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Investigating the potential correlation between sunscreen use and indoor tanning use among American high school students
3529
3870
Incidental skin cancer findings from total body skin examinations Angela Jiang, Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States; Dana Griffin, MD, Loyola University Medical Center, Department of Dermatology, Maywood, IL, United States; Jodi Speiser, MD, Loyola University Medical Center, Department of Pathology, Maywood, IL, United States; Martin Weinstock, MD, PhD, Veterans Affairs Medical Center, Dermatoepidemiology Unit, Providence, RI, United States; Hanna Mar, Loyola University Medical Center, Maywood, IL, United States; William Adams, MS, Loyola University Medical Center, Maywood, IL, United States; Stephanie Kliethermes, PhD, Loyola University Medical Center; Laura Winterfield, MD, Loyola University Medical Center, Department of Dermatology, Maywood, IL, United States; Murad Alam, MD, Northwestern University, Feinberg School of Medicine, Department of Dermatology, Chicago, IL, United States; Anthony Peterson, MD, Loyola University Medical Center, Department of Dermatology, Maywood, IL, United States
Investigating the potential correlation between sunscreen use and indoor tanning use among American high school students Yang Sheng, Case Western Reserve University School of Medicine, Cleveland, OH, United States; Jeremy Bordeaux, MD, University Hospitals Case Medical Center, Cleveland, OH, United States
Introduction: Dermatologists are routinely faced with the option of performing a total body skin examination (TBSE) versus a focused one on patients who present with a site-specific skin complaint found by the patient or referred by the primary care physician (PCP). While examining an at-risk patient thoroughly may take extra time, its merit is the potential early detection of skin cancer or other important signs. This study evaluates the detection of previously unidentified (by patient or PCP) skin cancers found on dermatologist-performed TBSE. Methods: Review of dermatology medical records of patients who were found to have biopsy-proven skin cancer between 2011 and 2013. Results: The 1044 patients who met inclusion criteria had a total of 1581 biopsyproven skin cancers. 813 (51.3%) of these biopsy-proven tumors were found on TBSE, with 1.9% of tumors detected by TBSE being melanoma, 62.4% being basal cell carcinoma (BCC) and 32.9% squamous cell carcinoma (SCC). Melanoma—Of 31 biopsy-diagnosed melanomas, 16 were found on TBSE. The melanomas found on TBSE had an average Breslow depth of 0.5 mm (0.2 mm-1.0 mm). When patients referred to dermatology for an identified potential melanoma were found to have such a tumor, mean Breslow depth was 1.04 mm (0.2 mm-6.9 mm) (P ¼.33). Basal cell carcinoma—Among the 988 biopsy-proven BCCs, 553 (53%, P \.001) were found on TBSE. BCC was 1.63 (95% CI 1.33-2.00) times more to be detected on dermatologist initiated TBSE versus focal examination initiated by patient concern for skin cancer. Squamous cell carcinoma—Of 521 biopsy-proven SCCs, 220 (42%, P \.001) were found on TBSE. Patients were more likely to identify SCCs versus other types of skin cancer as potential malignancies on presentation. Conclusions: TBSEs are highly sensitive for skin cancer when performed by trained dermatologists. We found that melanomas found by dermatologists were thinner than patient-identified or referred melanomas. BCCs were significantly more likely to be found on TBSE than detected by patients or PCPs. SCCs were identified by patients or PCPs less than 60% of the time. Given that SCCs can present as hyperkeratotic or ulcerated lesions, it is not surprising that patients can more easily identify SCCs than BCCs. Over 50% of skin cancers were identified by TBSE in this study, suggesting that evaluation of only the referred lesion cannot serve as a substitute for TBSE. Additionally, any reassurance provided would be inadequate in the absence of a TBSE. Commercial support: None identified.
