Vol. 30. No. 1


Although the increasing incidence of skin cancer has concerned dermatologists for years, the true magnitude of this epidemic has recently come into focus. In 2006, more than 3.5 million new cases of nonmelanoma skin cancer were diagnosed in the United States, with the estimated cost of treatment in the Medicare population over $400 million dollars per year.1,2 In addition, large increases in skin cancer incidence were noted in Canada, Northern Ireland, Scotland, and the Netherlands. Given these trends, physicians treating skin cancer must identify tumors at low and high risk for recurrence and metastasis, and be familiar with available treatment options, including newer therapeutic alternatives. In this issue of Seminars in Cutaneous Medicine and Surgery, experts in the field focus on recent developments in cutaneous oncology, providing us with a comprehensive look at current and future trends affecting skin cancer patients and their physicians. As the number of patients affected by skin cancer continues to increase, efforts to prevent ultraviolet (UV) radiation-induced tumors have intensified. New chemopreventive agents targeting stages of skin cancer development, or reversing UV-induced immune suppression, are being extensively studied. When used in conjunction with traditional sunscreens, these agents may provide enhanced protection against the harmful effects of UV radiation. Drs Camp and Elmets provide a framework for understanding how these agents work and under what circumstances they could prove most useful. Another hot topic is whether lasers or topical treatments can effectively treat nonmelanoma skin cancer, thereby providing an alternative to the more traditional modalities of surgery and radiation. Drs Brightman, Warycha, Anolik, and Geronemus review the data regarding these alternative strategies, which could benefit patients who have numerous small, superficial tumors, or who are reluctant to undergo surgery. To optimize patient care, it is critical to identify skin cancer patients at risk for poor outcomes and standardize the classification, staging, and treatment of high-risk tumors. Drs LeBoeuf and Schmults summarize the National Comprehensive Cancer Network’s treatment guidelines for classification and management of high risk cutaneous squamus cell carcinoma, as well as the American Joint Committee on Cancer staging guidelines. The development of reliable prognostic models and validated staging systems for this tumor will facilitate the design of clinical studies and will ultimately guide future treatment decisions for affected patients. The most common post-transplant malignancy for immunosuppressed organ transplant recipients is skin cancer. Drs Singh and Brewer review the management alternatives for organ transplant recipients affected by skin cancer, including surgery, adjuvant radiation, and chemotherapy, as well as options for chemoprophylaxis and reduction of immunosuppression. Also addressed are special considerations, including the approach to patients with regional and distant metastatic disease, and management issues in patients with multiple primary nonmelanoma skin cancers and melanoma. Merkel cell carcinoma is an unusual, aggressive cutaneous tumor, seen more frequently in immunosuppressed patients, whose incidence is also increasing. It was recently found to be associated with a novel doublestranded DNA virus, the Merkel cell polyoma virus, a discovery that has sparked great interest in viral tumorigenesis. Drs Wang, Byrne, Jacobs, and Taube discuss new developments in the diagnosis, staging, and management of Merkel cell carcinoma , and provide an update on current thinking regarding the pathogenesis of this rare tumor. An increasingly attractive option for patients with aggressive or advanced nonmelanoma skin cancer is targeted molecular therapy. The new generation of targeted molecular inhibitors provides hope for a subpopulation of patients with advanced skin cancer, potentially enhancing their quality of life as well as their life expectancy. Drs O’Bryan and Ratner provide an overview of recent developments and future possibilities for treatment of unresectable or metastatic squamous cell carcinoma, basal cell carcinoma, and dermatfibrosarcoma protuberans. We are grateful to the authors for sharing their expertise and knowledge with us for this special issue. It is through educational, clinical, and research efforts like theirs that the morbidity, mortality, and cost of the skin cancer epidemic will eventually be mitigated.

New Agents for Prevention of Ultraviolet-Induced Nonmelanoma Skin Cancer

Craig A. Elmets, MD | Jennifer W. Turnham, BS | Mohammad Athar, PhD | William L. Camp, MD, MPH

With the incidence of nonmelanoma skin cancer on the rise, current prevention methods,
such as the use of sunscreens, have yet to prove adequate to reverse this trend. There has
been considerable interest in identifying compounds that will inhibit or reverse the biochemical
changes required for skin cancers to develop, either by pharmacologic intervention
or by dietary manipulation. By targeting different pathways identified as important in
the pathogenesis of nonmelanoma skin cancers, a combination approach with multiple
agents or the addition of chemopreventative agents to topical sunscreens may offer the
potential for novel and synergistic therapies in treating nonmelanoma skin cancer.
Semin Cutan Med Surg 30:6-13 © 2011 Elsevier Inc. All rights reserved.


