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LEARNING OBJECTIVES

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Learning Objectives

  • Recognize different types of skin cancer including basal cell carcinoma (BCC), squamous cell carcinoma (SCC), melanoma, and Merkel cell carcinoma (MCC). Understand various treatment modalities.

  • Determine when referral to a dermatology specialist is indicated.

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Key Clinical Points

  1. Skin cancers are common in older adults, and the vast majority of skin cancers in this population represent basal and SCC.

  2. Malignant melanoma and MCC are more aggressive and carry a higher risk of lymph node and distant metastasis.

  3. Overall, definitive treatment of these skin cancers is well tolerated by older adults.

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INTRODUCTION

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Nearly 5 million adults in the United States are treated each year for skin cancer, as compared to 10.3 million for all other cancer diagnoses. Approximately 10,000 people die annually of skin cancer in the United States; one an hour from melanoma and one every 4 hours from nonmelanoma skin cancer (NMSC). There are three common types of skin cancer: basal cell carcinoma (BCC) (79% of skin cancers), squamous cell carcinoma (SCC) (14%), and melanoma (5%). Other skin cancer types comprise the remaining 2%. While melanoma accounts for only 5% of skin cancer diagnoses, it accounts for 75% of skin cancer deaths. Basal and SCCs are considerably less lethal, but these tumors are associated with significant morbidity. As with most malignancies, the incidence of skin cancer increases with age. Owing to their sheer numbers, the public health burden from skin cancer is great.

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One in five people in the United States and one in three Caucasians will develop skin cancer during their lifetime. Treatment of NMSC has increased in the Medicare fee for service population by nearly 77% from 1992 to 2006. The incidence of skin cancer continues to rise faster than any other cancer, and skin cancer has been labeled as “today’s epidemic” in the lay press. In addition, data on the incidence and prevalence of basal and SCCs are likely underestimated as these cancers are not reported in state or national cancer registries. Importantly, a significant proportion of skin cancer diagnoses are made in patients of advanced age.

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ETIOLOGY

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Both genetic and environmental risk factors are implicated in the development of skin cancer. The most common known environmental risk factor is chronic and/or acute intense intermittent ultraviolet light exposure in the form of sunlight, artificial tanning devices (tanning booths), and sunburns. The Centers for Disease Control and Prevention Behavior Risk Factor Surveillance System data estimate that nearly 34% of all adults and 69% of adolescents in the United States develop at least one sunburn annually. Sunburns are most common in Caucasian men, young adults, and high-income groups in national surveys. About 30% of adults routinely practiced sun-protection behaviors, most common in women and older adults. Approximately 60% of parents apply sunscreen to their children. Substantial proportions of adolescents, young adults, and females use indoor tanning, about one-third ...

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