2412 Increasing incidence of Merkel cell cancer in Sweden Oscar Zaar, MD, Department of Dermatology, Gothenburg, Sweden; John Paoli, MD, PhDDepartment of Dermatology, Gothenburg, Sweden; Bernt Lindel€ of, MD, PhD, Department of Dermatology, Stockholm, Sweden Background: Merkel cell carcinoma (MCC) is a rare aggressive neuroectodermal skin cancer with a high recurrence rate and a high mortality rate. Risk factors for MCC are reported to include high age, UV-exposure, white skin type and immunosuppression. The incidence is reported to be increasing in the USA and several European countries. The purpose of this study was to calculate the incidence of MCC in Sweden. Methods: The study design is a retrospective cohort study of population-based data for MCC collected by the Swedish Cancer Registry (SCR) to determine the incidence of MCC in Sweden and the clinical characteristics of these tumors including demographics, TNM classification, body part distribution, and overall survival after diagnosis. Anonymous data were collected from all registered cases between 1993 and 2012 using both systematized nomenclature of medicine (SNOMED) and International Classification of Diseases for Oncology (ICD), thus ensuring both the clinician’s and the pathologist’s classifications. The study obtained approval from the regional ethical review board. Results: A total of 606 cases of MCC were identified during the 20-year study period. The median age of the patients was 81 years (range 21-99) and a majority, 54 %, were women but age-adjusted incidence was higher in men. The incidence per 100,000 of MCC in Sweden in 1993-2012 increased from 0.09 to 0.20 for men (P\.05) and 0.120.17 for women (P ¼.091), age-adjusted for the world standard population. For both sexes, the increase was from 0.11 to 0.19, an increase of 73 % (P \.001). The most common site of the primary tumor was the head and neck with 52 % of the cases. The size of the tumor was \5 cm in 82 % of the cases. The majority of the tumors (91%) had no known lymphatic spread and only a few patients had confirmed distant metastases (3%) when diagnosed.
Skin cancer, one of the most common cancers in the United States, has shown no decline in incidence in the last few years. Two drivers of high skin cancer incidence are poor sunscreen use and the popularity of indoor tanning. Recently, there has been a push for skin cancer education for high school students to decrease the risk of skin cancer. Yet there has been no increase in the number of students wearing sunscreen in the last few years, although indoor tanning use has significantly declined. To better understand the trend, this study investigated the proportions of high school students using sunscreen and using indoor tanning devices to analyze if there was any correlation between the two variables. The study sought to determine whether poor sunscreen use was associated with frequent indoor tanning. Data were collected from 13,583 questionnaires given to high school students as part of the 2013 National Youth Risk Behavior Survey run by the Centers for Disease Control and Prevention. The students’ responses to two questions (one about sunscreen use and one about the use of an indoor tanning device), as well as demographic information such as sex, grade, and race/ethnicity, were analyzed to calculate whether the percentages of students who never or often used an indoor tanning device differed according to their sunscreen use. Overall, there was a positive and statistically significant (P \.05) association with sunscreen use and indoor tanning use, especially among male, Hispanic/Latino, black/African American, and ninth-grade students. There was no statistically significant correlation between the two variables for white students and female students. The study’s findings can ultimately help tailor educational tools for high school students to appreciate that both sunscreen use and indoor tanning avoidance will reduce their risk of skin cancer. Commercial support: None identified.
3843 Measuring the costs of shave and punch biopsy techniques using timedriven activity based costing Oluwatobi Ogbechie, MD, MBA, Mount Auburn Hospital, Cambridge, MA, United States; Thomas Wang, Brigham and Women’s Hospital, Boston, MA, United States; Vinod Nambudiri, MD, MBA, Brigham and Women’s Hospital, Boston, MA, United States; Arash Mostaghimi, MD, MPA, Brigham and Women’s Hospital, Boston, MA, United States Background: Implementing value-based health systems will require restructuring delivery models and physician reimbursement. Outpatient reimbursements are largely based on Current Procedural Terminology (CPT) codes derived from relative value units accounting for training length and time estimates, and practice costs. Despite the same payment, many dermatologic procedures are performed using techniques that vary in time and direct costs. We used time-driven activity based costing (TDABC) to calculate the true costs of shave and punch biopsies, which share a CPT code and Medicare reimbursement of $104.93. Furthermore, we examined variations in true costs to understand factors not reflected in CPT. Methods: The TDABC method approximates procedure costs by multiplying the quantity and cost per resource, both human and material. Two independent observers selected eligible patients seen by dermatologists at an academic practice in Boston from Dec 2014 to Aug 2015. Biopsies were timed, and materials used were recorded on custom-designed process maps for each biopsy type. TDABC financial models were constructed using these process maps. Statistical analyses were conducted using 2-tailed t-test. Results: 46 biopsies (29 shave, 17 punch) were observed. Shave biopsies cost $54.71 to perform: $26.45 for physician time (PT), $4.01 for nurse time (NT), $23.19 for materials, and $1.06 for space and equipment costs (SEC). Punch biopsies cost $78.91, significantly more across each category (P \.002): $42.70 for PT, $6.42 for NT, $28.10 for materials, and $1.69 for SEC. PT made up 48% and 54%, and materials made up 42% and 36% of total costs for shave and punch biopsies respectively. Given the Medicare reimbursement of $104.93, practices could earn an average of $50.22 and $26.02 on shave and punch biopsies respectively to cover other indirect costs.
