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Incidence of non-melanoma skin cancer in the US population aged 65 years and older, 2014
Journal Pre-proof Incidence of non-melanoma skin cancer in the US population aged 65 years and older, 2014 Howard Rogers, MD, PhD, Mara Beveridge, MD, Jonas Puente, MSc, Sarah Wixson, PhD, MS, Bryan Loy, MD, Laura E. Happe, PharmD, MPH PII:
S0190-9622(19)32687-8
DOI:
https://doi.org/10.1016/j.jaad.2019.08.079
Reference:
YMJD 13803
To appear in:
Journal of the American Academy of Dermatology
Received Date: 31 August 2018 Revised Date:
20 August 2019
Accepted Date: 28 August 2019
Please cite this article as: Rogers H, Beveridge M, Puente J, Wixson S, Loy B, Happe LE, Incidence of non-melanoma skin cancer in the US population aged 65 years and older, 2014, Journal of the American Academy of Dermatology (2019), doi: https://doi.org/10.1016/j.jaad.2019.08.079. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier on behalf of the American Academy of Dermatology, Inc.
1 2 3 4 5 6 7 8 9 10
Article type: Research letter Title: Incidence of non-melanoma skin cancer in the US population aged 65 years and older, 2014 Howard Rogers MD, PhD1, Mara Beveridge MD2, Jonas Puente MSc3, Sarah Wixson PhD, MS,4 Bryan Loy MD4, Laura E. Happe PharmD, MPH3 Advanced Dermatology, Norwich, Connecticut; 2Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio; 3Humana Inc., Louisville, Kentucky at the time the study was conducted; 4Humana Inc., Louisville, Kentucky 1
11 12 13 14 15 16 17
Corresponding Author: Mara Beveridge University Hospitals Case Medical Center 11100 Euclid Avenue, Lakeside 3500 Cleveland, OH 44106 Email: [email protected]
18 19 20 21 22 23 24 25 26 27 28 29
Funding Sources: None Conflict of Interest Disclosure: None Declared IRB approval status: N/A Manuscript word count: 500 [excluding capsule summary, abstract, references, figures, tables] Abstract word count: N/A Capsule summary word count: N/A References: 5 Figures: 1
30
To the Editor: Non-melanoma skin cancer (NMSC) is the most common malignancy in the United States
31
(US) with substantial associated morbidity, cost, and small but significant mortality;1 yet its incidence is
32
not nationally reported and must be estimated. The most recent peer-reviewed study analyzed data
33
from 2012 and calculated the total number of incident NMSCs in the US population at 5,434,193 and the
34
total number of persons treated for NMSC at 3,315,554.3 Here we offer an update based on more recent
35
and complete data by including the Medicare Advantage (MA) population. MA is a growing cohort of
36
Medicare provided by private insurance companies that is separate from Traditional Medicare and was
37
not included in prior analyses. MA plans are diverse; some operate like health maintenance
38
organizations (HMOs) and others like preferred provider organizations (PPOs).
39
Our analyses were based on 2014 claims data from the Medicare Limited Data Set Standard Analytic
40
Files (5% Sample Data Set) and Humana MA, one of the nation’s largest MA programs.4 Analysis was
41
limited to those aged 65 and older. The utilization of each treatment modality (excision, destruction,
42
Mohs surgery) was also evaluated. The methodology for calculation of NMSC incidence based on the 5%
43
Sample Data Set was described previously2,3,5 and was applied to the Humana MA population as well.
44
Rates were then extrapolated based on US Census Bureau data to account for the non-Medicare
45
population.
46
Our results show that in 2014 there were an estimated 3,450,062 treated NMSCs in 2,071,528 persons
47
in the US population aged 65 years and older (1.67 treated NMSCs/ affected patient) (Figure 1). This
48
translates to an incidence case rate of 75 NMSCs/1000 people and an incidence rate of 45 persons with
49
NMSC/1000 people. The most common procedure was destruction (37%), followed by Mohs (33%) and
50
excision (30%).
