To the editor: It is estimated that over 4,000,000 adults were treated for non-melanoma skin cancer (NMSC) between 2007 and 2011, with average annual treatment costs of approximately $4.8 billion in the U.S. population.1 The average annual number of adults treated for skin cancer in the U.S. population has increased from 3.4 million in 2002–2006 to 4.9 million in 2007–2011 with the average annual total cost for skin cancer increasing from $3.6 billion to $8.1 billion, or an increase of 126.2%, demonstrating that the health and economic burden of skin cancer treatment is vastly increasing.2 The aim of this study was to identify factors that predict lower QOL scores in patients undergoing Mohs micrographic surgery (MMS) for NMSC.
The Skin Cancer Index (SCI), a 15-item validated QOL questionnaire, was administered to a prospective cohort of NMSC patients at a two-physician academic dermatologic surgery center. The SCI was used as it is disease-specific to NMSC and has been previously validated in a dermatologic surgery setting.3 A 5-point response format was used to assess the extent each item described the feelings of the patient, with 1 (very much) to 5 (not at all), with a higher score indicating better quality of life. Patients diagnosed with a NMSC attending the Brigham and Women’s Hospital Mohs and Dermatologic Surgery Center from March 2014 through March 2015 were eligible for participation in the study. A two-sample t-test with unequal variances and Welch’s approximation was used to examine factors predictive of overall SCI score and the social, emotional, and appearance subscales. Statistical analyses were performed using Stata version 12.0 (College Station, TX). The Partners Human Research Committee approved this study.
Table 1 summarizes the characteristics of the study cohort. A total of 389 patients were included in the study. Eleven declined to participate. In our overall analysis, independent predictors of lower overall SCI score were younger age (p<0.001), female gender (p<0.001), being employed (p<0.001), and tumor location on the head and neck (p=.01) (Table 2). Independent predictors of lower subscale scores were as follows, social subscale: employment (p<0.001) and previous history of skin cancer (p=.032); emotional subscale: younger age (p<0.001) and female gender (p<0.001); appearance subscale: younger age (p<0.001), female gender (p<0.001), employment (p<0.001), and tumor location of the head and neck (p<0.001).
Table 1.
Baseline Cohort Characteristics
| Variable | n | % |
|---|---|---|
| Total patients | 389 | --- |
| Mean age (SD), years | 66.5 (13.1) | --- |
| Age range, years | 20–95 | --- |
| Gender | ||
| Race | ||
| Employment status | ||
| Immunosuppression | ||
| Previous history of skin cancer | ||
| Comorbidities | ||
| Type of skin cancer treated | ||
| Location of skin cancer | ||
| Mean tumor diameter (SD), cm | 1.42 (1.00) | --- |
| Mean post-operative area size (SD), cm | 2.68 (5.67) | --- |
| Median QOL scores (IQR)** | ||
Abbreviations: IQR, inter-quartile range; QOL, quality of life; SD, standard deviation.
Less than 5% of patients with the following co-morbidities: COPD, stroke, breast cancer, prostate cancer, lymphoma, leukemia, colon cancer, lung cancer, depression, ulcerative colitis.
Each raw score was standardized as follows: (raw score-1) × (100/4).
Table 2.
Analysis of Factors Predictive of Overall Skin Cancer Index and Subscale Scores
| Overall Skin Cancer Index Score | Mean (SD) | p value |
|---|---|---|
| Age (lower quartile) | 52.2 (12.6) | <0.001 |
| Male | 81.4 (15.4) | <0.001 |
| Employed | 73.8 (18.3) | <0.001 |
| Head/neck location (including lip/ear) | 76.7 (17.8) | 0.01 |
| Social Subscale Score | Mean (SD) | p value |
| Employed | 86.5 (15.1) | <0.001 |
| Previous history of skin cancer | 90.0 (13.1) | .032 |
| Emotional Subscale Score | Mean (SD) | p value |
| Age (lower quartile) | 43.2 (18.3) | <0.001 |
| Male | 71.7 (20.6) | <0.001 |
| Appearance Subscale Score | Mean (SD) | p value |
| Age (lower quartile) | 39.3 (23.5) | <0.001 |
| Male | 82.9 (23.1) | <0.001 |
| Employed | 70.6 (28.9) | <0.001 |
| Head/neck location (including lip/ear) | 73.6 (28.1) | <0.001 |
Abbreviation: SD, standard deviation.
Other studies of quality of life in skin cancer patients are rare and have focused on other factors or study questions.4,5 We find the employment finding to be particularly interesting since it persisted once age-adjusted. Older people who may otherwise not suffer greatly from their skin cancer suffer more if they are still working. This is important for physicians to understand – patients work longer now than in prior generations, and this may affect the toll their skin cancer is taking on them. A greater understanding of QOL in NMSC patients will lead to a more patient-centered treatment approach to disease and better overall outcomes that are important to NMSC patients.
Funding Source:
Mr Karia is supported by a Cancer Epidemiology, Prevention, and Control Training Grant (NCI T32 CA009314).
Footnotes
Conflicts of Interest Disclosure: None reported
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