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Researchers investigated treatment success rates for patients with field cancerization who received biopsies and treatment simultaneously.

Traditionally, patients with field cancerization undergo a biopsy and then return to their dermatologist for treatment. However, some dermatologists perform the biopsy and treatment on the same day to improve patient satisfaction, increase efficiency, and curb costs.

Noting concerns about the unconfirmed efficacy of same-day treatment and the potential overtreatment of benign lesions, a team of dermatologists from the University of North Carolina–Chapel Hill evaluated the success rate of same-day biopsy and treatment for this patient population.

A total of 63 patients at the UNC Dermatology Clinic underwent same-day biopsy and treatment from July 2016 to October 2019. The median age was 73 years, and most lesions were found in male patients (81%).

A total of 237 lesions underwent simultaneous diagnosis and treatment, which involved curettage with or without light electrodessication. Of these, 20 lesions recurred or required additional treatment. According to the findings, most lesions were nonmelanoma skin cancers (66%) or actinic keratosis (23%). The team estimated that 89% of biopsies would require follow-up treatment. Same-day treatment reduced this rate to 10.6%—an absolute risk reduction of 78%, with a number needed to treat of 1.3 (Table).

Physician’s Weekly (PW) spoke with Puneet Jolly, MD, PhD, who elaborated on his team’s results and the significance of improving clinical efficiency while reducing costs and burden for patients with field cancerization.

PW: What makes this study an important topic to investigate?

Dr. Jolly: Skin cancer is, by far, the most common cancer diagnosed in the United States. Chronic sun exposure and immunosuppression are two important risk factors implicated in the development of skin cancer. A substantial number of patients develop something called “field cancerization,” whereby their innate ability to repair sun damage is overwhelmed. These patients are prone to developing innumerable skin cancers throughout their lives.

Normally, patients come in for an appointment and concerning skin lesions are biopsied. After a few days, the physician views the biopsy reports and then contacts the patient with the results. If a skin cancer is diagnosed, patients need to make another appointment to have these areas treated. Sometimes, multiple appointments are needed.

As dermatologists, we consistently encounter a few problems in relation to the scenario outlined above: (i) problems with patient access, (ii) patient fatigue/frustration with logistical issues of having multiple appointments to address biopsied skin cancers, and (iii) increasing costs associated with skin cancer treatment.

The average number of individuals treated for skin cancer in the United States rose from 3.4 million to 4.9 million between 2002-2006 and 2007-2011, while the cost of treating skin cancer rose 126% from $3.6 billion to $8.1 billion. Annual spending for skin cancers increased more than for any other cancer.

Our training helps us identify skin cancers and distinguish between more and less aggressive lesions. Most diagnosed skin cancers are of the less aggressive subtypes. These often can be treated using quicker, non-surgical procedures such as curettage.

With same-day biopsy and curettage, patients do not require a second appointment for treatment. This also allows for better patient access since another established or new patient could use that appointment slot. The cost of treatment is also less, which alleviates some of the stress on our healthcare system.

Can you explain what you and your colleagues set out to determine with this study? 

This study had two main goals: (i) how effective we were at diagnosing precancerous/skin cancer lesions that would eventually need additional treatment, and (ii) how effective we were at eliminating the need for additional appointments/treatments to address the biopsied lesions. The study was a retrospective review. We examined the efficacy of this treatment in 224 lesions with a median follow-up of 32 months. We wanted to examine variations in success/failure depending on location, tumor type, and different patient characteristics, such as immunosuppression.

Our success in identifying precancerous lesions/skin cancers was approximately 89%, and treatment was considered successful (adequate treatment of skin cancer without recurrence) at a rate of 91%.

The table focuses on factors linked with treatment failure among 244 lesions. Why is this significant?

We wanted to examine which factors were associated with treatment failures. For example, immunosuppression is known to increase a person’s risk of developing skin cancer. In this study, about one-third of lesions treated were in immunocompromised patients, but almost half of treatment failures came from lesions on these patients.

Treatment success significantly differed between lesion locations, demonstrating the highest success rate on the trunk (98%) compared to the face, ear, or neck locations (77%).

Finally, we treated different skin cancers and found that certain types were more likely to clear successfully than others. Same-day curettage showed a 92% success rate for basal cell carcinoma. Success rates for squamous cell carcinoma in situ (superficial) and invasive squamous cell carcinoma were 88% and 64%, respectively. While success rates did not significantly vary by lesion size, there was a trend toward lower success with larger lesions.

What findings from your study are important to emphasize to our physician readers, particularly dermatologists?

This technique is particularly effective in treating most nonaggressive lesions in patients with actinic field cancerization. While we did not conduct a formal survey, patients are overwhelmingly in favor of approaching treatment in this manner. It is safe and effective, reduces cost, and improves patient access.

How would you like to see dermatologists incorporate your findings into practice?

I believe many providers already use this technique. Our goal was to demonstrate its efficacy and outline specific risk factors that lower the success rate for this technique. By showing its effectiveness and safety, we hope more providers will feel comfortable using it.

What would you like future research to focus on?

A follow-up study to examine the cost savings and improvement in patient access would be very interesting.