ORIGINAL ARTICLE, p 1069
Nonmelanoma skin cancer (NMSC) is the most commonly diagnosed cancer in Europe, the U.S.A. and Australia, among others.1–3 In many of these countries, the sheer volume of new cases and high rates of multiple recurrences make it one of the costliest cancers.4–6 NMSC cuts a wide swath across many sectors of society. With at least one in five Americans receiving a diagnosis of NMSC during their lifetime,7 this cancer likely affects those with well-known and established risk factors as well as average-risk individuals. Rates continue to rise in elderly populations, although NMSC is now more commonly diagnosed in historically lower-risk younger persons, probably attributed at least in part to tanning bed use.8,9 Studies in special populations such as childhood cancer survivors10 and transplant patients11 reveal striking and dramatic reports of near-epidemic proportions of NMSC.
Lomas et al.12 should be commended for their expert and systematic review of the worldwide incidence of NMSC. In particular, they used strong and tight criteria, which provides near-optimal internal and external validity, establishing a new standard for subsequent similar reviews. Establishing a new international benchmark from numerous registries will be an important outgrowth of their systematic review. The data are very timely as the economic burden of NMSC in an ageing population is at hand. Many European registries report annual increases of 5–6% per year, whereas many registries in Australia note recent trends of plateauing cases of NMSC.12 While it is premature to generate significant conclusions regarding these incidence trends, it is possible that long-standing nationwide prevention activities in Australia13 may be contributing to this unanticipated finding.
Lomas et al. report the new initiatives from the National Institute for Health and Clinical Excellence (NICE) guidelines that truly address the burden of NMSC in the U.K. NICE guidelines14 reveal that the current annual number of basal cell carcinomas (BCCs) is probably closer to 55 000–60 000, surpassing official estimates of 48 000 per year. This gap may be explained by the fact that most U.K. cancer registries do not register multiple BCCs in the same individual. For example, it is estimated that 44% of residents of Scotland have a recurrent BCC within 3 years of their first BCC. Moreover, not all BCCs are submitted for histology, with one estimate indicating that up to 50% of general practitioners who remove suspected BCCs never submit them for histology.14
Collecting an accurate number of NMSCs from doctors’ offices, private settings and hospitals is akin to ‘herding cats’, and anticancer organizations and cancer control authorities have played little role to date in promoting an organized and dedicated approach for obtaining an accurate NMSC count. While an accurate count could provide much needed information on the true burden of NMSC, far more added value could be realized. A dedicated population-based registry of NMSC cases would enable matching of the network of transplant registries and childhood cancer survivor cohorts in Europe and the U.S.A. Currently, such matches rely on patient self-report and an unwieldy process that often requires layers of bureaucracy to obtain pathology reports. Strikingly, with a recent meta-analysis finding an estimated 12% increased overall risk for subsequent cancers for individuals first diagnosed with BCC (compared with those without prior BCCs),15 population-based registries could play an invaluable role for clinicians and epidemiologists searching for potential predictive markers for the development of subsequent cancers. The absence of an official count of NMSCs also precludes measuring the real effect of the tanning bed epidemic that has plagued much of Europe and the U.S.A. Finally, accurate counts reflecting the toll of NMSC on individuals could help to determine the impact of sun-protection programmes throughout Europe, the U.S.A. and Australia.
Where registration of NMSC does not occur, dedicated funding should be provided to incorporate mandatory registration. Where registration at the local, state or Federal level is a statute or regulation, funding should be provided to assist registrars in the collection of histology data from physicians’ offices and hospitals alike. The results from this study suggest a compelling need to convene epidemiologists, dermatologists, health services researchers and registrars to pilot a full registry system in two to three countries, and the U.K. or U.S.A. would be an ideal place to start. Whether there is a financial return on investment is questionable and potentially evaluable. It defies logic that cancer control authorities and public health officials can barely estimate the real and accurate burden of disease for the most common cancer in the industrialized world. Lomas et al. have described the burden of NMSC, and provided us with baseline values and the impetus to seek new and creative solutions to measuring the disproportionate burden of this disease.