning use as well as the utilization of various substances including alcohol, cigarettes, marijuana, non-prescription use of prescription drugs, steroids, ecstasy, cocaine and heroin. Logistic regression was performed to evaluate association. Univariate analysis showed that females were twice as likely to engage in indoor tanning as males (unadjusted odds ratio, 2.0; 95%CI, 1.6-2.5; P<0.001). The multivariate analysis identified any lifetime use of steroids as the variable most strongly associated with indoor tanning (adjusted OR, 5.5; 95% CI, 3.4-9.1; P<.001). In males, this potential association was even stronger (adjusted OR, 7.1; 95% CI, 3.6-14.0; P<.001). Any 30 day alcohol consumption, cigarette, and marijuana use were also associated with IT, as were select lifetime illicit drug use (heroin, glue sniffing and non-prescription prescription use). This study provides evidence for an association between substance use and indoor tanning practices in Colorado high school students. Identifying risky health behavior patterns can facilitate preventative health efforts to reduce indoor tanning among adolescents. These findings may be used in clinic settings to broaden patient risk assessments and tailor appropriate counseling.
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Association of non-melanoma skin cancer with second non-cutaneous malignancy in the Women’s Health Initiative K Ransohoff1, M Stefanick2, S Li1, A Kurian3, H Wakelee3, A Wang1, H Hedlin2, E Paskett4, J Han5 and J Tang1 1 Department of Dermatology, Stanford University School of Medicine, Stanford, CA, 2 Medicine; Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, 3 Oncology, Stanford University School of Medicine, Stanford, CA, 4 Department of Internal Medicine, College of Medicine Epidemiology, Ohio State University, Columbus, OH and 5 School of Public Health, Indiana University, Indianapolis, IN Non-melanoma skin cancer (NMSC) is the most prevalent cancer in the United States and adults with NMSC have been reported to have higher rates of non-cutaneous malignancies. We examined the rates of development of non-cutaneous cancers in those with and without history of NMSC in the Women’s Health Initiative Observational Study, a large prospective cohort which collected important cancer-related covariates and has long-term follow up data. Looking at WHI participants who had history of NMSC at baseline (N ¼ 11,692) and without NMSC history (N ¼ 109,927), using cox proportional hazards modeling, we found a significant association between NMSC and risk of total cancers (hazard ratio (HR) ¼ 1.25, 95% confidence intervals (CI) ¼ 1.20-1.31). In cancer-specific adjusted models, we also observed an increase in risk of breast cancer (HR ¼ 1.24, 95% CI ¼ 1.14-1.34), lung cancer (HR ¼ 1.21, 95% CI ¼ 1.08-1.37), NHL (HR ¼ 1.40, CI ¼ 1.18-1.65), leukemia (HR ¼ 1.28, CI ¼ 1.02-1.60) and melanoma (HR ¼ 2.1, 95% CI ¼ 1.78-2.48); whereas, we observed no increased risk of colon, ovarian, endometrial, or pancreatic cancers. Our finding that NMSC diagnosis is associated with increased risk of all cancers, lung cancer, breast cancer, NonHodgkin lymphoma/leukemia and melanoma, even adjusting for known risk factors for these cancers, supports prior studies investigating this relationship. Observation of the types of cancers associated with NMSC may inform studies of tumor etiology, and ultimately guide targeted screening strategies for survivors of NMSC.
