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NONMELANOMA SKIN CANCER (NMSC)

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SUMMARY

  • Nonmelanoma skin cancers are extraordinarily common, accounting for approximately 3 million new cases per year in the United States alone.

  • Multiple treatment options are available, ranging from EDC to excision to Mohs surgery.

  • Treatment decisions should be guided by both patient and tumor characteristics, and should always be individually tailored.

image Beginner Tips

  • Common treatment options for NMSC include EDC, excision, and Mohs micrographic surgery.

  • The cost and ease of simple options such as EDC should always be weighed against both the increased healing time and decreased efficacy of these approaches when compared with excision or Mohs.

image Expert Tips

  • High-risk tumors may benefit from management in a multidisciplinary fashion.

  • Adjuvant radiation therapy may be useful for select tumors at very high risk of recurrence.

image Don’t Forget!

  • Select patients and tumors may benefit from primary medical management with topical or intralesional therapies.

  • All surgical therapies entail risk, but this should be weighed against their effectiveness, rapid healing, and low recurrence rates.

  • LN2 treatment for NMSC is fundamentally different from AK treatment; intensity and depth of freeze must be significantly greater in order to lead to tumor destruction, and this will likely lead to significant surrounding tissue damage and hypopigmentation.

image Pitfalls and Cautions

  • Simple approaches such as cryotherapy and EDC should not be used on tumors at significant risk of recurrence.

  • Appropriate tumor and patient selection for medical management or treatment with cryotherapy or EDC is critical; for example, some BCCs demonstrate both superficial and nodular growth patterns.

image Patient Education Points

  • Full informed consent includes a discussion of both the ease of a particular procedure and the length and complexity of the healing process.

  • Remind patients that even with very low rates of recurrence or complications, those numbers are not zero. Patients may otherwise fail to appreciate that a 98% chance of tumor clearance without complications means that, for a clinician who treats 100 patients per month, 2 patients monthly may have these undesirable outcomes.

image Billing Pearls

  • Documentation is critical, and medical necessity is the ultimate arbiter of appropriateness.

  • Some patients have poor (or no) prescription medication coverage; for them, medical management is generally not desirable.

INTRODUCTION

One of the most frequent reasons that patients present to a primary care office for an excision or destructive treatment is for the treatment of nonmelanoma skin cancer (NMSC). Indeed, as a group, these cancers represent the most common malignancy in the United States, with over 3 million cases annually.1 NMSC is more common than all other malignancies combined, and its incidence continues to increase2; this burden has translated into a significant year-on-year increase in disease-related spending.3 As the incidence of NMSC continues to increase, there are significant public health, patient safety, and cost implications, making it ...

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