Need for a New Skin Cancer Management StrategyNeed for a New Skin Cancer Management Strategy

The worldwide incidence of skin cancer (especially nonmelanoma skin cancer) has increased markedly during the last decades.^{1 - 2} The ramifications for health care systems worldwide are enormous. An evaluation of the diagnosis-treatment codes, combined with the zip codes of patients of a large outpatient dermatology clinic at Catharina Hospital in the Netherlands, reveals that more than 50% of dermatologists' time is spent on skin cancer and skin premalignant neoplasms (unpublished data, June 2009). When evaluating and extrapolating the figures from this database for the Netherlands, we found an incidence of approximately 80 000 skin malignant neoplasms in 2007 (unpublished data, June 2009), indicating at least double the amount of skin cancer cases compared with the expected incidence in 2015 of 37 000 cases in the Netherlands.² This article explores opportunities for the development of a skin cancer management system to provide structured and multidisciplinary care.

New groups at risk for developing multiple skin cancers have been identified (Table). Because the population is aging and skin cancer incidence is increasing in the younger population, more young adults will be confronted during their lifespan with multiple new tumors.^{6 - 12} Skin cancer can, therefore, be regarded as a chronic disease, ie, a disease of long duration and generally slow progression, as defined by the World Health Organization.¹³ Progression should, in this case, be regarded as development of new tumors.

Nonmelanoma skin cancer has been considered a relatively mild health problem for a long time because of the low mortality rate. However, the morbidity and economic burden of nonmelanoma skin cancer for the health care system are high.¹⁴ In the United States, skin cancer has taken fifth place with respect to cancer costs, behind prostate, lung and bronchus, colon and rectum, and breast carcinomas.¹⁵ To manage the future costs and quality of care for patients with skin cancer, revised health strategies are needed. These strategies should be combined in a disease management system that organizes care for one well-documented health problem according to a systematic approach that includes prevention, education, multidisciplinary care, information technology, and management (Figure).¹⁶

Several organizational models of chronic disease management have been proposed and implemented internationally.¹⁷ The World Health Organization recently discussed ways to operate these programs across care settings and among health care professionals.¹³ Although there is increasing evidence that disease management systems provide more efficient, high-quality, and cost-effective care,¹⁸ not all studies of disease management programs or nurse-led care show statistically significant improvements. For chronic diseases, such as diabetes mellitus and heart failure, these systems have demonstrated significant improvement of disease control and a reduction of complications.^{19 - 21} The differences in the outcomes of various studies may be related to methodologic weaknesses, confounding factors, and inherent differences in populations at risk for various diseases.^{22 - 24}

There is a clear and immediate opportunity to evaluate the potential benefits as part of a renewed health strategy for effective chronic care in our aging society.¹⁸ By applying the disease management systems approach, multiple opportunities for chronic skin cancer care become apparent in prevention, education, multidisciplinary care, information technology, and management¹⁶ (Figure). The disease management system is embedded within a supportive overall organization structure, which is based on firm financial support that must be available for all aspects of the system, including prevention-based efforts. Such efforts are needed to manage the inflow of future patients from various high-risk groups to the core detection and treatment parts of the system. The disease management system emphasizes collaboration in the detection of skin cancer, whereas multiple aspects (trained nurses, standardized treatment, guidelines, and information technology) contribute to effective treatment. By the monitoring and evaluation of treatments, various aspects of the system can undergo continuous quality improvement.

Population-based primary prevention, which is an important part of chronic disease management, requires targeted approaches for the groups at risk: young children, adolescents, young adults, and patients with skin cancer.¹⁸ Because most people underestimate their susceptibility to skin cancer and the severity of the problem, messages need to create awareness, highlight the advantages of protection, and discuss ways to cope with barriers to adopting protective behaviors.²⁵ Specific action plans, such as how and when to use sunscreen, are needed to promote implementation of sun protective measures.^{26 - 27}

In chronic disease management, self-management support of patients is central to improving care and outcomes.²⁸ Online information, questionnaires, and checklists with photographs of skin cancer could help people recognize skin malignant neoplasms. Early detection of skin cancer has multiple advantages: it leads to the diagnosis of smaller skin cancers, which are less difficult to treat. The correct diagnosis and treatment of primary skin cancers leads to fewer recurrences. These recurrences are more difficult and expensive to treat and involve a higher risk of further recurrences.^{28 - 30}

As members of the multidisciplinary treatment team, general practitioner physicians should actively participate and collaborate with dermatologists in the process of prevention and treatment, including prognosis and follow-up plans. This result could be achieved with the use of a central electronic medical record that crosses institutional borders or by using Web access to medical records in hospitals.^{31 - 32} Store-and-forward teledermatology, in which a dermatologist evaluates photographs with historical and demographic information, is an effective, accurate, and valid approach for the routine treatment of patients with skin cancer referred by physicians.^{33 - 34} May et al³⁴ demonstrated that 51% of visits to dermatologists are unnecessary and could be avoided with use of store-and-forward teledermatology, which has helped to improve prioritization, efficiency of service, and patient care. Hsiao and Oh³⁵ showed that the overall mean intervals for initial evaluation, biopsy, and surgery were 44, 19, and 21 days shorter, respectively, with use of teledermatology compared with conventional consultation.

