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Background: Accurate evaluation of basal cell carcinoma (BCC) in the United States was not possible
before the 2011 release of BCC-specific International Classification of Diseases, Ninth Revision, Clinical
Modification codes.
Objective: We sought to describe BCC (including locally advanced BCC [LABCC]) incidence/prevalence
and the characteristics of patients in a commercially insured US population.
Methods: This retrospective cohort study used Truven Health MarketScan database insurance claims.
Patients, aged 18 years or older with 2 or more BCC claims at least 30 days apart from October 1, 2011, to
September 30, 2012, were continuously enrolled in medical and pharmacy benefits for 12 months before
and after the index claim. A specific algorithm was used to classify patients with LABCC.
Results: A total of 56,987 patients with BCC were identified (39,035 incident cases; 17,952 prevalent cases).
Age-adjusted BCC incidence and prevalence were 226.09 and 342.64 per 100,000 persons, respectively.
These values project to 542,782 patients (incidence) and 822,593 patients (prevalence) in the 2012 US
population. LABCC was uncommon (471 cases identified; projected US incidence and prevalence: 4399 and
7940 patients, respectively).
Limitations: Use of medical claims data and retrospective analysis are limitations.
Conclusion: In a study designed to distinguish patients with LABCC from the general BCC population
based on BCC-specific International Classification of Diseases, Ninth Revision, Clinical Modification
codes, 0.8% were found to have LABCC, the majority having pre-existing disease. ( J Am Acad Dermatol
2016;75:957-66.)
Key words: basal cell carcinoma; epidemiology; incidence; locally advanced disease; metastatic disease;
nonmelanoma skin cancer; prevalence; retrospective claims analysis.
From Mount Sinai School of Medicine, New Yorka; Novartis Information contained in this article has been presented, in part, at
Pharmaceuticals Corp, East Hanoverb; Novartis Ireland Ltd, the following medical congresses: 73rd AAD Annual Meeting,
Dublinc; and State University of New York Downstate Medical March 20-24, 2015, San Francisco, CA; AMCP 2015 Nexus,
Center College of Medicine.d October 26-29, 2015, Orlando, FL; and ISPOR 20th Annual
Novartis Pharmaceuticals Corp supported this study and publica- International Meeting, May 16-20, 2015, Philadelphia, PA.
tion, and editorial support from BioScience Communications, Supplementary tables are online-only.
New York, NY. Accepted for publication June 12, 2016.
Disclosure: Dr Goldenberg has served as a consultant to Genen- Reprint requests: Gary Goldenberg, MD, Mount Sinai School of
tech, Novartis, and Xoft, and as a speaker for Genentech and Medicine, 5 E 98th St, 5th Floor, New York, NY 10029. E-mail:
Novartis. Dr Karagiannis was a full-time employee of Novartis at garygoldenbergmd@gmail.com.
the time the study was conducted. Drs Palmer, ONeill, Kisa, and Published online July 27, 2016.
Herrera, and Mr Lotya are full-time employees of Novartis. Dr 0190-9622/$36.00
Siegel has served as an investigator, speaker, and consultant for 2016 by the American Academy of Dermatology, Inc.
Genentech, LEO Pharma, and Valeant, and as a consultant for http://dx.doi.org/10.1016/j.jaad.2016.06.020
Novartis.
957
958 Goldenberg et al J AM ACAD DERMATOL
NOVEMBER 2016
Basal cell carcinoma (BCC), a subset of non- to classify these subgroups. The demographic and
melanoma skin cancer (NMSC), is the most common clinical characteristics of the overall BCC cohort
cancer in the United States, with an estimated 2.7 and these 2 subgroups are also described.
million cases diagnosed annually.1,2 Total costs for
skin cancer increased substantially from 2002 to METHODS
2011eto a greater extent than cost increases for all Study design
other cancer siteseowing to increases in the number This was a retrospective cohort study using health
of persons treated, and to insurance claims data from
per-person treatment costs.3 the Commercial Claims and
The overwhelming majority CAPSULE SUMMARY Encounters database within
of patients with BCC can be the Truven Health
dAccurate evaluation of basal cell
cured using a variety of treat- MarketScan database. These
carcinoma (BCC) epidemiology was not
ment modalities, including data contain claims from
possible before release of BCC-specific
curettage, excision, Mohs mi- approximately 100
International Classification of Diseases,
crographic surgery, radia- employers, health plans,
Ninth Revision, Clinical Modification
tion, and topical therapy; and government and public
codes.
