Research

JAMA Dermatology | Original Investigation

Anatomical Distributions of Basal Cell Carcinoma and

Squamous Cell Carcinoma in a Population-Based Study
in Queensland, Australia
Padmini Subramaniam, MBBS, MSc, MClinSc; Catherine M. Olsen, PhD, MPH; Bridie S. Thompson, PhD;
David C. Whiteman, MBBS, PhD; Rachel E. Neale, BVSc, PhD; for the QSkin Sun and Health Study Investigators

Supplemental content
IMPORTANCE Keratinocyte cancers (KCs), including basal cell carcinoma (BCC) and squamous
cell carcinoma (SCC), are the most common cancers among fair-skinned populations
worldwide. Although studies have indicated that the anatomical distribution of BCC and SCC
differ, few have compared them directly in well-defined population samples.

OBJECTIVES To describe and compare the anatomical distribution of BCC and SCC in a
population-based sample in Queensland, Australia.

DESIGN, SETTING, AND PARTICIPANTS This study was nested within the population-based
QSkin Sun and Health Study in Queensland, Australia. Of 37 103 study participants linked to
national medical insurance records, 3398 diagnosed with KCs from September 1, 2010, to
September 30, 2012, were identified, and information about their KCs was extracted from
pathology reports. Data were analyzed from January 1, 2013, to March 30, 2016.

MAIN OUTCOMES AND MEASURES The relative tumor densities (RTDs) on defined body sites,
calculated by dividing the proportion of tumors occurring at a specified site by the proportion
of skin area of that site.

RESULTS A total of 5150 KCs with complete data were identified in 2374 study participants
(1339 men [56.4%] and 1035 women [43.6%]; mean [SD] age, 59.7 [7.4] years). Of these,
3846 KCs (74.7%) were BCCs. Most BCCs were on the head and/or neck (1547 [40.2%]) and
the trunk (1305 [33.9%]); most SCCs were on the head and/or neck (435 [33.4%]) and upper
limbs (455 [34.9%]). The greatest differences in RTDs between BCC and SCC were on the
hand (BCC:SCC ratio, 1:14) and the back and/or buttocks (BCC:SCC ratio, 8:1). Relative tumor
densities of KCs were higher on the scalp and ear in men compared with women, and on the
upper arm in women compared with men. The pattern of RTDs did not differ with age for
BCC. Compared with younger adults (40-54 years), the RTDs in older adults (55-69 years)
were 2-fold higher for SCC on the scalp (0.38 [95% CI, 0.00-0.81] vs 1.07 [95% CI, 0.75-1.38])
and the back and/or buttocks (0.05 [95% CI, 0.00-0.12] vs 0.12 [95% CI, 0.07-0.16]).

CONCLUSIONS AND RELEVANCE The high RTDs on sun-exposed body sites for BCC and SCC
are in keeping with sun exposure as the primary etiologic factor for both tumors. However, for
BCC, the low RTD on the hand and high RTDs on less sun-exposed sites suggest a complex
association between sun exposure and occurrence of BCC. Knowledge about the anatomical
distribution of BCC and SCC may provide insight into their diagnoses and causes. Author Affiliations: Author
affiliations are listed at the end of this
article.
Group Information: Members of the
QSkin Sun and Health Study are listed
at the end of the article.
Corresponding Author: Padmini
Subramaniam, MBBS, MSc, MClinSc,
Department of Population Health,
QIMR Berghofer Medical Research
Institute, Locked Bag 2000, Royal
Brisbane Hospital, Brisbane,
QLD 4029, Australia
JAMA Dermatol. 2017;153(2):175-182. doi:10.1001/jamadermatol.2016.4070 (padmini.subramaniam
Published online November 23, 2016. @qimrberghofer.edu.au).

