Old Solutions May Be the New Answer: How the Use of Modern Superficial Radiation Therapy Might Address Disparities in Dermatologic Care
Alison Tran, M.D., M.A., Ed.M.1* and Lio Yu, M.D., DABR2
1Menter Dermatology Research Institute, Baylor University Medical Center; Heights Dermatology, Dallas, TX
2Director of Radiation Oncology, Laserderm Dermatology, Smithtown, NY
Dear Editor:
It is well-known that people of lower socioeconomic status (SES) are more likely to have poorer health outcomes. According to the United States Census Bureau, the poverty rate was 11.4% in 2020, up from 10.5% in 2019; Blacks/African Americans had the highest poverty rate (19.5%), followed by Hispanics (17%)1. Further, non-metropolitan Blacks/African Americans had the highest incidence of poverty (30.7%), followed by non-metropolitan American Indians/Alaska Natives (29.6%)2. Healthcare disparities are the inequity in access to healthcare, quality of care, or outcomes that vary based on a multitude of factors: sex, race/ethnicity, age, and SES3, which often determines spatial distribution of areas concentrated with low-income or impoverished (concentrated poverty) individuals and families, and consequently, resources available.
Skin cancer is the most common cancer in the United States (US), and the incidence of melanoma and non-melanoma skin cancer (NMSC) continues to rise4. It is estimated that the overall incidence of Basal Cell Carcinoma (BCC) increased by 145% between 1976-1984 and 2000-2010, and the overall incidence of Squamous Cell Carcinoma (SCC) increased 263% over that same period5. BCC is the most common form of skin cancer contributing to 65-75% of skin cancer in whites, but SCC is the most common skin malignancy among African Americans and Asian Indians6. Although skin cancer is less common in patients with skin of color, it is associated with greater morbidity and mortality, which may be related to delayed diagnosis7. Patients living in non-metropolitan counties have poorer outcomes due to reduced access to cancer treatment and substantially longer travel times8; this extends to dermatologic care9.
Quality of care has reportedly improved throughout the years, but access to care has not3. Dermatologists currently make up 1.3% of the total active US physician workforce10, which will unlikely significantly increase due to insufficient funding9. Yet, the projected increase in dermatology visits between 2013 and 2025 is 16%, among the highest of all specialties9. Further, most counties with African, Hispanic, and Native American majorities lack dermatologists11. Currently, there is an average 29-day wait time for new patients9. However, this may be longer in rural areas/areas lacking a dermatologist, likely even longer for dermatologists who perform Mohs micrographic surgery (MMS) (~1.8% of all dermatologists)12.
Radiation for skin cancer has been available since the advent of X-ray radiation in the late 19th century, which was limited in energy and thus targeted superficial cutaneous neoplasms13. Over 100 years ago, superficial radiation therapy (SRT) was developed. By 1975, 55.5% of dermatology offices in North America either had SRT or Grey Renz Devices available for use, and 44.3% of dermatologists reported regularly using them in the outpatient setting14. Despite the technological advancements (high-resolution ultrasound guidance) over the years and ample evidence demonstrating its efficacy for treating NMSC, it has declined in use and is not taught in dermatology residency programs since surgical intervention became the gold standard. Recently, there has been resurfacing interest in SRT, with several studies15, 16 coupled with clinical trial data showing excellent cosmetic results and comparable local control and cure rates to surgery14. Our recent study shows an absolute lesion control that is comparable to MMS (99.7%) after an average of 7.5 weeks of treatment, with a stable control rate of 99.6% when the follow-up duration was over 12 months and 99.4% at 5 years follow-up16. By subtype, local control for BCC, SCC and squamous cell carcinoma in situ (SCCIS) at 5-years follow-up was 99.2%, 99.2% and 100%16. The treatment was well tolerated with a Radiation Treatment Oncology Group (RTOG) grades of 1 and 2 in 95% of lesions16, which is reflective of the extant literature indicating that radiotherapy for NMSC is generally well tolerated with most commonly reported symptoms that are transient, localized and self-limited15. Further, it is often covered by insurance and can be administered by radiation therapists across many settings: general medical/surgical/specialty hospitals, outpatient care/cancer centers, radiation therapy facilities, outpatient dermatology/physician offices, and medical and diagnostic laboratories. Additionally, although melanoma is primarily considered a surgical disease, radiotherapy has been shown to be useful palliatively as it may help sensitize melanotic lesions to immunotherapy and provide symptom palliation in metastatic cases17. Despite it being deemed radioresistant or responding atypically to radiotherapy due to it having a wide “shoulder” in cell survival curves (high repair efficacy at low doses), doses given with higher fractionations overcomes this “shoulder” as it responds better to larger radiation fractions17. The etiology of healthcare disparities is multifactorial, and one treatment modality cannot completely eradicate this longstanding and pervasive issue. However, disparities in access to oncodermatologic care may be addressed through effortful/collaborative care involving dermatologists, general or specialized providers dealing with skin cancer (i.e., surgeons /ENT specialists), radiation oncologists, and radiation therapists.