however, a small proportion organizations, representing
have disease that is refrac- dIn a commercially insured US population, approximately 30 million
tory, inoperable, or metasta- 2012 BCC incidence and prevalence covered lives. All US census
tic. The term advanced estimates projected to 542,782 and regions are represented, with
BCC refers to locally inva- 822,593 patients, respectively; locally the most predominant being
sive BCC that is not amenable advanced BCC was uncommon (\1%). the South and North Central
to surgical or radiation d
Accurate BCC epidemiology estimates (Midwest) regions. Enrollees
therapy interventions, or will facilitate optimal resource allocation. in the database include em-
that has metastasized to ployees, dependents, and
regional lymph nodes or retirees with primary or
beyond.4-6 Medicare supplemental coverage through privately
Historically, BCC has been excluded as a category insured fee-for-service, point-of-service, or capitated
from cancer registry databases because the health plans. All study data were accessed using
number of patients with these generally localized techniques compliant with the Health Insurance
tumors greatly exceeds the number of patients with Portability and Accountability Act of 1996. No
other malignancies. Moreover, because administra- identifiable protected health information was
tive data could not distinguish among NMSC extracted, so this study did not require informed
subtypes, previous studies have focused on NMSC consent or institutional review board approval.
as a whole.1,7-9 The release of BCC-specific
International Classification of Diseases, Ninth Identification of patients with BCC
Revision, Clinical Modification (ICD-9-CM) codes Patients aged 18 years or older with at least 2
in October 2011 has allowed for more accurate claims and a diagnosis of BCC in any location during
epidemiologic analysis of this malignancy. the identification period (October 1, 2011, to
In a previous study, an algorithm was devel- September 30, 2012), with the claims separated by
oped to classify patients with commercial at least 30 days, were identified. A diagnosis of BCC
insurance and NMSC into 3 groups: patients with was based on any of the following ICD-9-CM codes:
metastatic disease, patients with locally advanced 173.01, 173.11, 173.21, 173.31, 173.41, 173.51,
disease, and all others.9 Although demographic 173.61, 173.71, 173.81, or 173.91. The date of first
data and insurance coverage were described, diagnosis of BCC during the identification period
information on patient comorbidities was not was designated as the index date. Included patients
provided. The study focused on NMSC, as were continuously enrolled in fee-for-service
BCC-specific ICD-9-CM codes were unavailable. medical and pharmacy benefit plans during the
In contrast, the current study used BCC-specific 12-month periods before and after the index date.