(Reprinted) 175

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 Research Original Investigation
B
asal cell carcinoma (BCC) and squamous cell carci-
noma (SCC), collectively termed keratinocyte cancers
(KCs), are the most common cancers among fair-
skinned populations worldwide. Australia has the highest
incidence,1 with approximately 434 000 people (or nearly 2%
of the population) estimated to have been diagnosed with KCs
in the calendar year 2008.2 The cost of managing KCs in Aus-
tralia was projected to reach A$703 million (US $536 million)
in 2015.3
Although UV radiation is the major risk factor for BCC and
SCC, their anatomical distributions differ. Squamous cell car-
cinoma occurs primarily on sites habitually exposed to sun-
light, such as the face and exposed parts of the upper and lower
limbs, whereas BCC occurs on these sites and those less fre-
quently exposed to sunlight, such as the trunk.4-15
Most studies report the proportion of tumors on speci-
fied body sites without taking into account the proportion of
surface area of the defined body site, which prevents direct
comparison of tumor burden across different anatomical sites.
A few studies have reported the relative tumor density
(RTD),5,6,16-19 calculated as the ratio of the proportion of tu-
mors at a specific anatomical site to the proportion of skin sur-
face area at that site, or have reported surface area–adjusted
incidence rates.5-7 These studies5,6,17,18 showed that the high-
est RTDs occurred on the face for both cancers, but analysis
of facial subsites has been limited.
Some studies suggest that the body site distribution of BCC
and SCC varies with age and sex,5,17,18 although few studies have
compared both tumor types from 1 population sample. Given
the relatively small number of studies reported to date, the aim
of our study was to compare the anatomical distribution of BCC
and SCC arising in participants from a large, population-
based cohort in Queensland, Australia, and to investigate
differences according to age and sex.
Methods
This study is nested within the QSkin Sun and Health Study,
which consists of 43 794 residents of Queensland, Australia.
Participants aged 40 to 69 years were randomly selected from
the Australian electoral roll (enrollment to vote is compul-
sory) and recruited in 2010. They completed a survey that in-
cluded questions about ancestry, lifestyle, skin phenotype, past
treatment of skin lesions, and sun exposure history. Details of
the survey have been published previously.20 This study was
approved by the human ethics committees of the QIMR Berg-
hofer Medical Research Institute and Queensland University
of Technology, Brisbane, Queensland. All participants pro-
vided written informed consent for linkage of records with the
Medicare Australia database.
Through record linkage to Medicare Australia, Australia’s
national health insurance scheme, we identified participants
in the QSkin cohort who had been treated for skin cancer from
September 1, 2010, to September 30, 2012. Medicare Austra-
lia subsidizes health care for all Australians and records infor-
mation about medical services to Australian residents, ex-
cept for some services delivered in public hospitals. The data
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Anatomical Distributions of Skin Cancers in Queensland, Australia
Key Points
Question How great are the differences in anatomical
distributions of basal cell carcinoma (BCC) and squamous cell
carcinoma (SCC)?
Findings In this population-based study, the anatomical
distribution of 3398 keratinocyte cancers arising during 2 years of
follow-up of 37 103 Australians consisted of BCCs primarily on the
head and neck and trunk and SCCs predominantly on the upper
limbs and head and neck. Sites with the greatest discrepancy in
relative tumor densities between BCC and SCC were the hand and
back and buttocks.
Meaning Basal cell carcinoma and SCC have high relative tumor
densities on the head, consistent with sun exposure as the primary
etiologic factor; however, for BCC, the low relative tumor densities
on the hand and high relative tumor densities on less sun-exposed
sites suggest a complex association with sun exposure.
held by Medicare Australia records medical billing events for
KCs and the type of procedure undertaken, but no details about
histologic type or specific anatomical site are recorded. We
therefore obtained the corresponding pathology reports for
each treatment event by linking our QSkin data set to pathol-
ogy service providers for those participants identified from the
Medicare Australia data as having had KC treatments.
The diagnosis, treatment procedures, and anatomical site
of each tumor were manually abstracted from the pathology
reports. We included only primary BCCs and SCCs; recurrent
lesions, defined as the regrowth of a previously treated ma-
lignant neoplasm, were excluded. Thus, we cross-checked all
biopsies, excisions, and reexcisions of apparently multiple BCC
or SCC lesions diagnosed within a 6-month period on the same
anatomical site in the same person in Medicare Australia rec-
ords and pathology reports and omitted verified recurrent le-
sions from our analysis.
Analysis
Data were analyzed from January 31, 2013, to March 30, 2016.
We were able to match 65% of individual Medicare Australia
claims for KC treatment (72.1% of people) with pathology re-
ports. The median follow-up duration of the participants was
12.6 (range, 4.0-19.8) months. Almost all lesions for which we
had pathology reports (99.5%) had complete information on
body site and histologic findings and were included in the
analysis. To allow for differences in the skin surface area at dif-
ferent body sites, the RTD for each body site was calculated
by dividing the proportion of tumors at a defined anatomical
site by the mean proportion of the skin surface area of that
site.16 An RTD of 1 corresponds to the density of tumors on the
whole body.
The proportion of the surface area of skin attributed to each
body site was based on the estimated proportion of surface area
described by Lund and Browder.21 We classified body sites into
4 broad areas—head and/or neck, trunk (including shoul-
ders), upper limbs, and lower limbs—that constituted 9.0%,
32.0%, 19.0%, and 40.0% of the skin surface, respectively.
These 4 body sites were further subdivided into subsites as
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 Anatomical Distributions of Skin Cancers in Queensland, Australia Original Investigation Research

