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Incidence and Prevalence of Advanced/Metastatic CSCC

Insights From: Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center; Anna C. Pavlick, DO, NYU Langone Hospitals; Todd E. Schlesinger, MD, FAAD, FASMS, Dermatology & Laser Center of Charleston
Published: Tuesday, Dec 11, 2018



Transcript: 

Robert L. Ferris, MD, PhD: Skin cancer that’s nonmelanoma skin cancer is primarily comprised of basal cell carcinomas and squamous cell carcinomas. In the general population, basal cell carcinomas predominate. Historically, we’ve thought about a 2- to 3-fold disproportionate basal cell carcinoma, but those are much more indolent. In the post-transplant or immunosuppressed population, squamous cell carcinoma is more prevalent. Recently, cutaneous squamous cell carcinoma has been increasing in incidence; part of this is probably due to the elderly and older populations in the United States as well as more aggressive screening. There seems to be a rise of around 300% since the 1970s and 1980s.

Anna C. Pavlick, DO: We don’t really know exactly how many CSCC cases there are because it’s one of the few malignancies that’s not registered in the cancer research database. We think there’s probably between [800,000 and 1,000,000] cases of CSCC of the skin diagnosed every year; how many of those are locally advanced, most likely a small percentage—about 25% of the cases. Most are either locally recurrent or things people thought weren’t anything, when in fact they were CSCC.

Robert L. Ferris, MD, PhD: It’s important to recognize that what we call “advanced” squamous cell carcinoma of the skin depends in part on how we stage it. One of the deficiencies of prior staging systems is that they didn’t actually recognize some of the high-risk features and put them in the appropriate staging category, so that we would acknowledge them, stage them as advanced, and then treat them appropriately with imaging or other therapeutic interventions. In that regard, probably somewhere around 5% to 15% would be advanced squamous cell carcinomas, either due to large tumor diameter, the potential to spread to lymph nodes, perineural invasion or bone invasion—features that we now consider characteristic of advanced squamous cell carcinoma, which are now more accurately reflected.

It’s also important to recognize that skin cancer is not routinely monitored in cancer center registries across the United States. Our numbers are somewhat deficient because we don’t have a good denominator for how many skin cancers are out there. Unlike lung cancer, colorectal cancer, and breast cancer, where we are mandated to keep recording registries, we only see the advanced setting when they come in and need multimodality therapy. So knowing what that denominator is that are actually advanced is a bit of a challenging statistic.

Anna C. Pavlick, DO: A very small number of patients with locally advanced disease go on to metastasis; however, when things are neglected—when people decide that this is something that they don’t want to address—there’s very high likelihood that over time it will spread to the lymph nodes or even distantly to the lungs and the bone.

Robert L. Ferris, MD, PhD: The number of aggressive or advanced skin cancers that metastasize, again, is a bit hard to summarize because one would need to know the total number that is seen in a given year. But it’s estimated it’s somewhere around 5000 to 8000 cases that may have nodal metastasis in the United States in a given year. So that’s certainly the minority, but it’s an increasing fraction; it’s disproportionate in those individuals who have some sort of immunosuppression or are in the elderly populations.

At the University of Pittsburgh [UPMC] Hillman Cancer Center we have an advanced skin cancer clinic that is staffed by head and neck surgeons, dermatologists, Mohs surgeons, medical oncologists, and radiation oncologists; we have a center of excellence in a referral base. I think major academic centers also do, which leads to us seeing several cases per week because the catchment area is so broad. These are challenging cases. In addition, Pittsburgh and our institution have done a lot in the organ transplantation world; we have a large population that we’ve transplanted and therefore immunosuppressed. Those individuals are at higher risk, probably explaining why we see 1 to 2 cases every week with advanced cutaneous squamous cell carcinoma.

Transcript Edited for Clarity 
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Transcript: 

Robert L. Ferris, MD, PhD: Skin cancer that’s nonmelanoma skin cancer is primarily comprised of basal cell carcinomas and squamous cell carcinomas. In the general population, basal cell carcinomas predominate. Historically, we’ve thought about a 2- to 3-fold disproportionate basal cell carcinoma, but those are much more indolent. In the post-transplant or immunosuppressed population, squamous cell carcinoma is more prevalent. Recently, cutaneous squamous cell carcinoma has been increasing in incidence; part of this is probably due to the elderly and older populations in the United States as well as more aggressive screening. There seems to be a rise of around 300% since the 1970s and 1980s.

Anna C. Pavlick, DO: We don’t really know exactly how many CSCC cases there are because it’s one of the few malignancies that’s not registered in the cancer research database. We think there’s probably between [800,000 and 1,000,000] cases of CSCC of the skin diagnosed every year; how many of those are locally advanced, most likely a small percentage—about 25% of the cases. Most are either locally recurrent or things people thought weren’t anything, when in fact they were CSCC.

Robert L. Ferris, MD, PhD: It’s important to recognize that what we call “advanced” squamous cell carcinoma of the skin depends in part on how we stage it. One of the deficiencies of prior staging systems is that they didn’t actually recognize some of the high-risk features and put them in the appropriate staging category, so that we would acknowledge them, stage them as advanced, and then treat them appropriately with imaging or other therapeutic interventions. In that regard, probably somewhere around 5% to 15% would be advanced squamous cell carcinomas, either due to large tumor diameter, the potential to spread to lymph nodes, perineural invasion or bone invasion—features that we now consider characteristic of advanced squamous cell carcinoma, which are now more accurately reflected.

It’s also important to recognize that skin cancer is not routinely monitored in cancer center registries across the United States. Our numbers are somewhat deficient because we don’t have a good denominator for how many skin cancers are out there. Unlike lung cancer, colorectal cancer, and breast cancer, where we are mandated to keep recording registries, we only see the advanced setting when they come in and need multimodality therapy. So knowing what that denominator is that are actually advanced is a bit of a challenging statistic.

Anna C. Pavlick, DO: A very small number of patients with locally advanced disease go on to metastasis; however, when things are neglected—when people decide that this is something that they don’t want to address—there’s very high likelihood that over time it will spread to the lymph nodes or even distantly to the lungs and the bone.

Robert L. Ferris, MD, PhD: The number of aggressive or advanced skin cancers that metastasize, again, is a bit hard to summarize because one would need to know the total number that is seen in a given year. But it’s estimated it’s somewhere around 5000 to 8000 cases that may have nodal metastasis in the United States in a given year. So that’s certainly the minority, but it’s an increasing fraction; it’s disproportionate in those individuals who have some sort of immunosuppression or are in the elderly populations.

At the University of Pittsburgh [UPMC] Hillman Cancer Center we have an advanced skin cancer clinic that is staffed by head and neck surgeons, dermatologists, Mohs surgeons, medical oncologists, and radiation oncologists; we have a center of excellence in a referral base. I think major academic centers also do, which leads to us seeing several cases per week because the catchment area is so broad. These are challenging cases. In addition, Pittsburgh and our institution have done a lot in the organ transplantation world; we have a large population that we’ve transplanted and therefore immunosuppressed. Those individuals are at higher risk, probably explaining why we see 1 to 2 cases every week with advanced cutaneous squamous cell carcinoma.

Transcript Edited for Clarity 
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