ICD-9-CM codes to estimate the incidence and For continuous enrollment, patients could not have a
prevalence of BCC, locally advanced BCC gap in enrollment of more than 40 days. Patients
(LABCC), and metastatic BCC (MBCC) in a were further characterized as having incident or
commercially insured US population. Because prevalent BCC according to the absence or presence,
specific ICD-9-CM codes are not available for respectively, of an NMSC claim in the 12-month
LABCC and MBCC, additional criteria were used period before the BCC index date (ICD-9-CM 173.x
J AM ACAD DERMATOL Goldenberg et al 959
VOLUME 75, NUMBER 5
Table I. Characteristics of BCC, LABCC, and MBCC cohorts (incident and prevalent cases)
Incident cases Prevalent cases
BCC LABCC MBCC BCC LABCC MBCC
Characteristic n = 39,035 n = 261 n=7 n = 17,952 n = 210 n = 16
Age at index date, y: mean (SD)* 63.2 (13.6) 72.2 (13.7) 71.3 (14.9) 68.3 (13.5) 74.0 (12.8) 72.1 (10.7)
Age group, y: n (%)*
18-24 39 (0.1) 0 0 6 (0.0) 0 0
25-34 463 (1.2) 1 (0.4) 0 103 (0.6) 0 0
35-44 2490 (6.4) 7 (2.7) 0 598 (3.3) 3 (1.4) 0
45-54 7563 (19.4) 21 (8.0) 1 (14.3) 2300 (12.8) 10 (4.8) 2 (12.5)
55-64 12,263 (31.4) 48 (18.4) 2 (28.6) 4489 (25.0) 48 (22.9) 2 (12.5)
$65 16,217 (41.5) 184 (70.5) 4 (57.1) 10,456 (58.2) 149 (71.0) 12 (75.0)
Gender, n (%)yz
Male 21,093 (54.0) 139 (53.3) 6 (85.7) 11,724 (65.3) 134 (63.8) 10 (62.5)
Female 17,942 (46.0) 122 (46.7) 1 (14.3) 6228 (34.7) 76 (36.2) 6 (37.5)
Region, n (%)yz
Northeast 7096 (18.2) 23 (8.8) 0 3404 (19.0) 24 (11.4) 3 (18.8)
North Central 9502 (24.3) 86 (33.0) 1 (14.3) 3890 (21.7) 46 (21.9) 5 (31.3)
South 14,211 (36.4) 101 (38.7) 3 (42.9) 6664 (37.1) 100 (47.6) 2 (12.5)
West 7868 (20.2) 51 (19.5) 3 (42.9) 3865 (21.5) 36 (17.1) 6 (37.5)
Unknown 358 (0.9) 0 0 129 (0.7) 4 (1.9) 0
Plan type, n (%)y
Comprehensive 8682 (22.2) 94 (36.0) 2 (28.6) 5532 (30.8) 96 (45.7) 5 (31.3)
EPO 328 (0.8) 2 (0.8) 0 153 (0.9) 1 (0.5) 0
HMO 4636 (11.9) 28 (10.7) 1 (14.3) 1862 (10.4) 18 (8.6) 6 (37.5)
POS 2391 (6.1) 9 (3.4) 0 1000 (5.6) 7 (3.3) 1 (6.3)
PPO 19,077 (48.9) 115 (44.1) 4 (57.1) 8078 (45.0) 75 (35.7) 3 (18.8)
POS with capitation 170 (0.4) 1 (0.4) 0 88 (0.5) 0 0
CDHP 1448 (3.7) 3 (1.1) 0 475 (2.6) 4 (1.9) 0
HDHP 786 (2.0) 4 (1.5) 0 238 (1.3) 1 (0.5) 0
Missing/unknown 1517 (3.9) 5 (1.9) 0 526 (2.9) 8 (3.8) 1 (6.3)
Employment status, n (%)y
Active full-time 11,655 (29.9) 42 (16.1) 0 3531 (19.7) 20 (9.5) 1 (6.3)
Active part-time or seasonal 319 (0.8) 0 0 109 (0.6) 2 (1.0) 0
Early retiree 2832 (7.3) 12 (4.6) 1 (14.3) 1040 (5.8) 18 (8.6) 0
Medicare-eligible retiree 11,500 (29.5) 119 (45.6) 3 (42.9) 7476 (41.6) 107 (51.0) 6 (37.5)
Retiree (status unknown) 2091 (5.4) 11 (4.2) 2 (28.6) 1302 (7.3) 11 (5.2) 1 (6.3)
COBRA continue 71 (0.2) 0 0 19 (0.1) 0 0
Long-term disability 52 (0.1) 1 (0.4) 0 29 (0.2) 0 0
Surviving spouse/dependent 1061 (2.7) 24 (9.2) 0 477 (2.7) 17 (8.1) 1 (6.3)
Other/unknown 9454 (24.2) 52 (19.9) 1 (14.3) 3969 (22.1) 35 (16.7) 7 (43.8)
Comorbidities, n (%)