Conclusions: MCC is a rare disease in Sweden, but the incidence is increasing. Incidence rates are higher than those in other Nordic countries and the rate at which incidence is increasing is slightly higher. This study supports the finding that high age, male sex and UV exposure are risk factors for MCCs. Interventions are required to increase awareness of MCC among clinicians and the general population.
Discussion: The data show TDABC’s feasibility for calculating dermatology service costs. Physician time and material costs are the major cost drivers of both punch and shave biopsies, which independently vary significantly in cost. Especially for practice management and financial planning in risk-sharing practices, TDABC is a useful tool to understand the financial impact of using various techniques for a given procedure. While TDABC may not capture all differences between biopsy types, its simple cost-accounting strategies quickly identify key cost factors. More studies are needed to assess TDABC’s feasibility to measure biopsy follow-up and out-of-pocket patient costs. Innovative specialist reimbursement systems will require additional identification of major cost factors for practice sustainability.
Commercial support: None identified.
Commercial support: None identified.
MAY 2016
J AM ACAD DERMATOL
AB119
3870
Incidental skin cancer findings from total body skin examinations Angela Jiang, Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States; Dana Griffin, MD, Loyola University Medical Center, Department of Dermatology, Maywood, IL, United States; Jodi Speiser, MD, Loyola University Medical Center, Department of Pathology, Maywood, IL, United States; Martin Weinstock, MD, PhD, Veterans Affairs Medical Center, Dermatoepidemiology Unit, Providence, RI, United States; Hanna Mar, Loyola University Medical Center, Maywood, IL, United States; William Adams, MS, Loyola University Medical Center, Maywood, IL, United States; Stephanie Kliethermes, PhD, Loyola University Medical Center; Laura Winterfield, MD, Loyola University Medical Center, Department of Dermatology, Maywood, IL, United States; Murad Alam, MD, Northwestern University, Feinberg School of Medicine, Department of Dermatology, Chicago, IL, United States; Anthony Peterson, MD, Loyola University Medical Center, Department of Dermatology, Maywood, IL, United States
Investigating the potential correlation between sunscreen use and indoor tanning use among American high school students Yang Sheng, Case Western Reserve University School of Medicine, Cleveland, OH, United States; Jeremy Bordeaux, MD, University Hospitals Case Medical Center, Cleveland, OH, United States
Introduction: Dermatologists are routinely faced with the option of performing a total body skin examination (TBSE) versus a focused one on patients who present with a site-specific skin complaint found by the patient or referred by the primary care physician (PCP). While examining an at-risk patient thoroughly may take extra time, its merit is the potential early detection of skin cancer or other important signs. This study evaluates the detection of previously unidentified (by patient or PCP) skin cancers found on dermatologist-performed TBSE. Methods: Review of dermatology medical records of patients who were found to have biopsy-proven skin cancer between 2011 and 2013. Results: The 1044 patients who met inclusion criteria had a total of 1581 biopsyproven skin cancers. 