Non-melanoma Skin Cancer

Dr Julia Verne Director SWPHO

South West Public Health Observatory

Skin Cancer Non Melanoma Skin Cancer: Squamous Cell Carcinoma and Basal Cell Carcinoma

Very high and underestimated number of Non Melanoma Skin Cancers • 10 times more common than Malignant Melanoma • Often arise in surgically difficult anatomical sites • Associated with high morbidity and can impact on quality of life • Metachronous tumours • Burden on the NHS South West Public Health Observatory

Skin cancer registration in the UK – a baseline assessment

South West Public Health Observatory

Methodology • A proforma was developed focusing on the registration methodology for Malignant Melanoma (MM), Squamous Cell Carcinoma and Basal Cell Carcinoma (BCC) and insitu non Melanoma Skin Cancer (NMSC). It covered registry specific information, understanding of UKACR rules, and completeness of data captured via Royal College of Pathologist proformas, and completeness of staging. • All cancer registries were invited to complete this online survey using Survey Monkey (a web-based survey tool).

South West Public Health Observatory

Results •

Data are received via 3-7 methods , with an average of 4.5 methods per

registry. Pathology and death certificates are the main data sources. •

Nearly all cancer registries record staging information for MM but few record it for SCC and BCC. Some registries receive staging information but do not enter it on their data computer systems.

•

Of the registries who replied, 5 record more than the first SCC, 3 more than the first BCC and 4 more than the first in situ NMSC. In addition the rules for NMSC registration differs across all the registries.

•

The main barrier to the registration of additional SCC, BCC or in situ NMSC per patient, is the cost of the process. It is believed that an efficient automated electronic system would enable registries to make better use of data collected in Trusts.

South West Public Health Observatory

Skin cancer: staging information held on cancer registry databases BCC TNMpT

SCC TNMpT

Clark Level

MM TNMpT

Clark

Breslow

NYCRIS Trent ECRIC Thames OCIU SWCIS WMCIU

NWCIS WCISU

Not held Partial coverage Complete or near complete coverage No information

Scotland

NICR

South West Public Health Observatory

Conclusion • This research highlights the need to develop a standard format across the cancer registries for receiving all skin cancer information, and priority should be given to the consistent recording of diagnosis data. • The quality of skin cancer data would improve with a well defined and mandated pathology data set, with pre-coded reports automatically sent to cancer registries. • Improvements in registration would lead to improvements in our understanding of the most common cancer in the UK and could play a monitoring role in the quality of care received by patients. South West Public Health Observatory

Skin cancer incidence and mortality in England

Data from the UK Association of Cancer Registries national database for registered incidence and from the Clinical and Health Outcomes Knowledge Base web site (http://www.nchod.nhs.uk) for mortality are shown for 2006 by Strategic Health Authority

South West Public Health Observatory

Recorded Skin Cancer in the South West 12000

Number of registrations

10000

8000 BCC 6000

Melanoma Other C44

4000

SCC

2000 0 1990 1993 1996 1999 2002 2005

South West Public Health Observatory

• Despite an underestimate, the incidence of Basal Cell Carcinomas in England are still 1.8 times more common than lung • (UKACR database (based on total number of BCC registered in England)/National Cancer Intelligence Service) 2006

South West Public Health Observatory

BCC Incidence (ASR per 100,000), by sex, by SHA 2006 160

Age-standardised incidence rate per 100,000

140

120

100

80

60

40

20

0 North East

North West

Yorkshire & East Midlands West Midlands The Humber

East of England

London

South Central

South East Coast

South West

Strategic Health Authority

Data Source: UKACR

Men

Women

South West Public Health Observatory

BCC Incidence (ASR per 100,000), by sex, by SHA 2006

• In all SHAs, apart from London and South East Coast, men have a higher incidence rate than women • Overall England ASR of 76 per 100,000 persons is distorted by minimal registration in London and South East Coast

• Average ASR of other SHAs is 93 per 100,000 persons, which could be a better average for comparison • Highest rate is in South West, 121 per 100,000 persons • Lowest rate in East of England, 57 per 100,000 persons (excluding London and South East Coast)

South West Public Health Observatory

BCC Incidence (ASR per 100,000), by sex, England 2002-06 trend 100

90

Age-standardised incidence rate per 100,000

80

70

60

50

40

30

20

10

0 2002

Data Source: UKACR

2003

2004 Year Men

2005

Women

2006

Persons

South West Public Health Observatory

BCC Incidence (ASR per 100,000), by sex, England 2002-06 trend • From 2002 to 2006 ASR has risen significantly in both men and women •(p < 0.01) • Increase in men is larger, 16% compared to 14% for women • Overall number of extra cases in 2006 compared to 2002 is 8400.