Myocardial infarctiony 661 (1.7) 10 (3.8) 0 396 (2.2) 5 (2.4) 0
Congestive heart failurey 1608 (4.1) 17 (6.5) 0 1093 (6.1) 17 (8.1) 1 (6.3)
Peripheral vascular diseasey 2211 (5.7) 22 (8.4) 3 (42.9) 1600 (8.9) 20 (9.5) 3 (18.8)
Cerebrovascular diseasey 2577 (6.6) 33 (12.6) 0 1740 (9.7) 31 (14.8) 2 (12.5)
Dementiax 251 (0.6) 7 (2.7) 0 145 (0.8) 4 (1.9) 0
Chronic pulmonary diseasey 3962 (10.1) 32 (12.3) 1 (14.3) 2255 (12.6) 35 (16.7) 4 (25.0)
Rheumatic diseasey 801 (2.1) 6 (2.3) 0 475 (2.6) 7 (3.3) 1 (6.3)
Peptic ulcer disease 220 (0.6) 1 (0.4) 0 121 (0.7) 0 0
Mild liver disease 882 (2.3) 5 (1.9) 0 443 (2.5) 5 (2.4) 3 (18.8)
Diabetes without CCy 5221 (13.4) 60 (23.0) 2 (28.6) 2819 (15.7) 47 (22.4) 4 (25.0)
Diabetes with CCy 1305 (3.3) 11 (4.2) 1 (14.3) 765 (4.3) 13 (6.2) 3 (18.8)
Hemiplegia or paraplegiay 121 (0.3) 3 (1.1) 0 90 (0.5) 3 (1.4) 0
Renal diseasey 1528 (3.9) 16 (6.1) 0 1239 (6.9) 16 (7.6) 6 (37.5)
Any malignancyy{ 4260 (10.9) 1 (0.4) 0 3525 (19.6) 4 (1.9) 2 (12.5)
Moderate/severe liver diseasex 54 (0.1) 1 (0.4) 0 38 (0.2) 0 0
Continued
962 Goldenberg et al J AM ACAD DERMATOL
NOVEMBER 2016
Table I. Contd
Incident cases Prevalent cases
BCC LABCC MBCC BCC LABCC MBCC
Characteristic n = 39,035 n = 261 n=7 n = 17,952 n = 210 n = 16
Metastatic solid tumory 280 (0.7) 0 2 (28.6) 328 (1.8) 3 (1.4) 10 (62.5)
AIDS/HIVy 64 (0.2) 1 (0.4) 0 57 (0.3) 3 (1.4) 0
Charlson Comorbidity Index score, 0.9 (1.6) 1.0 (1.5) 2.9 (2.5) 1.4 (2.0) 1.3 (1.8) 6.3 (3.7)
mean (SD)*k#
BCC, Basal cell carcinoma; CC, chronic complications; CDHP, consumer-directed health plan; COBRA, Consolidated Omnibus Budget
Reconciliation Act; EPO, exclusive provider organization; HDHP, high-deductible health plan; HMO, health maintenance organization; LABCC,
locally advanced BCC; MBCC, metastatic BCC; POS, point of service; PPO, preferred provider organization; SD, standard deviation.
*P \ .0001, incident vs prevalent cases for BCC (Wilcoxon rank sum test).
y
P # .0005, incident vs prevalent cases for BCC (x 2 test).
z
P \ .05, incident vs prevalent cases for LABCC (x 2 test).
x
P # .05, incident vs prevalent cases for BCC (x 2 test).
{
Including lymphoma and leukemia, except malignant neoplasm of skin.
k
P \ .05, incident vs prevalent cases for LABCC (Wilcoxon rank sum test).
#
P \ .05, incident vs prevalent cases for MBCC (t test).
prevalence estimates are somewhat lower than those More specifically, we confirmed that the incidence
in previously published retrospective claims ana- and prevalence of BCC, LABCC, and MBCC are
lyses of incident and prevalent NMSC cases, which highest in the older age categories (particularly in
were conducted before availability of BCC-specific patients aged 65 years or older) and higher in males
ICD-9-CM codes.1,7,9,12 Other factors may also ac- than in females.9 Future studies might focus on
count for the lower estimates reported in our study, treatment patterns and health care use and costs for
as compared with previous analyses. A recent study these patient populations.
