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Special Reports

Updates in Treatment and Clinical Pathways for Skin Cancer

June 20, 2019

Skin cancer is the most common type of cancer in the United States, and there are more diagnoses of skin cancer than all other cancers combined.1,2 The number of skin cancer cases is increasing, in particular for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).2 This is partly a result of increased awareness of disease but also due to UV exposure while tanning, which has become more common. Skin cancer that results from UV exposure has led to increasing incidences of cancers located on the torso as well as the head and neck, based on the latest population-based studies.2 During the decade from 2000-2010, the incidence of SCC rose 263%, while BCC cases increased by 145%.2

BCC alone is the most common cancer in the United States, with an estimated 2 million people diagnosed per year.3 SCC is the second most common, with half the incidence.3 In immunocompromised patients, BCC is at least three times more common than SCC. Estimates are imprecise, however, as clinicians are not required to report nonmelanoma skin cancers to registries.2 An estimated 3 million people were treated for nonmelanoma skin cancers in 2012, compared to approximately 1.6 million other cancer diagnoses that year.2

Metastasis in BCC is rare, and the disease is infrequently life-threatening.4 Localized SCC is highly curable, at a rate of 95% for patients in the early stages.4 The number of US deaths from BCC and SCC range from 2000 to more than 15,000 each year in the United States, with rates decreasing.5,6 Those who are most vulnerable to BCC and SCC are elderly patients who either received a delayed diagnosis or are immunocompromised, including those with organ transplants.5

Merkel cell carcinoma (MCC) cases are a small fraction of nonmelanoma skin cancers, with around 2488 cases per year. However, its incidence is dramatically increasing by about 2.5-fold over 10 years, 3-fold over 15 years, and 5.4-fold over 18 years.7 Between 2000 and 2013 alone, rates of MCC increased by 95%.8 The increasing incidence of this skin cancer type has been attributed to the aging population.8

Nonmelanoma skin cancers account for less than 0.1% of all cancer deaths.2 However, MCC is a much more aggressive cancer than other types of nonmelanoma skin cancers, with rapid growth and early metastases. Prior to diagnosis, 63% of the primary lesions grew rapidly in the preceding 3 months, and 26% to 36% of cases have lymph node involvement on presentation, with up to half eventually developing metastases. A smaller portion, 6% to 16%, have distant metastases on presentation, with up to one-third subsequently spreading. Approximately 25% to 50% of patients with MCC experience disease recurrence.7,8

Depending on the stage at presentation, the 5-year relative or MCC-specific survival rates are 41% to 77%.7,8 For patients with MCC who receive chemotherapy, prognosis is poor, with about 10% surviving 3 years after systemic treatment initiation.9

Melanoma of the skin affected an estimated 1,195,608 people in the United States in 2016.10 It is estimated that 96,480 new cases of melanoma will be diagnosed in 2019, with about 7230 patients dying of melanoma in the Unites States in the same year.10 However, these figures may be an underestimate, as many melanomas treated in the outpatient setting are not reported. The incidence of melanoma continues to increase dramatically, with rates increasing in men more rapidly than any other malignancy and in women more rapidly than any other malignancy expect lung cancer.10

In the United States, it is estimated that 84% of patients initially present with localized disease, 9% with regional disease, and 4% with distant metastatic disease. In general, prognosis is good for patients with localized disease or smaller primary tumors (1.00-mm thickness or less), with more than 90% of patients achieving 5-year survival.10 For patients with larger tumors (>1.0-mm thickness), survival ranges from 50% to 90%, depending on tumor thickness, ulceration, and mitotic rate.11 When regional nodes are involved, survival rates are roughly halved.11 Long-term survival in patients with distant metastatic melanoma has historically been less than 10%, although the emergence of effective systemic therapies has made long-term remission possible for a larger proportion of patients.12

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