Table 1. Proportions, RTDs, and BCC:SCC Ratio by Body Site

BCC Lesions SCC Lesions
(n = 3846) (n = 1304)
Body Surface BCC to SCC Ratio
Body Site Area, % No. (%) [95% CI] RTD (95% CI)a No. (%) [95% CI] RTD (95% CI)a (95% CI)
Head and/or neck 9.0 1547 (40.2) [39-42] 4.47 (4.30-4.64) 435 (33.4) [31-36] 3.71 (3.42-3.99) 1.2 (1.1-1.3)
Scalp 3.7 89 (2.2) [2-3] 0.63 (0.50-0.75) 46 (3.5) [3-5] 0.95 (0.68-1.22) 0.7 (0.5-0.9)
Ears 0.5 138 (3.6) [3-4] 7.18 (6.00-8.35) 54 (4.1) [3-5] 8.28 (6.12-10.45) 0.9 (0.6-1.2)
Face 2.4 1086 (28.2) [27-30] 11.77 (11.17-12.36) 295 (22.6) [20-25] 9.43 (8.48-10.37) 1.3 (1.1-1.4)
Most exposedb 1.3 712 (18.5) [17-20] 14.24 (13.30-15.18) 213 (16.6) [14-18] 12.56 (11.02-14.11) 1.1 (1.0-1.3)
Less exposedc 1.3 384 (10.0) [9-11] 7.68 (6.95-8.41) 107 (8.2) [7-10] 6.31 (5.17-7.46) 1.2 (1.0-1.5)
Least exposedd 0.3 129 (3.4) [3-4] 11.18 (9.28-13.08) 29 (2.2) [1-3] 7.41 (4.75-10.08) 1.5 (1.0-2.2)
Neck 2.4 234 (6.1) [5-7] 2.54 (2.22-2.85) 40 (3.1) [2-4] 1.28 (0.89-1.67) 2.0 (1.4-2.8)
Trunk 32.0 1305 (33.9) [32-35] 1.06 (1.01-1.11) 109 (8.4) [7-10] 0.26 (0.21-0.31) 4.1 (3.4-4.9)
Chest and/or 13.0 647 (16.8) [15-18] 1.29 (1.20-1.38) 83 (6.4) [5-8] 0.49 (0.39-0.59) 2.6 (2.1-3.3)
abdomen
Back and/or 19.0 658 (17.1) [16-18] 0.90 (0.84-0.96) 26 (2.0) [1-3] 0.10 (0.07-0.14) 8.6 (5.8-12.6)
buttocks
Upper limbs 19.0 528 (13.7) [13-15] 0.72 (0.67-0.78) 455 (34.9) [32-37] 1.84 (1.70-1.97) 0.4 (0.4-0.4)
Upper arm 8.0 234 (6.1) [5-7] 0.76 (0.67-0.85) 56 (4.3) [3-5] 0.54 (0.40-0.67) 1.4 (1.1-1.9)
Forearm 6.0 257 (6.7) [6-8] 1.11 (0.98-1.25) 223 (17.1) [15-19] 2.85 (2.51-3.19) 0.4 (0.3-0.5)
Hande 5.0 37 (1.0) [1-1] 0.19 (0.13-0.25) 176 (13.5) [12-15] 2.70 (2.33-3.07) 0.1 (0.1-0.1)
Lower limbs 40.0 466 (12.1) [11-13] 0.30 (0.28-0.33) 305 (23.4) [21-26] 0.58 (0.53-0.64) 0.5 (0.5-0.6)
Thigh 19.0 67 (1.7) [1-2] 0.09 (0.07-0.11) 30 (2.3) [1-3] 0.12 (0.08-0.16) 0.8 (0.5-1.2)
Lower leg 14.0 377 (9.8) [9-11] 0.70 (0.63-0.77) 258 (19.8) [18-22] 1.41 (1.26-1.57) 0.5 (0.4-0.6)
Footf 7.0 22 (0.6) [0-1] 0.08 (0.05-0.12) 17 (1.3) [1-2] 0.19 (0.10-0.27) 0.4 (0.2-0.8)
All 100 NA NA NA NA NA
d
Abbreviations: BCC, basal cell carcinoma; NA, not applicable; RTD, relative Includes under eyebrow, upper and lower eyelids, medial and lateral canthus,
tumor density; SCC, squamous cell carcionoma. and nasolabial fold.
a e
Calculated as the ratio of the proportion of tumors at a specific anatomical site Includes back of hand, palmar skin, and fingernail.
to the proportion of skin surface area at that site. f
Includes dorsum of foot, toes, plantar skin, and toenail.
b
Includes ears, nose, cheeks, and lips.
c
Includes forehead, eyebrows, chin, jaw, temple, and preauricular area.

shown in Table 1. The classification of facial subsites accord-
ing to their sun exposure was adapted and modified from
previous studies5,6 as follows: most exposed included the
ears, nose, cheeks, and lips; less exposed, the forehead, eye-
brows, chin, jaw, temple, and preauricular area; and least ex-
posed, under the eyebrow, upper and lower eyelids, medial and
lateral canthus, and nasolabial fold.
We calculated the RTDs and 95% CIs for BCC and SCC over-
all and within the strata of sex and age groups (40-54 and 55-69
years). We calculated the ratio of RTDs for BCC to SCC for each
anatomical site and 95% CIs of these ratios, overall and within
strata of age and sex.22 Statistical analysis was conducted using
SAS (version 9.4; SAS Institute, Inc) and Excel (Microsoft)
software.
Results
Of the 43 794 QSkin participants, 39 033 consented to link-
age with Medicare and 37 103 were linked to the Medicare
Australia database (Figure 1). Of these, we identified 3398
participants who were treated for KCs during the study
period. Histopathology reports for at least 1 KC lesion were
retrieved and matched for 2387 of these participants (70.2%)
(1346 men [56.4%] and 1041 women [43.6%]; mean [SD] age,
59.7 [7.4] years). Participants with available histopathologic
data were similar with respect to age and sex to those with-
out available data.
Most participants reported having white European ances-
try (2327 [97.5%]) and 1473 (68.3%) had lived longest as a
child or youth in the north and central regions (10°S-30° S
parallels) of Australia. For skin characteristics, 1820 partici-
pants (76.3%) had fair skin, 2265 (94.9%) reported that their
skin burned after exposure to 30 minutes of midday sun, and
2079 (87.1%) reported that they tanned after long-term sun
exposure.
From the pathology reports, we identified 5189 primary
KC lesions in 2387 participants. We excluded 39 BCCs and SCCs
from 13 participants with missing site information. Of the 5150
KCs from 2374 participants included in the final analysis, 3846
(74.7%) were BCCs. Of these, 3233 lesions (62.8%) were treated
in men and 2891 (57.3%) were treated in people aged 60 to 69
years. Among the participants with a histologically con-
firmed BCC or SCC, 806 (42.6%) had multiple BCCs (range, 2-40
lesions), and 223 (28.1%) had multiple SCCs (range 2-8 le-
sions). Three hundred eight participants (12.9% of those with
KC) had both BCC and SCC. Of those with BCC, 16.3% also had
SCC, and of those with SCC, 38.7% also had BCC.