by Rogers et al,1 for example, was based on a Several study limitations should be noted. First,
Medicare fee-for-service population, as compared administrative claims data, such as those used in the
with the younger, commercially insured population current study, are not collected for research
in our study. purposes; the diagnostic coding on administrative
Our study was also designed to distinguish claims is recorded by physicians for the purpose of
patients with LABCC and MBCC from the general supporting reimbursement. As such, these data are
BCC population based on BCC-specific ICD-9-CM never complete or detailed enough to provide a
codes; LABCC accounted for 0.8% of all BCC cases clinically precise description of patients, and the
and MBCC was exceedingly rare at 0.04% of the BCC impact of disease severity and other descriptive
cohort. The age-adjusted incidence rates of LABCC parameters (eg, lesion size, sun exposure) cannot
and MBCC project to only 4399 and 108 cases in the be assessed. Second, the generalizability of the study
United States, respectively, and the age-adjusted results is limited by the use of claims data from a
prevalence rates project to 7940 and 384 cases, commercially insured US population. The reported
respectively. Compared with the overall BCC cohort, findings may not apply, for example, to patients in
patients with LABCC and MBCC were more likely to other countries, to uninsured patients, or to those
be older, and those with MBCC were more likely to insured by Medicare and Medicaid (we would note,
have comorbidities. however, that the database used is generally
Several factors may explain the differences representative of the US population with respect to
between the BCC and LABCC estimates derived in age and gender, according to estimates from the US
the current study and those derived from previous Census Bureau). Third, medical claims databases
studies. The most common difference is the use of may not capture all the services that patients receive.
NMSC claims to identify patients with BCC, but other They may omit out-of-pocket transactions, changes
factors may be relevant as well. Dacosta Byfield in health care insurance enrollment, and changes in
et al,9 for example, used diagnostic imaging to claims submissions made by physicians. Fourth, the
identify patients with LABCC, whereas we used a inclusion criterion requiring that patients have 2
more conservative definition of LABCC. Despite the claims for BCC separated by at least 30 days may
differences in estimates across studies, our results have led to underestimation of the number of cases;
confirm the rare nature of these disease subtypes. however, it should be noted that this type of
J AM ACAD DERMATOL Goldenberg et al 963
VOLUME 75, NUMBER 5
Table II. Characteristics of BCC, LABCC, and MBCC cohorts (total cases)
Total cases
BCC LABCC MBCC
Characteristic n = 56,987 n = 471 n = 23
Age at index date, y: mean (SD) 64.9 (13.8) 73.0 (13.3) 71.9 (11.8)
Age group, y: n (%)
18-24 45 (0.1) 0 0
25-34 566 (1.0) 1 (0.2) 0
35-44 3088 (5.4) 10 (2.1) 0
45-54 9863 (17.3) 31 (6.6) 3 (13.0)
55-64 16,752 (29.4) 96 (20.4) 4 (17.4)
$65 26,673 (46.8) 333 (70.7) 16 (69.6)
Gender, n (%)
Male 32,817 (57.6) 273 (58.0) 16 (69.6)
Female 24,170 (42.4) 198 (42.0) 7 (30.4)
Region, n (%)
Northeast 10,500 (18.4) 47 (10.0) 3 (13.0)
North Central 13,392 (23.5) 132 (28.0) 6 (26.1)
South 20,875 (36.6) 201 (42.7) 5 (21.7)
West 11,733 (20.6) 87 (18.5) 9 (39.1)
Unknown 487 (0.9) 4 (0.8) 0
Plan type, n (%)
Comprehensive 14,214 (24.9) 190 (40.3) 7 (30.4)
EPO 481 (0.8) 3 (0.6) 0
HMO 6498 (11.4) 46 (9.8) 7 (30.4)
POS 3391 (6.0) 16 (3.4) 1 (4.3)
PPO 27,155 (47.7) 190 (40.3) 7 (30.4)
POS with capitation 258 (0.5) 1 (0.2) 0
