Patient Factors and Their Association with Nonmelanoma Skin Cancer Morbidity and the Performance of Self-skin Exams: A Cross-Sectional Study

Mohs micrographic surgery (MMS) is used for the treatment of nonmelanoma skin cancer (NMSC) with the advantage of increased tissue preservation.1 The utilization of MMS has increased over the years from three percent in 1995 to 17 percent in 2010.2 Furthermore, MMS has the best long-term cure rate of any basal cell carcinoma (BCC) treatment.1 MMS is indicated for the removal of all BCCs on the central face, eyelids, eyebrows, nose, lips, and chin (area H).3 With the exception of primary superficial BCCs less than or equal to 0.5cm in healthy individuals, MMS is also appropriate for all BCCs of the cheeks, forehead, scalp, neck, jawline, and pretibial surface (area M).3 MMS is also appropriate for primary aggressive and recurrent aggressive squamous cell carcinoma (SCC) in all areas.3 In areas H and M for any size tumor and for all lesions greater than 2cm, MMS is suitable for primary SCC without aggressive histologic features.3 The defect size after MMS has been used as a precise measure of morbidity and can be influenced by delay in treatment, initial examination by a primary provider, misdiagnosis, failure to obtain a biopsy before treatment, or multiple surgical removals.4 Skin cancer morbidity has been evaluated in various populations. Studies of the African American and Hispanic populations demonstrate that skin cancer presents at a later stage than compared with Caucasian patients, potentially due to lower awareness, more advanced stages at diagnosis, and barriers to healthcare access and utilization.5,6 Patients with darker skin types (Fitzpatrick IV to VI) have a diminished ability to identify NMSC.7 Furthermore, Hispanics perform skin cancer surveillance less frequently than Caucasians.8 For instance, only 17.6 percent of Hispanics have ever conducted a self-skin exam and only 9.2 percent have had a total cutaneous examination by a healthcare professional.8 Presentation of NMSC can differ in people with darker skin compared to lighter skin individuals. In darker skinned patients, BCC can present with pigmentation in the majority of cases, and dark papules can also present as nodules, plaques, and ulcers.5 Interestingly, in non-Hispanic individuals aged 60 to 85, NMSC appears to be more common on the left side (53.1% of cases), while it is more common on the right side (54.0% of cases) in Hispanic individuals of the same age group.9 The impact of socioeconomic status (SES) on NMSC morbidity is mixed. In Denmark, high SES, defined by education level and disposable income, was strongly associated with an increased risk for BCC.10 However, for SCC there was no association with educational level and only a slight association with income.10 BCC and SCC survival was not affected by socioeconomic indicators.10 Recently, skin cancers on the trunk and limbs in younger people from urban areas has been increasing, perhaps due to affluence and resultant leisure-related, sporadic sun exposure.11 In Scotland, the most economically privileged quintile had the highest skin cancer incidence.12 Overall, identification of NMSC among all racial groups is poor and demonstrates the need for improved public education.13 The authors sought to evaluate whether patient factors including sex, Hispanic ethinicity, SES, sun-safe practices, and self-skin exams were associated with greater NMSC morbidity using the MMS defect area to compare patient demographics. Given the authors’ large local Hispanic population in South Miami, they additionally sought to confirm previous findings regarding self-skin exam in the Hispanic versus non-Hispanics.