51
In the Traditional Medicare population, there were an estimated 2,148,220 NMSCs treated with
52
1,321,100 affected persons and an NMSC incidence rate of 78 NMSCs/1000 people (total population
53
27.60 million). The procedures used to treat NMSC were destruction – 822,540 (38%), excision –
54
636,300 (30%), and Mohs surgery - 683,260 (32%). In the MA population, there were an estimated
55
815,899 NMSCs treated with 449,598 affected persons and an NMSC incidence rate of 69 NMSCs/1000
56
people (total population 11.76 million). The frequency of procedures employed to treat NMSC was
57
destruction – 266,488 (33%), excision – 260,785 (32%), and Mohs surgery - 288,626 (35%). The non-
58
Medicare portion of the population was estimated to have 485,943 NMSC with 300,831 affected
59
persons in a population of 6.84 million.
60
This study provides the most up-to-date and sophisticated estimate of NMSC for the US elderly
61
population and demonstrated the need to include the growing MA population in future estimates since
62
their NMSC rates differ from Traditional Medicare. It is unclear why this difference was observed but
63
possibilities include socioeconomic or racial differences, selection bias related to choice of Medicare
64
plan, variations in benefit design, or physician behavior. This study was not designed to evaluate these
65
factors which will be the subject of future studies.
66 67
68
References:
69 70
1. “Skin Cancer.” American Cancer Society. Web. 23 May 2017.
71 72 73 74 75 76 77 78 79 80 81 82
2. Rogers HW, Weinstock MA, Harris AR, Hinckley MR, Feldman SR, Fleischer AB, Coldiron BM. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol. 2010 Mar;146(3):283-7. 3. Rogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence Estimate of Nonmelanoma Skin Cancer (Keratinocyte Carcinomas) in the U.S. Population, 2012. JAMA Dermatol. 2015 Oct;151(10):1081-6. 4. “Standard Analytical Files (Medicare Claims) – LDS.” CMS.gov, Centers for Medicare and Medicaid Services. Web. 7 April 2017. https://www.cms.gov/research-statistics-data-andsystems/files-for-order/limiteddatasets/standardanalyticalfiles.html 5. Joseph AK, Mark TL, Mueller C. The period prevalence and costs of treating nonmelanoma skin cancers in patients over 65 years of age covered by Medicare. Dermatol Surg. 2001 Nov;27(11):955-9.
83 84
85 86 87 88 89 90 91 92 93 94
95
Figure 1. Incidence of Non-melanoma Skin Cancer and Persons with Non-melanoma Skin Cancer in the US Population aged 65 years and older, 2014 Key: NMSC=non-melanoma skin cancer
S0190-9622(19)32687-8
DOI:
https://doi.org/10.1016/j.jaad.2019.08.079
Reference:
YMJD 13803
To appear in:
Journal of the American Academy of Dermatology
Received Date: 31 August 2018 Revised Date:
20 August 2019
Accepted Date: 28 August 2019
Please cite this article as: Rogers H, Beveridge M, Puente J, Wixson S, Loy B, Happe LE, Incidence of non-melanoma skin cancer in the US population aged 65 years and older, 2014, Journal of the American Academy of Dermatology (2019), doi: https://doi.org/10.1016/j.jaad.2019.08.079. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier on behalf of the American Academy of Dermatology, Inc.
1 2 3 4 5 6 7 8 9 10
Article type: Research letter Title: Incidence of non-melanoma skin cancer in the US population aged 65 years and older, 2014 Howard Rogers MD, PhD1, Mara Beveridge MD2, Jonas Puente MSc3, Sarah Wixson PhD, MS,4 Bryan Loy MD4, Laura E. Happe PharmD, MPH3 Advanced Dermatology, Norwich, Connecticut; 2Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio; 3Humana Inc., Louisville, Kentucky at the time the study was conducted; 4Humana Inc., Louisville, Kentucky 1
11 12 13 14 15 16 17
Corresponding Author: Mara Beveridge University Hospitals Case Medical Center 11100 Euclid Avenue, Lakeside 3500 Cleveland, OH 44106 Email: [email protected]
18 19 20 21 22 23 24 25 26 27 28 29
Funding Sources: None Conflict of Interest Disclosure: None Declared IRB approval status: N/A Manuscript word count: 500 [excluding capsule summary, abstract, references, figures, tables] Abstract word count: N/A Capsule summary word count: N/A References: 5 Figures: 1
30
To the Editor: Non-melanoma skin cancer (NMSC) is the most common malignancy in the United States
31
(US) with substantial associated morbidity, cost, and small but significant mortality;1 yet its incidence is
32
not nationally reported and must be estimated. The most recent peer-reviewed study analyzed data
33
from 2012 and calculated the total number of incident NMSCs in the US population at 5,434,193 and the
34
total number of persons treated for NMSC at 3,315,554.3 Here we offer an update based on more recent
35
and complete data by including the Medicare Advantage (MA) population. MA is a growing cohort of
36
Medicare provided by private insurance companies that is separate from Traditional Medicare and was
37
not included in prior analyses. MA plans are diverse; some operate like health maintenance
38
organizations (HMOs) and others like preferred provider organizations (PPOs).