Decreasing pediatric skin biopsy rates of lesions that were pigmented in a large health system MA Levoska4, R Jansen1, G Jacobsen3, M Jahnke1, D Hekman2 and M Eide1,3 1 Dermatology, Henry Ford Hospital, Detroit, MI, 2 Medical College of Wisconsin, Milwaukee, WI, 3 Public Health Sciences, Henry Ford Hospital, Detroit, MI and 4 Wayne State University School of Medicine, Detroit, MI Pediatric melanoma is difficult to clinically detect, which can delay diagnosis. Diagnostic tools, such as dermatoscopes, have evolved, improving evaluation and management of pigmented lesions. We sought to quantify biopsy rates of pigmented lesions and assess clinical suspicion in pediatric patients in a large US health system to assess changes over time. We identified a cohort of patients ages 0-18 years who underwent biopsies of skin lesions in 2004, 2007 and 2010. Using electronic data from a large health plan, biopsy rates for incident pigmented lesions and confidence intervals were calculated. Differential diagnoses recorded by clinicians at time of biopsy were used to classify lesions into categories of low, intermediate, high or unknown clinical suspicion. Kappa coefficients were calculated to compare histology with clinical suspicion. We identified 251 health plan pediatric patients for biopsy rate calculation. Biopsy rates of lesions that were pigmented declined by 44% from 2004 (182.9/100,000) to 2010 (102.0/100,000). Rates declined more in older children, with a 52.9% decline in preadolescents aged 10-14 years old and 53.3% in adolescents aged 15-18 years old. Biopsies of intermediate clinical suspicion declined by 64.3% during the study period with concurrent improvement in the kappa coefficients between clinical suspicion and histology: 0.04, 0.06 and 0.10 respectfully. Pediatric biopsy rates of lesions that were pigmented declined between 2004 and 2010, especially among preadolescents and adolescents. We theorize that clinicians may be more confident in their differential diagnoses due to improved diagnostic ability or patient reassurance related to the use of dermatoscopes. Findings may refute concerns of an increase in medically unnecessary skin biopsies, at least in the pediatric population.
206
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The influence of health insurance status on stage at diagnosis of cutaneous melanoma O Trofymenko University of Arizona College of Medicine - Tucson, Tucson, AZ The incidence of cutaneous melanoma has increased worldwide and in the United States over the last several decades. Later stage of melanoma diagnosis is associated with increased mortality. Retrospective review of Surveillance, Epidemiology, and End Results (SEER) database was conducted to evaluate the relationship between health insurance status of the patient diagnosed with melanoma of the skin and the stage of melanoma at diagnosis. The query of 2007-2012 data for Medicare-ineligible patients resulted in 20,305 records. 51.43% of patients were male. Interquartile age range was 52-59 years old. 3.50% were uninsured, 3.59% were on Medicaid, and 92.91% of patients had private insurance. On univariate analysis, significantly fewer patients with private insurance (8.85%), relative to those on Medicaid (28.53%) and uninsured (19.69%), presented with late stage of melanoma (p<0.001). When patient demographic characteristics and county socioeconomic factors were accounted for, the differences remained significant for both uninsured (odds ratio (OR) 2.20; 95% confidence interval [CI]: 1.81 e 2.68) and Medicaid (OR 3.87; 95% CI: 3.25 e 4.61) cohorts. The results suggest the existence of potential barriers to preventative care and surveillance that delay detection and treatment of cutaneous melanoma in both uninsured and Medicaid populations.
S36 Journal of Investigative Dermatology (2016), Volume 136
Outcomes and tumor characteristics of melanoma in patients with hypothyroidism K Hrynewycz and LA Mark Dermatology, Indiana University School of Medicine, Indianapolis, IN The incidence of malignant melanoma is on the rise, though the etiology and behavior remains complex and multifactorial. There is evidence that melanoma cells express functional thyroid stimulating hormone (TSH) receptors and TSH acts as a growth factor for melanomas, stimulating the mitogen-activated protein kinase pathway. An increased prevalence of hypothyroidism has been demonstrated in those with cutaneous melanoma and to date there are no clinical studies that evaluate tumor characteristics in patients with hypothyroidism and melanoma, or outcomes of such patients with or without levothyroxine therapy. The purpose of this study was to assess if patients with hypothyroidism diagnosed with melanoma fair worse than those without hypothyroidism. We performed a retrospective review of patients with melanoma seen at Indiana University multidisciplinary melanoma program from 20102015 and 2,551 patients were identified. Those with hypothyroidism found prior to or at the time of diagnosis of melanoma were included. Characteristics such as tumor site, depth, BRAF status and progression free and overall survival were delineated and compared to the 7th Edition American Joint Commission on Cancer Melanoma Staging and Classification data. The prevalence of hypothyroidism for both males and females was 14.1%, significantly higher than that of the general population. Of these patients with hypothyroidism, initial melanoma staging ranged from melanoma in situ to stage IIIC, only one patient harbored a BRAF mutation and all survived beyond 5 years from diagnosis. Our research suggests the prognosis for this cohort may, in fact, be better than those without hypothyroidism. Further studies are needed in both the clinic and laboratory settings such as assessing outcomes with and without hormone supplementation and evaluating the cellular response of a melanoma cell to treatment with levothyroxine. Additionally, our research supports the concept that hormonal regulation of melanoma may be present, which has the potential to open a previously uncharted approach to the treatment of melanoma.