South West Public Health Observatory

South West Skin Cancer Age Distribution, 2006 1400

1200

Age Specific Rate

1000

800

BCC female SCC female

MM female

600

BCC male SCC male MM male

400

200

85+

80-84

75-79

70-74

65-69

60-64

55-59

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

0 0-4

Source: UK Association of Cancer Registries national database

Age range

South West Public Health Observatory

BCC Incidence (ASR per 100,000), by age, England 2002-06 average 800

700

Age-specific incidence rate per 100,000

600

500

400

300

200

100

0 0-4

5-9

10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84

85+

Age group

Data Source: UKACR

Men

Women

South West Public Health Observatory

BCC Incidence (ASR per 100,000), by age, England 2002-06 average • Age-standardised rates increase with age • Below 50 years of age, women higher than men, or no significant difference • At 50 years and older, men have higher rates than women, peaking in 8084 age-group where rates in men 66% higher.

South West Public Health Observatory

Figure 4: Age standardised incidence rates for non-melanoma skin cancer in the South West Region by deprivation quintile (2003-2005). Rates standardised to standard European population 250

Rate per 100,000

200

150

Males Females 100

50

0 Least deprived

Most deprived

Deprivation Quintile Source: South West Public Health Observatory

Admission rates to hospital at least once a year (HES data – England) 16 14 12 10 Male

8

Female

6

Persons

4

Non Melanoma Skin Cancer

2 0 2001

2002

2003

2004

2005

2006

Age standardised rate per 100 000

Age standardised rate per 100 000

Malignant Melanoma

160 140

120 100 Male

80

Female

60

Persons

40 20

0 2001

2002

2003

2004

2005

2006

South West Public Health Observatory

Skin Cancer total bed-days per year in England 25000

Total bed-days

20000

15000

10000

5000

0 2001

2002

2003

2004

2005

2006

2007

Year

Source: HES data

Male, Malignant Melanoma

Male, Non Melanoma Skin Cancer

Female, Malignant Melanoma

Female, Non Melanoma Skin Cancer

South West Public Health Observatory

Risk of metachronous skin cancers • N.B. previous rules on recording second SCCs and BCCs

South West Public Health Observatory

The analysis • South West SHA region • Based on first skin cancer registration per person 19982006.

• Combined with “next” skin cancer registration during 19982007. • Ignores effect of diagnoses before 1998

• Effect of registry rules regarded Non-Melanoma Skin Cancer ie generally a maximum of one BCC and one SCC per person

South West Public Health Observatory

Multiple skin cancer registrations Skin cancers (Melanoma and NMSC) diagnosed 98-07

Number of skin cancer diagnoses per person

People

1 2 3 4 5

106,736 6,492 269 16 1

South West Public Health Observatory

The Risk of a Second Skin Cancer Diagnosis Crude rate of 2nd skin cancers per 1000 people

2nd skin cancer diagnosed 98-07 after initial diagnosis during 1998-06 25

Expected initial crude rate 2nd diagnosis in year after first

20

Expected Obesrved 162 479 480 829 43 170 717 1478

SCC BCC Melanoma All

15 10 5 0

0

1

2

3

4

5

6 5 years 7 Over

Years since first skin cancer diagnosis

South West Public Health Observatory

The Risk of a Second Skin Cancer Diagnosis Crude rate of 2nd skin cancers per 1000 people

2nd skin cancer diagnosed 98-07 after initial BCC diagnosis during 1998-06 12

Expected initial crude rate 10

8 6

2nd diagnosis in year after first

4

SCC BCC Melanoma All

2

Expected 105 324 29 480

Obesrved 439 77 83 599

0

0

1

2

3

4

5

6 5 years 7 Over

Years since first skin cancer diagnosis

South West Public Health Observatory

The Risk of a Second Skin Cancer Diagnosis Crude rate of 2nd skin cancers per 1000 people

2nd skin cancer diagnosed 98-07 after initial SCC diagnosis during 1998-06 60

Expected initial crude rate 50

2nd diagnosis in year after first

40

Expected Obesrved 40 9 105 577 8 35 162 621

SCC BCC Melanoma All

30 20 10 0

0

1

2

3

4

5

6 5 years 7 Over

Years since first skin cancer diagnosis

South West Public Health Observatory

Initial breakdown of BBC according to the high risk site and size (data from the ongoing excision margin audit) High risk sites

Number of excisions

H Zone

350

Head and Neck

263

Others

248

Unspecified

36

Total

897

High risk size

Number of excision

BCC >= 2cm

29

Total

897 South West Public Health Observatory

BCC Histological subtypes (data from the ongoing excision margin audit) BCC Histological subtype Atypical Squamous Component Micronodular (