Clear guidelines of care are needed to provide standardized evidence-based treatments. It takes several years to prepare and implement a guideline. For example, it took more than 2 years to develop and implement the Dutch guideline of cutaneous melanoma and even longer for the guideline of basal cell carcinoma.^{36 - 37} A substantial acceleration of the process of adjusting guidelines could be achieved if clinics made their deidentified patient data about treatment type and outcomes of treatment available in electronic medical records. Automated techniques could be used to detect differences between guidelines for good practice and actual execution of medical processes.³⁸ Such differences can be used as a starting point to discover the reasons for nonadherence to create the most optimal treatment plan.

Care management with interventions by nurses has been shown to improve medical, psychosocial, and lifestyle outcomes for patients with chronic diseases, such as diabetes.²³ Taylor et al²³ showed that nurse care managers can improve medical outcomes without increasing physician visits. A review of nurse-led care in dermatology concluded that nurses are managing and treating a number of dermatologic conditions, such as eczema and leg ulcers, primarily by using treatment protocols. The nurses work in a variety of clinical contexts, including inpatient, outpatient, and community settings. Patients report various benefits, such as faster access to treatment, reduction in referral to a physician or dermatologist, and an increase in knowledge of their condition.²² Nurses are also being trained to participate in dermato-oncologic care for patients receiving organ transplants.³⁹

At Catharina Hospital, nurses trained on the job in dermato-oncology participate in secondary prevention and counseling. They also perform skin biopsies, photodynamic therapy, cryotherapy, and small excisions. Nurse-led care effectively results in the reduction of the high workload of dermatologists regarding skin cancer and has enhanced the capacity for providing care not only at Catharina Hospital but also in other hospitals.⁴⁰

Modern information technology plays an important role in shaping a disease management system.¹⁶ First, this system supports the classic functions of consulting, manipulating, and retrieving patient-related data. Second, these systems are proactive and allow diagnostic and treatment advice for clinically diagnosed lesions. During the past years, insights have been gained as to how such clinical decision support could be effectively integrated into the care process.⁴¹ Third, the system facilitates communication among the health care teams, for instance, assisting nurses in ascertaining which actions need to be executed or have already been completed for patients. The features pertaining to this so-called workflow management technology are customary for managing various chronic diseases.⁴² Yet the potential of this technology has not been fully exploited in the health care domain in general and certainly not for skin cancer management.⁴³ For example, workflow management systems could be used to enforce adherence to standardized treatment practices while being sufficiently flexible to allow for incidental deviations. Also, these systems could monitor deadlines and signal missing medical information, contributing to improved treatment quality. At Catharina Hospital, workflow management has increased the number of patients treated with photodynamic therapy from 6 to 10 patients per day.

It is feasible to use the enormous amount of data with regard to dermato-oncology, with the help of the information technology system described herein, to evaluate adherence to guidelines and effectiveness of treatments (eg, complications and recurrences). Evaluation can lead to adjustment of guidelines so that effectiveness can be improved or associated costs reduced. So-called process-mining techniques have recently been applied to achieve these goals in the treatment of strokes.⁴⁴ The differences between 2 hospitals in treatment strategies and results could be analyzed to gain a better understanding of these treatment strategies and their outcomes.⁴⁴

The development of the disease management system proposed herein requires sufficient financial resources, thus justifying placing skin cancer disease management on the political agenda and the agenda of insurance companies. As shown in the Figure, financial support is necessary for all aspects of the disease management system, including prevention. Health insurance companies now focus on reducing costs of treatment of skin cancer, whereas primary and secondary prevention of skin cancer is not reimbursed. Funds need to be allocated to restructuring, providing financial incentives (including prevention), training staff, and monitoring progress.¹³

Skin cancer, as a chronic disease, demands robust organization and central coordination by the dermatologist. Dermatologists need to demonstrate their value as medical professionals and their collective capacity to organize and deliver efficient and high-quality dermatologic care.⁴⁵ The organization should focus on benchmarking and optimizing the skin cancer treatment process. Business management strategies (Six Sigma,⁴⁶ for instance) are needed to identify and remove causes of factors that negatively affect profitability and errors in manufacturing and business processes. In the past years, health care organizations and professionals have begun implementing these types of business strategies with significant success; financial savings mounted to $2.9 million during a 3-year period; other departments reported annual savings of $5 million.^{46 - 48}

Skin cancer needs to be regarded as a chronic disease and should not be considered a solitary event requiring the treatment of one tumor. The workload for all medical personnel involved in the treatment of patients with skin cancer will significantly increase in the next few years. Population-based chronic disease management is a necessary approach to deal with the growing burden of this chronic illness. Adjustments in health care must be made regarding prevention, education, multidisciplinary care, information technology, and management. Combining these strategies in a disease management system will lead to efficient, evidence-based, high-quality care to help dermatologists deal proactively with chronic diseases such as skin cancer.

Correspondence: Simone van der Geer, MD, Department of Dermatology, Erasmus University Medical Center, Burg's Jacobsplein 51, 3015 CA Rotterdam, Netherlands (s.vandergeer@erasmusmc.nl).

Accepted for Publication: November 13, 2009.

Author Contributions: Drs van der Geer, Reijers, and Krekels had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: van der Geer, Reijers, van Tuijl, and Krekels. Acquisition of data: Krekels. Analysis and interpretation of data: Reijers. Drafting of the manuscript: van der Geer, Reijers, de Vries, and Krekels. Critical revision of the manuscript for important intellectual content: van der Geer, Reijers, van Tuijl, de Vries, and Krekels. Administrative, technical, and material support: van der Geer, Reijers, de Vries, and Krekels. Study supervision: van Tuijl and Krekels.

Financial Disclosure: None.