In this issue of the BJD, trends in the incidence of basal cell carcinoma (BCC) in Sweden are described, complementing a recent series of population-based reports on BCC incidence in several European countries.[2–4]
Although it is well known that BCC is by far the most frequent type of cancer worldwide, very few population-based data on its incidence were available until recently. While causing significant morbidity and having an important impact on healthcare costs, BCC was often excluded from cancer registries due to its favourable prognosis and the workload involved in manual registration. However, extrapolations of regional population-based studies provided worrisome insights into BCC occurrence.
The increasing trend in the number of new patients, which is expected to increase even more with ageing populations, is the common denominator of the flow of recent population-based studies. These studies also demonstrate a vast number of multiple primary BCCs throughout the patient's lifespan, comprising up to 35% of all cases. These large numbers of patients culminate in enormous amounts of follow-up visits by dermatologists. Furthermore, not only are multiple BCCs frequent among patients with BCC, but there are also increased numbers of other sun-related skin conditions such as actinic keratosis (AK), squamous cell carcinoma and melanoma of the skin. All of these increase the burden of dermatology care. Opportunities for improving efficiency can be found in the diagnostic pathway, as well as in reducing follow-up visits in secondary care. Recently, some initiatives were taken to reduce the workload and cost of dermatology care by showing variation in follow-up care and also demonstrating how the number of unnecessary follow-up visits can be reduced by implementing personalized discharge letters.
Studies on the total BCC count on top of patient numbers enable a more realistic estimate of dermatologists' workload, and reflect more accurately the pressure on the healthcare system, as well as the public health budget, which was shown to have increased already by 67% between 2007 and 2017 in the Netherlands.
The rise of more aggressive types of BCC particularly is an important observation made by Kappelin et al., which may need further investigation. It seems likely that histological confirmation is mostly lacking among the less aggressive subtypes, as the authors explain. However, all recent population-based studies included histologically confirmed cases only and are therefore prone to a certain amount of underestimation of the real number of BCCs. Nonetheless, the digitalization of pathology reports and medical records has already demonstrated the increased possibilities to finally produce reliable BCC incidence rates for population-based cancer registries.
It becomes increasingly clear that even though BCC is already known to be the most frequent cancer worldwide, the exact magnitude of the disease has been largely underestimated. Combined with the increasing trend in incidence over time this urges health policymakers to take action in keeping dermatology care accessible and affordable to all patients with skin cancers that will arise in the next decade.
we would like to thank Dr Marlies Wakkee for her critical review of this commentary.
The British Journal of Dermatology. 2022;186(9):921 © 2022 Blackwell Publishing