No End in Sight: The Skin Cancer Epidemic Continues

Brett M. Coldiron, MD | Matthew R. Donaldson, MD

The incidence of nonmelanoma skin cancer (NMSC) continues to increase. Multiple reports
from the United States and Europe suggest we are in the midst of an epidemic. European
studies show substantial NMSC incidence increases during the last 2 decades. In the
United States, a recent analysis of Medicare Claims data showed that procedures performed
for NMSC nearly doubled from 1994 to 2006. From these data, the total number of
new NMSC in 2006 was estimated to be 3,507,693. Procedure data for 2006-2008 from the
5% Medicare Claims sample dataset corroborate the reported trajectory of incidence
increase. Destructions, excisions, and Mohs procedures for NMSC have increased by
2.6% per year during the last 2 years. On the basis of this current rate of increase, the
annual incidence of NMSC in the United States in 2008 would be nearly 3.69 million.
Recognizing the NMSC epidemic is critical as the incidence—and cost—will continue to
Semin Cutan Med Surg 30:3-5 © 2011 Elsevier Inc. All rights reserved.


Do Lasers or Topicals Really Work for Nonmelanoma Skin Cancers?

Lori A. Brightman, MD | Melanie Warycha, MD | Robert Anolik, MD | Roy G Geronemus, MD

Novel strategies are urgently needed to address the millions of nonmelanoma skin cancers
treated in the United States annually. The need is greatest for those patients who are poor
surgical candidates or those prone to numerous nonmelanoma skin cancers and therefore
at risk for marked disfigurement. Traditional treatment strategies include electrosurgery
with curettage, radiation therapy, cryotherapy, excision, and Mohs micrographic surgery.
Alternatives to traditional treatment, including topical medications and light or laser therapies,
are becoming popular; however, there are various degrees of efficacy among these
alternative tactics. These alternatives include topical retinoids, peels, 5-fluorouracil, imiquimod,
photodynamic therapy, and lasers. The purpose of this paper is to review the
available data regarding these alternative strategies and permit the reader to have a sense
of which therapies are reasonable options for care.
Semin Cutan Med Surg 30:14-25 © 2011 Elsevier Inc. All rights reserved.


Update on the Management of High-Risk Squamous Cell Carcinoma

Chrysalyne D. Schmults, MD, MSCE | Nicole R. LeBoeuf, MD

Cutaneous squamous cell carcinoma (CSCC) is the second most common malignancy
occurring in white patients in the United States and incidence rates are increasing. While
the majority of the 87,000-760,000 cases that occur yearly in the U.S. are curable, 4%
develop lymph node metastases and 1.5% die from the disease. Given the frequency of
occurrence of CSCC, it is estimated to cause as many deaths yearly as melanoma, with the
majority occurring in patients with high risk tumors or in those at high risk for metastasis
due to a variety of host factors, most commonly systemic immunosuppression. There are
currently no standardized prognostic or treatment models to assist clinicians in most
effectively identifying and managing these patients. Identification of patients at risk for poor
outcomes as well as standardization regarding classification, staging, and treatment of
high-risk tumors is critical for optimizing patient care. In this article, available literature on
the classification and management of high risk CSCC is briefly summarized, emphasizing
new information.
Semin Cutan Med Surg 30:26-34 © 2011 Elsevier Inc. All rights reserved.


Current Approaches to Skin Cancer Management in Organ Transplant Recipients

Jerry D. Brewer, MD | Meena K. Singh, MD

Approximately 225,000 people are living with organ transplants in the United States. Organ
transplant recipients have a greater risk of developing skin cancer, including basal cell
carcinoma, squamous cell carcinoma, and malignant melanoma, with an approximately 250
times greater incidence of squamous cell carcinoma in certain transplant recipients,
compared with the general population. Because skin cancers are the most common
posttransplant malignancy, the resultant morbidity and mortality in these high-risk patients
is quite significant.
Semin Cutan Med Surg 30:35-47 © 2011 Elsevier Inc. All rights reserved.