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 Research Original Investigation Anatomical Distributions of Skin Cancers in Queensland, Australia

Anatomical Distribution of BCC and SCC limbs (34.9%) and head and/or neck (33.4%) (Table 1 and
The most commonly diagnosed sites of the 3846 identified Figure 2). Although the differences in the proportion of le-
BCCs were on the head and/or neck (40.2%) and trunk (33.9%). sions on the most commonly affected sites were small, we
The 1304 SCCs occurred with similar frequency on the upper found marked differences in the RTDs once we accounted for
the surface area of these sites (Table 1, Figure 2, and Figure 3).
Figure 1. Outline of Data Collection Process for the Study Participants For BCCs, highest RTDs were observed on the head and/or neck
(RTD, 4.47; 95% CI, 4.30-4.64), which was 4 times higher than
43 794 Participants in QSkin cohort on the trunk, the second most commonly affected site (RTD,
1.06; 95% CI, 1.01-1.11). Similarly, SCCs occurred at highest
39 033 (89.1%) Consent for Medicare density on the head and/or neck region (RTD, 3.71; 95% CI, 3.42-
Australia linkage
3.99), which was twice as high as that on the upper limbs (RTD,
1.84; 95% CI, 1.70-1.97).
37 103 (95.1%) Linkage with Medicare
Australia data
Subsites with the highest RTDs for BCC were the most
(14.24; 95% CI, 13.30-15.18) and least (11.18; 95% CI, 9.28-
13.08) sun- exposed face. The lowest RTD s for BCC
3398 (9.2%) Treated for keratinocyte
cancersa, b were observed on the foot (0.08; 95% CI, 0.05-0.12), thigh
(0.09; 95% CI, 0.07-0.11), and hand (0.19; 95% CI,
2387 Participants (5189 lesions) with 0.13-0.25). Sites with the highest RTDs for SCC were the
histology reports diagnosing most sun-exposed face (12.56; 95% CI, 11.02-14.11) and ears
keratinocyte cancersc
(8.28; 95% CI, 6.12-10.45). The lowest RTDs of SCC were
observed on the back and/or buttocks (0.10; 95% CI, 0.07-
2374 Participants (5150 lesions) 13 Participants (39 lesions) with 0.14), thigh (0.12; 95% CI, 0.08-0.16), and foot (0.19; 95%
with complete data incomplete data (not included) CI, 0.10-0.27).
The greatest disparity in RTD was seen on the hand, for
which the RTD for SCC was 14 times higher than that for BCC
3846 (74.7%) Lesions are BCC 1304 (25.3%) Lesions are SCC
(2.70 [95% CI, 2.33-3.07] vs 0.19 [95% CI, 0.13-0.25]). At the
other extreme, BCCs occurred on the back and/or buttocks at
The number of basal cell carcinoma (BCC) (n = 3846) and squamous cell
a more than 8-fold higher RTD (0.90; 95% CI, 0.84-0.96) than
carcinoma (SCC) (n = 1304) lesions included in the analysis was derived from
participants recruited for the QSkin Sun and Health Study, who gave consent for SCCs (0.10; 95% CI, 0.07-0.14) (Table 1). Overall, RTDs for SCC
linkage with Medicare Australia, were treated for keratinocyte cancers, and had on the upper and lower limbs were almost twice those of BCC,
histologic verification of BCC and SCC. whereas BCCs were twice as dense as SCCs on the neck and
a
Includes excision and destructive therapies. chest and/or abdomen. For participants with multiple le-
b
Includes treatment for BCC, SCC, intraepidermal carcinoma, and sions, the RTDs on the body sites followed a similar pattern of
keratoacanthoma.
c
distribution to the overall distribution of lesions (eTable 1 in
Includes BCC and SCC only.
the Supplement).

Figure 2. Relative Tumor Densities of Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) by Body Sites

15
14
BCC broad area
13
12 BCC subsite
11
Relative Tumor Density

SCC broad area

10
SCC subsite
9
8
7
6
5
4
3
2
1
0
All Scalp Ears Overall Most Less Least Neck All Chest Back All Upper Forearm Hand All Thigh Lower Foot
Subsites Face Exposed Exposed Exposed Subsites and/or and/or Subsites Arm Subsites Leg
Faces Face Face Abdomen Buttocks

Head and/or Neck Trunk Upper Limb Lower Limb

Body Sites

Relative tumor density is calculated as the ratio of the proportion of tumors at a trunk, upper limbs, and lower limbs) for BCC and SCC and for their respective
specific anatomical site to the proportion of skin surface area at that site. subsites.
Distribution is shown for the 4 broad areas of body sites (head and/or neck,