Data availability: All data generated or analyzed during this study are included in this published article.
Conflicts of Interests: Dr. Alison Tran has no conflicts of interest to disclose. Dr. Lio Yu is the National Radiation Oncologist for SkinCure Oncology and has received research, speaking and/or consulting support from SkinCure Oncology.
Acknowledgements
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Author Contributions: The authors whose names appear on the submission have contributed sufficiently to the manuscript and approved the final submitted version of the manuscript.
References
- Shrider EA, Kollar M, Chen F, et al. Income and Poverty in the United States: 2020. Census.gov. https://www.census.gov/library/publications/2021/demo/p60-273.html. Published September 14, 2021. Accessed September 21, 2022.
- Economic Research Service: U.S. Department of Agriculture. Rural Poverty & Well-being. USDA ERS - Rural Poverty & Well-Being. https://www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being/. Published March 7, 2022. Accessed September 21, 2022.
- Buster KJ, Stevens EI, Elmets CA. Dermatologic health disparities. Dermatol Clin. 2012; 30(1): 53-viii. doi: 10.1016/j.det.2011.08.002.
- McDaniel B, Badri T, Steele RB. Basal Cell Carcinoma. [Updated 2022 Sep 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482439/.
- Muzic JG, Schmitt AR, Wright AC, et al. Incidence and Trends of Basal Cell Carcinoma and Cutaneous Squamous Cell Carcinoma: A Population-Based Study in Olmsted County, Minnesota, 2000 to 2010. Mayo Clin Proc. 2017; 92(6): 890-898. doi: 10.1016/j.mayocp.2017.02.015.
- Gupta AK, Bharadwaj M, Mehrotra R. Skin Cancer Concerns in People of Color: Risk Factors and Prevention. Asian Pac J Cancer Prev. 2016; 17(12): 5257-5264. doi: 10.22034/APJCP.2016.17.12.5257.
- Gloster HM, Neal K. Skin cancer in skin of color. J Am Acad Dermatol. 2006; 55: 741-760. doi: 10.1016/j.jaad.2005.08.063.
- Segel JE, Lengerich EJ. Rural-urban differences in the association between individual, facility, and clinical characteristics and travel time for cancer treatment. BMC Public Health20, 196 (2020). doi: 10.1186/s12889-020-8282-z.
- Feng H, Berk-Krauss J, Feng PW, et al. Comparison of Dermatologist Density Between Urban and Rural Counties in the United States. JAMA Dermatol. 2018; 154(11): 1265-1271. doi: 10.1001/jamadermatol.2018.3022.
- Physician specialty data report: Active physicians in the largest specialties, 2019. https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-largest-specialties-2019. Published December 2019. Accessed September 21, 2022.
- Vaidya T, Zubritsky L, Alikhan A, et al. Socioeconomic and geographic barriers to dermatology care in urban and rural U.S. populations. J Am Acad Dermatol, 2018; 78(2): 406–8. doi: 10.1016/j.jaad.2017.07.050.
- Albertini JG. Mohs micrographic surgery workforce in the US. Dermatology. https://www.practiceupdate.com/content/mohs-micrographic-surgery-workforce-in-the-us/77592. Published December 25, 2018. Accessed September 21, 2022.
- Gianfaldoni S, Gianfaldoni R, Wollina U, et al. An Overview on Radiotherapy: From Its History to Its Current Applications in Dermatology. Open Access Maced J Med Sci. 2017; 5(4): 521-525. Published 2017 Jul 18. doi: 10.3889/oamjms.2017.122.
- Nestor MS, Berman B, Goldberg D, et al. Consensus Guidelines on the Use of Superficial Radiation Therapy for Treating Nonmelanoma Skin Cancers and Keloids [published correction appears in J Clin Aesthet Dermatol. 2019 Jun; 12(6): 14]. J Clin Aesthet Dermatol. 2019; 12(2): 12-18.
- Yu L, Oh C, Shea CR. The treatment of non-melanoma skin cancer with image-guided superficial radiation therapy: An analysis of 2917 invasive and in situ keratinocytic carcinoma lesions. Oncol Ther. 2021; 9, 153-166. doi: 10.1007/s40487-021-00138-4.
- Tran A, Moloney M, Kaczmarksi P, et al. Analysis of image-guided superficial radiation therapy (IGSRT) on the treatment of early stage non-melanoma skin cancer (NMSC) in the outpatient dermatology setting (Preprint). 2022. doi: 10.1101/2022.09.14.22279951.
- Shi W. Radiation Therapy for Melanoma. In: Ward WH, Farma JM, editors. Cutaneous Melanoma: Etiology and Therapy [Internet]. Brisbane (AU): Codon Publications; 2017 Dec 21. Chapter 8. Available from: https://www.ncbi.nlm.nih.gov/books/NBK481863/ doi: 10.15586/codon.cutaneousmelanoma.2017.ch8.