CDHP 1923 (3.4) 7 (1.5) 0
HDHP 1024 (1.8) 5 (1.1) 0
Missing/unknown 2043 (3.6) 13 (2.8) 1 (4.3)
Employment status, n (%)
Active full-time 15,186 (26.6) 62 (13.2) 1 (4.3)
Active part-time or seasonal 428 (0.8) 2 (0.4) 0
Early retiree 3872 (6.8) 30 (6.4) 1 (4.3)
Medicare-eligible retiree 18,976 (33.3) 226 (48.0) 9 (39.1)
Retiree (status unknown) 3393 (6.0) 22 (4.7) 3 (13.0)
COBRA continue 90 (0.2) 0 0
Long-term disability 81 (0.1) 1 (0.2) 0
Surviving spouse/dependent 1538 (2.7) 41 (8.7) 1 (4.3)
Other/unknown 13,423 (23.6) 87 (18.5) 8 (34.8)
Comorbidities, n (%)
Myocardial infarction 1057 (1.9) 15 (3.2) 0
Congestive heart failure 2701 (4.7) 34 (7.2) 1 (4.3)
Peripheral vascular disease 3811 (6.7) 42 (8.9) 6 (26.1)
Cerebrovascular disease 4317 (7.6) 64 (13.6) 2 (8.7)
Dementia 396 (0.7) 11 (2.3) 0
Chronic pulmonary disease 6217 (10.9) 67 (14.2) 5 (21.7)
Rheumatic disease 1276 (2.2) 13 (2.8) 1 (4.3)
Peptic ulcer disease 341 (0.6) 1 (0.2) 0
Mild liver disease 1325 (2.3) 10 (2.1) 3 (13.0)
Diabetes without CC 8040 (14.1) 107 (22.7) 6 (26.1)
Diabetes with CC 2070 (3.6) 24 (5.1) 4 (17.4)
Hemiplegia or paraplegia 211 (0.4) 6 (1.3) 0
Renal disease 2767 (4.9) 32 (6.8) 6 (26.1)
Any malignancy* 7785 (13.7) 5 (1.1) 2 (8.7)
Moderate/severe liver disease 92 (0.2) 1 (0.2) 0
Continued
964 Goldenberg et al J AM ACAD DERMATOL
NOVEMBER 2016
BCC, Basal cell carcinoma; CC, chronic complications; CDHP, consumer-directed health plan; COBRA, Consolidated Omnibus Budget
Reconciliation Act; EPO, exclusive provider organization; HDHP, high-deductible health plan; HMO, health maintenance organization; LABCC,
locally advanced BCC; MBCC, metastatic BCC; POS, point of service; PPO, preferred provider organization; SD, standard deviation.
*Including lymphoma and leukemia, except malignant neoplasm of skin.
approach is commonly used in database studies for population. Sixth, we did not use surgical and
other therapeutic areas to ensure that the patient destruction codes as part of our BCC identification
actually has the disease in question. In addition, a protocol, as it was believed this would have
primary focus of our study was to identify patients broadened the scope of the study too much and
with advanced BCC to derive incidence and compromised the sensitivity of our estimates,
prevalence estimates for this subpopulation, and it especially given our emphasis on advanced BCC;
was thought that advanced patients, even if this approach may also have led to underestimation
treated within a month, would have follow-up past of the overall number of BCC cases. Finally, patients
this period. Fifth, because there were no BCC treatment-seeking behavior may have affected the
codes available in the year preceding the time incidence of LABCC identified by the algorithm used
frame of the study, we defined the prevalent in this study.
population as those patients with an NMSC claim in In summary, BCC incidence and prevalence
the previous year. This conservative approach estimates from our study project to 542,782
could have led to underestimation of the and 822,593 patients, respectively. LABCC was
incident population/overestimation of the prevalent uncommon, being identified in only 0.8% of BCC
966 Goldenberg et al J AM ACAD DERMATOL
NOVEMBER 2016
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Rep. 2014;3:40-45.
likely contributes disproportionately to the health 7. Eide MJ, Krajenta R, Johnson D, et al. Identification of
burden of BCC. MBCC was also rare in this study patients with nonmelanoma skin cancer using health
population (0.04% of the BCC cohort). maintenance organization claims data. Am J Epidemiol. 2010;
171:123-128.
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