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 Anatomical Distributions of Skin Cancers in Queensland, Australia
Figure 3. Relative Tumor Densities (95% CIs) of Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC)
at Different Body Sites
A Basal cell carcinoma B Squamous cell carcinoma
4.47 (95% CI, 4.30-4.64)
1.06 (95% CI, 1.01-1.11)
0.72 (95% CI, 0.67-0.78)
0.30 (95% CI, 0.28-0.33)
Sex Differences in the Anatomical Distribution
of BCC and SCC
For BCC, we found little difference between men and women
in the RTDs overall, except that the relative density of BCCs
on the ears and scalp were 3.7-fold (2.68 [95% CI, 1.51-3.84] vs
10.03 [95% CI, 8.27-11.80]) and 1.6-fold (0.45 [95% CI, 0.28-
0.63] vs 0.74 [95% CI, 0.56-0.91]), respectively, higher in men
than in women. In contrast, BCCs occurred 80% more fre-
quently (in relative terms) on the upper arms of women than
men (RTDs, 1.05 [95% CI, 0.87-1.22] vs 0.58 [95% CI, 0.47-
0.69]). The occurrence of BCC on the face was marginally higher
in women than men (13.61 [95% CI, 12.14-14.49] vs 10.60 [95%
CI, 9.68-11.33]); this was most marked on the least exposed
areas of the face (13.83 [95% CI, 10.46-17.20]vs 9.50 [95% CI,
7.25-11.74]; 1.5-fold higher) (eTable 2 in the Supplement).
In contrast, the site distribution of SCC differed markedly
between men and women, with RTDs in men 10 times higher
on the scalp (1.35 [95% CI, 0.96-1.74] vs 0.13 [95% CI, 0.00-
0.30]) and 5 times higher on the ears (11.12 [95% CI, 8.10-
14.15] vs 2.36 [95% CI, 0.30-4.42]) compared with women. With
the exception of the forearm, the RTDs of SCC on the trunk
(0.23 [95% CI, 0.18-0.28] vs 0.33 [95% CI, 0.23-0.42]) and up-
per (1.74 [95% CI, 1.57-1.90] vs 2.04 [95% CI, 1.80-2.28]) and
lower (0.52 [95% CI, 0.45-0.59] vs 0.72 [95% CI, 0.61-0.83])
limbs was higher in women than in men.
Age Differences in the Anatomical Distribution
of BCC and SCC
The distributions of BCC were similar among younger and older
participants (Table 2) at all anatomical sites. For SCC, higher
RTDs were seen on the scalp (0.38 [95% CI, 0.00-0.81] vs 1.07
[95% CI, 0.75-1.38]), ears (5.63 [95% CI, 1.19-10.08] vs 8.80 [95%
CI, 6.37-11.23]), and back and/or buttocks (0.05 [95% CI, 0.00-
0.12] vs 0.12 [95% CI, 0.07-0.16]) in the older compared with
the younger participants. Although numbers were small, some
evidence suggested that the RTD of SCCs on the face was higher
among younger than older people, especially on the least sun-
exposed facial sites.
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Original Investigation Research
Head and/or neck
Upper limbs
3.71 (95% CI, 3.42-3.99) Trunk
Lower limbs
0.26 (95% CI, 0.21-0.31)
1.84 (95% CI, 1.70-1.97)
Relative tumor density is calculated
as the ratio of the proportion of
tumors at a specific anatomical site to
the proportion of skin surface area at
that site. Body maps show the
0.58 (95% CI, 0.53-0.64) relative tumor densities of BCC and
SCC according to the following body
site classifications: head and/or neck
(total body surface area, 9.0%), trunk
(total body surface area, 32.0%),
upper limbs (total body surface area,
19.0%), and lower limbs (total body
surface area, 40.0%).
Among younger participants, the RTD of BCC on the scalp
was higher than the RTD of SCC on the scalp (0.84 [95% CI,
0.56-1.13] vs 0.38 [95% CI, 0.00-0.81]), whereas the opposite
was observed among older participants (0.54 [95% CI, 0.40-
0.68] vs 1.07 [95% CI, 0.75-1.38]). On the back and buttocks,
the RTD of BCC compared with SCC was 18-fold higher among
younger participants (0.91 [95% CI, 0.79-1.03] vs 0.05 [95% CI,
0.00-0.12]), but just more than 7-fold higher among older
participants (0.90 [95% CI, 0.82-0.97] vs 0.12 [95% CI,
0.07-0.16]).
Discussion
In this study, we analyzed the anatomical site distributions of
BCC and SCC and compared them within strata of age and sex.
This study is, to our knowledge, one of the largest population-
based studies to compare the site distribution of BCC and SCC
within the same sample of participants.
Compared with the whole body, the head and/or neck re-
gion (face, ears, and neck) had a higher RTD of BCC than the
mean. Although the RTD of BCC was highest on sites of fre-
quent sun exposure, a large number of lesions also occurred
on body sites less frequently exposed to sunlight, particu-
larly the trunk. For SCC, RTDs higher than the mean were seen
on the frequently sun-exposed parts of the body, with the head
and/or neck region (face, ears, and neck), upper limbs (fore-
arm and hands), and lower legs all exhibiting high RTDs. The
highest RTDs were present on the most sun-exposed facial
sites, followed by the ears.
The pattern of distribution5,6,18 and the absolute tumor
densities17 of BCC and SCC were consistent with other Austra-
lian studies. However, studies from other countries have found
a much higher proportion of both cancer types on the head
and/or neck region, with as many as 80% of BCCs and SCCs
occurring on this site.7-15,23,24 A number of possible reasons
may explain this frequency. First, these studies differed in
age range of the participants and methodologic approach.
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 180
Table 2. Frequency Distribution and RTDs of BCC and SCC on Body Sites by Age Categories