813 (51.3%) of these biopsy-proven tumors were found on TBSE, with 1.9% of tumors detected by TBSE being melanoma, 62.4% being basal cell carcinoma (BCC) and 32.9% squamous cell carcinoma (SCC). Melanoma—Of 31 biopsy-diagnosed melanomas, 16 were found on TBSE. The melanomas found on TBSE had an average Breslow depth of 0.5 mm (0.2 mm-1.0 mm). When patients referred to dermatology for an identified potential melanoma were found to have such a tumor, mean Breslow depth was 1.04 mm (0.2 mm-6.9 mm) (P ¼.33). Basal cell carcinoma—Among the 988 biopsy-proven BCCs, 553 (53%, P \.001) were found on TBSE. BCC was 1.63 (95% CI 1.33-2.00) times more to be detected on dermatologist initiated TBSE versus focal examination initiated by patient concern for skin cancer. Squamous cell carcinoma—Of 521 biopsy-proven SCCs, 220 (42%, P \.001) were found on TBSE. Patients were more likely to identify SCCs versus other types of skin cancer as potential malignancies on presentation. Conclusions: TBSEs are highly sensitive for skin cancer when performed by trained dermatologists. We found that melanomas found by dermatologists were thinner than patient-identified or referred melanomas. BCCs were significantly more likely to be found on TBSE than detected by patients or PCPs. SCCs were identified by patients or PCPs less than 60% of the time. Given that SCCs can present as hyperkeratotic or ulcerated lesions, it is not surprising that patients can more easily identify SCCs than BCCs. Over 50% of skin cancers were identified by TBSE in this study, suggesting that evaluation of only the referred lesion cannot serve as a substitute for TBSE. Additionally, any reassurance provided would be inadequate in the absence of a TBSE. Commercial support: None identified.
2412 Increasing incidence of Merkel cell cancer in Sweden Oscar Zaar, MD, Department of Dermatology, Gothenburg, Sweden; John Paoli, MD, PhDDepartment of Dermatology, Gothenburg, Sweden; Bernt Lindel€ of, MD, PhD, Department of Dermatology, Stockholm, Sweden Background: Merkel cell carcinoma (MCC) is a rare aggressive neuroectodermal skin cancer with a high recurrence rate and a high mortality rate. Risk factors for MCC are reported to include high age, UV-exposure, white skin type and immunosuppression. The incidence is reported to be increasing in the USA and several European countries. The purpose of this study was to calculate the incidence of MCC in Sweden. Methods: The study design is a retrospective cohort study of population-based data for MCC collected by the Swedish Cancer Registry (SCR) to determine the incidence of MCC in Sweden and the clinical characteristics of these tumors including demographics, TNM classification, body part distribution, and overall survival after diagnosis. Anonymous data were collected from all registered cases between 1993 and 2012 using both systematized nomenclature of medicine (SNOMED) and International Classification of Diseases for Oncology (ICD), thus ensuring both the clinician’s and the pathologist’s classifications. The study obtained approval from the regional ethical review board. Results: A total of 606 cases of MCC were identified during the 20-year study period. The median age of the patients was 81 years (range 21-99) and a majority, 54 %, were women but age-adjusted incidence was higher in men. The incidence per 100,000 of MCC in Sweden in 1993-2012 increased from 0.09 to 0.20 for men (P\.05) and 0.120.17 for women (P ¼.091), age-adjusted for the world standard population. For both sexes, the increase was from 0.11 to 0.19, an increase of 73 % (P \.001). The most common site of the primary tumor was the head and neck with 52 % of the cases. The size of the tumor was \5 cm in 82 % of the cases. The majority of the tumors (91%) had no known lymphatic spread and only a few patients had confirmed distant metastases (3%) when diagnosed.