39
Our analyses were based on 2014 claims data from the Medicare Limited Data Set Standard Analytic
40
Files (5% Sample Data Set) and Humana MA, one of the nation’s largest MA programs.4 Analysis was
41
limited to those aged 65 and older. The utilization of each treatment modality (excision, destruction,
42
Mohs surgery) was also evaluated. The methodology for calculation of NMSC incidence based on the 5%
43
Sample Data Set was described previously2,3,5 and was applied to the Humana MA population as well.
44
Rates were then extrapolated based on US Census Bureau data to account for the non-Medicare
45
population.
46
Our results show that in 2014 there were an estimated 3,450,062 treated NMSCs in 2,071,528 persons
47
in the US population aged 65 years and older (1.67 treated NMSCs/ affected patient) (Figure 1). This
48
translates to an incidence case rate of 75 NMSCs/1000 people and an incidence rate of 45 persons with
49
NMSC/1000 people. The most common procedure was destruction (37%), followed by Mohs (33%) and
50
excision (30%).
51
In the Traditional Medicare population, there were an estimated 2,148,220 NMSCs treated with
52
1,321,100 affected persons and an NMSC incidence rate of 78 NMSCs/1000 people (total population
53
27.60 million). The procedures used to treat NMSC were destruction – 822,540 (38%), excision –
54
636,300 (30%), and Mohs surgery - 683,260 (32%). In the MA population, there were an estimated
55
815,899 NMSCs treated with 449,598 affected persons and an NMSC incidence rate of 69 NMSCs/1000
56
people (total population 11.76 million). The frequency of procedures employed to treat NMSC was
57
destruction – 266,488 (33%), excision – 260,785 (32%), and Mohs surgery - 288,626 (35%). The non-
58
Medicare portion of the population was estimated to have 485,943 NMSC with 300,831 affected
59
persons in a population of 6.84 million.
60
This study provides the most up-to-date and sophisticated estimate of NMSC for the US elderly
61
population and demonstrated the need to include the growing MA population in future estimates since
62
their NMSC rates differ from Traditional Medicare. It is unclear why this difference was observed but
63
possibilities include socioeconomic or racial differences, selection bias related to choice of Medicare
64
plan, variations in benefit design, or physician behavior. This study was not designed to evaluate these
65
factors which will be the subject of future studies.
66 67
68
References:
69 70
1. “Skin Cancer.” American Cancer Society. Web. 23 May 2017.
71 72 73 74 75 76 77 78 79 80 81 82
2. Rogers HW, Weinstock MA, Harris AR, Hinckley MR, Feldman SR, Fleischer AB, Coldiron BM. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol. 2010 Mar;146(3):283-7. 3. Rogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence Estimate of Nonmelanoma Skin Cancer (Keratinocyte Carcinomas) in the U.S. Population, 2012. JAMA Dermatol. 2015 Oct;151(10):1081-6. 4. “Standard Analytical Files (Medicare Claims) – LDS.” CMS.gov, Centers for Medicare and Medicaid Services. Web. 7 April 2017. https://www.cms.gov/research-statistics-data-andsystems/files-for-order/limiteddatasets/standardanalyticalfiles.html 5. Joseph AK, Mark TL, Mueller C. The period prevalence and costs of treating nonmelanoma skin cancers in patients over 65 years of age covered by Medicare. Dermatol Surg. 2001 Nov;27(11):955-9.
83 84
85 86 87 88 89 90 91 92 93 94
95
Figure 1. Incidence of Non-melanoma Skin Cancer and Persons with Non-melanoma Skin Cancer in the US Population aged 65 years and older, 2014 Key: NMSC=non-melanoma skin cancer