BCC Age Group (n = 3846) SCC Age Group (n = 1304)

Young (n = 1055)a Old (n = 2791)b Young to Old Young (n = 213)a Old (n = 1091)b Young to Old
Frequency, % RTD Frequency, % RTD Ratio Frequency, % RTD Frequency, % RTD Ratio
Body Site (95% CI) (95% CI)c (95% CI) (95% CI)c (95% CI) (95% CI) (95% CI)c (95% CI) (95% CI)c (95% CI)
Head and/or neck 38 (35-41) 4.22 (3.88-4.53) 41 (39-43) 4.57 (4.37-4.77) 0.9 (0.8-1.0) 36 (30-43) 4.02 (3.30-4.73) 33 (30-36) 3.65 (3.34-3.96) 1.1 (0.9-1.3)
Scalp 3 (2-4) 0.84 (0.56-1.13) 2 (1-3) 0.54 (0.40-0.68) 1.6 (1.0-2.4) 1 (0-3) 0.38 (0.00-0.81) 4 (3-5) 1.07 (0.75-1.38) 0.4 (0.1-1.1)
Ears 4 (3-5) 7.57 (5.28-9.89) 4 (3-4) 7.02 (5.66-8.39) 1.1 (0.8-1.6) 3 (1-5) 5.63 (1.19-10.08) 4 (3-6) 8.80 (6.37-11.23) 0.6 (0.3-1.5)
Research Original Investigation

Face 25 (23-28) 10.53 (9.38-11.56) 29 (28-31) 12.26 (11.55-12.96) 0.9 (0.8-1.0) 29 (23-35) 11.93 (9.40-14.46) 21 (19-24) 8.94 (7.92-9.95) 1.3 (1.1-1.7)
Most exposedd 17 (15-20) 13.32 (11.45-14.95) 19 (18-20) 14.64 (13.51-15.76) 0.9 (0.8-1.1) 18 (13-23) 13.72 (9.77-17.68) 16 (14-18) 12.34 (10.66-14.01) 1.1 (0.8-1.5)
Less exposede 8 (6-10) 6.11 (4.87-7.38) 11 (10-12) 8.27 (7.38-9.15) 0.7 (0.6-0.9) 8 (5-12) 6.50 (3.63-9.37) 8 (7-10) 6.28 (5.03-7.52) 1.0 (0.6-1.7)
Least exposedf 4 (3-5) 12.93 (9.07-16.84) 3 (3-4) 10.51 (8.35-12.67) 1.2 (0.9-1.8) 5 (2-8) 17.21 (7.31-27.12) 2 (1-2) 5.50 (2.98-8.02) 3.1 (1.5-6.5)
Neck 6 (4-7) 2.40 (1.82-3.00) 6 (5-7) 2.58 (2.21-2.96) 0.9 (0.7-1.2) 3 (1-6) 1.37 (0.37-2.37) 3 (2-4) 1.26 (0.84-1.68) 1.1 (0.5-2.4)

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Trunk 36 (33-39) 1.13 (1.04-1.22) 33 (31-35) 1.03 (0.98-1.09) 1.1 (1.0-1.2) 12 (8-17) 0.38 (0.24-0.52) 8 (6-9) 0.24 (0.19-0.29) 1.6 (1.1-2.4)
Chest and/or abdomen 19 (16-21) 1.45 (1.27-1.63) 16 (15-17) 1.23 (1.13-1.34) 1.2 (1.0-1.4) 11 (7-16) 0.87 (0.54-1.19) 5 (4-7) 0.42 (0.31-0.52) 2.1 (1.3-3.3)
Back and/or buttocks 17 (15-20) 0.91 (0.79-1.03) 17 (16-18) 0.90 (0.82-0.97) 1.0 (0.9-1.2) 1 (0-2) 0.05 (0.00-0.12) 2 (1-3) 0.12 (0.07-0.16) 0.4 (0.1-1.8)
Upper limbs 16 (14-18) 0.84 (0.72-0.95) 13 (12-14) 0.68 (0.61-0.74) 1.2 (1.0-1.5) 32 (26-39) 1.70 (1.37-2.04) 35 (33-38) 1.86 (1.71-2.01) 0.9 (0.7-1.1)
Upper arm 8 (7-10) 1.03 (0.82-1.24) 5 (4-6) 0.66 (0.55-0.76) 1.6 (1.2-2.0) 4 (1-6) 0.47 (0.15-0.79) 4 (3-6) 0.55 (0.40-0.70) 0.9 (0.4-1.8)
Forearm 6 (5-8) 1.07 (0.83-1.32) 7 (6-8) 1.13 (0.97-1.28) 1.0 (0.7-1.2) 13 (9-18) 2.19 (1.43-2.95) 18 (16-20) 2.98 (2.60-3.36) 0.7 (0.5-1.1)

JAMA Dermatology February 2017 Volume 153, Number 2 (Reprinted)