Skin cancer, one of the most common cancers in the United States, has shown no decline in incidence in the last few years. Two drivers of high skin cancer incidence are poor sunscreen use and the popularity of indoor tanning. Recently, there has been a push for skin cancer education for high school students to decrease the risk of skin cancer. Yet there has been no increase in the number of students wearing sunscreen in the last few years, although indoor tanning use has significantly declined. To better understand the trend, this study investigated the proportions of high school students using sunscreen and using indoor tanning devices to analyze if there was any correlation between the two variables. The study sought to determine whether poor sunscreen use was associated with frequent indoor tanning. Data were collected from 13,583 questionnaires given to high school students as part of the 2013 National Youth Risk Behavior Survey run by the Centers for Disease Control and Prevention. The students’ responses to two questions (one about sunscreen use and one about the use of an indoor tanning device), as well as demographic information such as sex, grade, and race/ethnicity, were analyzed to calculate whether the percentages of students who never or often used an indoor tanning device differed according to their sunscreen use. Overall, there was a positive and statistically significant (P \.05) association with sunscreen use and indoor tanning use, especially among male, Hispanic/Latino, black/African American, and ninth-grade students. There was no statistically significant correlation between the two variables for white students and female students. The study’s findings can ultimately help tailor educational tools for high school students to appreciate that both sunscreen use and indoor tanning avoidance will reduce their risk of skin cancer. Commercial support: None identified.
3843 Measuring the costs of shave and punch biopsy techniques using timedriven activity based costing Oluwatobi Ogbechie, MD, MBA, Mount Auburn Hospital, Cambridge, MA, United States; Thomas Wang, Brigham and Women’s Hospital, Boston, MA, United States; Vinod Nambudiri, MD, MBA, Brigham and Women’s Hospital, Boston, MA, United States; Arash Mostaghimi, MD, MPA, Brigham and Women’s Hospital, Boston, MA, United States Background: Implementing value-based health systems will require restructuring delivery models and physician reimbursement. Outpatient reimbursements are largely based on Current Procedural Terminology (CPT) codes derived from relative value units accounting for training length and time estimates, and practice costs. Despite the same payment, many dermatologic procedures are performed using techniques that vary in time and direct costs. We used time-driven activity based costing (TDABC) to calculate the true costs of shave and punch biopsies, which share a CPT code and Medicare reimbursement of $104.93. Furthermore, we examined variations in true costs to understand factors not reflected in CPT. Methods: The TDABC method approximates procedure costs by multiplying the quantity and cost per resource, both human and material. Two independent observers selected eligible patients seen by dermatologists at an academic practice in Boston from Dec 2014 to Aug 2015. Biopsies were timed, and materials used were recorded on custom-designed process maps for each biopsy type. TDABC financial models were constructed using these process maps. Statistical analyses were conducted using 2-tailed t-test. Results: 46 biopsies (29 shave, 17 punch) were observed. Shave biopsies cost $54.71 to perform: $26.45 for physician time (PT), $4.01 for nurse time (NT), $23.19 for materials, and $1.06 for space and equipment costs (SEC). Punch biopsies cost $78.91, significantly more across each category (P \.002): $42.70 for PT, $6.42 for NT, $28.10 for materials, and $1.69 for SEC. PT made up 48% and 54%, and materials made up 42% and 36% of total costs for shave and punch biopsies respectively. Given the Medicare reimbursement of $104.93, practices could earn an average of $50.22 and $26.02 on shave and punch biopsies respectively to cover other indirect costs.
Conclusions: MCC is a rare disease in Sweden, but the incidence is increasing. Incidence rates are higher than those in other Nordic countries and the rate at which incidence is increasing is slightly higher. This study supports the finding that high age, male sex and UV exposure are risk factors for MCCs. Interventions are required to increase awareness of MCC among clinicians and the general population.
Discussion: The data show TDABC’s feasibility for calculating dermatology service costs. Physician time and material costs are the major cost drivers of both punch and shave biopsies, which independently vary significantly in cost. Especially for practice management and financial planning in risk-sharing practices, TDABC is a useful tool to understand the financial impact of using various techniques for a given procedure. While TDABC may not capture all differences between biopsy types, its simple cost-accounting strategies quickly identify key cost factors. More studies are needed to assess TDABC’s feasibility to measure biopsy follow-up and out-of-pocket patient costs. Innovative specialist reimbursement systems will require additional identification of major cost factors for practice sustainability.
Commercial support: None identified.
Commercial support: None identified.
MAY 2016
J AM ACAD DERMATOL
AB119