Handg 1 (1-2) 0.25 (0.11- 0.38) 1 (1-1) 0.17 (0.10-0.24) 1.4 (0.7-2.8) 15 (11-20) 3.10 (2.13-4.07) 13 (11-15) 2.62 (2.22-3.02) 1.2 (0.8-1.7)
Lower limbs 10 (8-12) 0.25 (0.21-0.30) 13 (12-14) 0.32 (0.29-0.35) 0.8 (0.6-1.0) 19 (14-25) 0.48 (0.35-0.61) 24 (22-27) 0.60 (0.54-0.67) 0.8 (0.6-1.1)
Thigh 2 (1-3) 0.12 (0.07-0.17) 2 (1-2) 0.08 (0.06-0.11) 1.5 (0.9-2.4) 2 (0-4) 0.12 (0.02-0.23) 2 (1-3) 0.12 (0.07-0.17) 1.0 (0.4-2.7)
Lower leg 7 (6-9) 0.53 (0.42-0.65) 11 (10-12) 0.76 (0.68-0.84) 0.7 (0.6-0.9) 16 (11-21) 1.17 (0.82-1.53) 21 (18-23) 1.46 (1.29-1.63) 0.8 (0.6-1.1)
Footh 0 (0-1) 0.04 (0.00-0.09) 1 (0-1) 0.10 (0.05-0.14) 0.4 (0.1-1.4) 0 (0-1) 0.07 (0.00-0.20) 2 (1-2) 0.21 (0.11-0.31) 0.3 (0.0-2.4)
Total body 100 NA NA NA NA NA NA NA NA NA
d
Abbreviations: BCC, basal cell carcinoma; NA, not applicable; RTD, relative tumor density; SCC, squamous cell Includes ears, nose, cheeks, and lips.
carcinoma. e
Includes forehead, eyebrows, chin, jaw, temple, and preauricular area.
a
Indicates 40 to 54 years. f
Includes under eyebrow, upper and lower eyelids, medial and lateral canthus, and nasolabial fold.
b
Indicates 55 to 69 years. g
Includes back of hand, palmar skin, and fingernail.
c
Calculated as the ratio of the proportion of tumors at a specific anatomical site to the proportion of skin surface h
Includes dorsum of foot, toes, plantar skin, and toenail.

Copyright 2017 American Medical Association. All rights reserved.

area at that site.

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Anatomical Distributions of Skin Cancers in Queensland, Australia
 Anatomical Distributions of Skin Cancers in Queensland, Australia
Second, variability in medical care, such as differences in op-
portunistic screening practice, may have led to fewer lesions
being diagnosed on less habitually sun-exposed sites than in
Australia. This variability is particularly likely to influence the
body site distribution of BCC.25 Finally, the relatively higher
proportion of lesions on sites other than the head and/or neck
in Australia is likely owing to lifestyle and sun exposure
practices. For example, the climate in Australia is conducive
to outdoor recreational pursuits that are commonly enjoyed
with minimal clothing, which would contribute to higher
exposure on the trunk and limbs compared with other
populations.
The anatomical distribution of SCC corresponds closely
to the pattern of intensity of sun exposure, with the highest
density of lesions occurring on body sites frequently
exposed to sunlight. Basal cell carcinoma was less clearly
aligned with sun exposure patterns, with a relatively high
RTD on less frequently exposed body sites. The infrequent
exposure of these sites results in less melanin protection,
increasing the risk for sunburn. Basal cell carcinoma on less
exposed body sites may thus arise as a result of infrequent
or intermittent high doses of UV radiation.26 Alternatively,
the potential cells of origin of BCC on the trunk and but-
tocks may require a lower total dose of sun exposure to
become neoplastic. The relatively high RDT of BCC in the
periorbital region, which receives the least amount of
sunlight among the facial subsites, also supports the theory
that lower doses of UV radiation give rise to BCCs compared
with SCCs.
The RTD of SCC on the hand was 14 times higher than the
RTD of BCC (2.70 [95% CI, 2.33-3.07] vs 0.19 [95% CI, 0.13-
0.25]). The relative paucity of BCC on the hands, which are
chronically exposed to intense sunlight, has been reported in
clinical and epidemiologic studies previously.16,27 We calcu-
lated the BCC:SCC ratio in previous studies as 1:918 and 1:20.16
The difference in RTDs between BCC and SCC on the hands
cannot be explained simply by sun-exposure patterns. The
significantly greater thickness of the epidermis on the dor-
sum of the hand compared with the forearm28 may explain
the relative lack of BCC on the hands but fails to explain the
relative abundance of SCC. Basal cell carcinoma is postu-
lated to arise from basal cells that are situated deeper in the
epidermis of the skin, in contrast to the more superficially
placed squamous cells, thought to be the origin of SCC.
Thus, one plausible explanation for the marked differences
in the occurrence of BCC and SCC on the dorsum of the
hand is that the depth of epidermis protects the deeply situ-
ated basal cells from the UV rays compared with the expo-
sure received by the more superficial squamous cells. Stud-
ies have also suggested that BCC may arise from follicular
stem cells,29 so an alternate explanation for the lower RTD
of BCC could be the relative lack of hair on the back of the
hands compared with the forearm.
A limited number of studies have shown that the associa-
tion between the anatomical distributions of KC varies
according to sex. We found that the RTDs of BCC and SCC on
the scalp and ears were higher in men than in women, a pat-
tern that has been reported previously.6,7,18 This difference
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Original Investigation Research
is likely owing to sex differences in hair cover. Higher densi-
ties of KCs occurring on the upper arm of women compared
with men may be attributed to clothing choice, with more
women than men choosing to wear short-sleeved or sleeve-
less shirts.
Our findings did not show significant differences be-
tween the younger and the older groups for BCC. Higher RTDs
for SCCs seen on less exposed sites, such as the back and/or
buttocks region, in older compared with younger partici-
pants could be attributed to higher cumulative sun exposure
with increasing age. Differential treatment according to age (eg,
older people having more regular full-body screening) may
partly explain the age differences in SCC RTDs but is unlikely
to be entirely responsible because the same differences are not
observed for BCC.
This study has a number of strengths and weaknesses.
We recruited a large community-based sample from the
compulsory voting register. Moreover, because we identi-
fied patients with KCs through linkage with the national
insurance scheme and confirmed the diagnoses with
pathology reports, the information regarding diagnosis and
anatomical distribution is likely to be accurate. Although we
did not capture services delivered in public hospitals, the
2002 National Skin Cancer Survey reported that fewer than
2% of the survey participants underwent skin cancer treat-
ment in a hospital setting, indicating near-complete capture
of skin cancer events.30 A potential weakness in this analy-
sis is the lack of histologic confirmation of all KCs identified
in the Medicare records. We obtained pathology records
from the 2 largest and 2 smaller pathology service providers
for the state of Queensland, but we were unable to obtain
pathology reports from all laboratories in the state. How-
ever, we interrogated the Medicare data by item numbers
that broadly identify the site of the lesion, which showed
that the overall patterns of site distribution did not differ
between participants with and without pathology reports.
Therefore, the RTD estimates are likely to be representative
of the fair-skinned population of Queensland, and by infer-
ence to other populations residing in low latitudes,
although they may not be applicable to other population
groups.
Conclusions
The results from this large cohort study emphasized dif-
ferences in the anatomical distributions of BCC and SCC.
High densities of BCCs and SCCs observed on sun-exposed
body sites confirm sun exposure as the primary etiologic
factor for both tumors; the differences in RTDs of SCCs
by age and sex underscore the association with cumulative
sun exposure. In contrast, the observations that BCCs
occur relatively infrequently on the hand but relatively fre-
quently on body sites that are only intermittently exposed
to UV radiation point to more complex associations
with sun exposure. Understanding the etiology and patho-
genesis of BCC may lead to new avenues for prevention and
treatment.
(Reprinted) JAMA Dermatology February 2017 Volume 153, Number 2 181
 Research Original Investigation
ARTICLE INFORMATION
Accepted for Publication: September 2, 2016.
Published Online: November 23, 2016.
doi:10.1001/jamadermatol.2016.4070
Author Affiliations: Department of Population
Health, QIMR Berghofer Medical Research Institute,
Royal Brisbane Hospital, Queensland, Australia
(Subramaniam, Olsen, Thompson, Whiteman,
Neale); Institute of Health and Biomedical
Innovation, Queensland University of Technology,
Queensland, Australia (Subramaniam); National
Health and Medical Research Council Centre for
Research Excellence in Sun and Health, Queensland
University of Technology, Queensland, Australia
(Subramaniam, Whiteman, Neale); School of Public
Health, University of Queensland, Queensland,
Australia (Olsen).
Author Contributions: Drs Subramaniam and
Whiteman 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: Subramaniam,
Whiteman, Neale.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Subramaniam, Neale.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Subramaniam, Thompson.
Administrative, technical, or material support:
Subramaniam, Olsen, Whiteman.
Study supervision: Whiteman, Neale.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by
program grants APP552429, and APP1073898 from
the National Health and Medical Research Council
(NHMRC); by research fellowships from the
NHMRC (Drs Neale and Whiteman), and Australian
Postgraduate Award, the Queensland University of
Tehnology Vice Chancellor’s Top-Up scholarship,
and NHMRC Centre for Research Excellence in Sun
and Health (Dr Subramaniam).
Role of the Funder/Sponsor: The funding sources
had no role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Group Members: Participating investigators in the
QSkin Sun and Health Study included the following:
David C. Whiteman, MBBS, PhD, Catherine M.
Olsen, PhD, MPH, and Adèle C. Green, MBBS, PhD,
Department of Population Health, QIMR Berghofer
Medical Research Institute, Royal Brisbane Hospital,
Queensland, Australia (chief investigators); Rachel
E. Neale, BVSc, PhD, and Penelope M. Webb, MA,
DPhil, Department of Population Health, QIMR
Berghofer Medical Research Institute, Royal
Brisbane Hospital (associate investigators);
Rebekah A. Cicero, BA, Lea M. Jackman, DipBA,
Suzanne M. O’Brien, BN, Barbara A. Ranieri, and
Bridie S. Thompson, PhD, Department of
Population Health, QIMR Berghofer Medical
Research Institute, Royal Brisbane Hospital (study
team); Conrad J. Morze, MBBS, and H. Peter Soyer,
MD, Dermatology Research Centre, University of
Queensland, Queensland, Australia (clinical
collaborators); and Dallas English, PhD, University
of Melbourne, Melbourne, Australia, and Allison
182 JAMA Dermatology February 2017 Volume 153, Number 2 (Reprinted)
Copyright 2017 American Medical Association. All rights reserved.
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Anatomical Distributions of Skin Cancers in Queensland, Australia
Venn, PhD, Menzies Research Institute, Hobart,
Australia (scientific advisory board).
Previous Presentation: This study was presented
as an abstract at the 21st Australasian
Epidemiological Association Annual Scientific
Meeting; October 10, 2014; Auckland, New
Zealand.
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