Prospective quality of life impact of keratinocyte carcinomas: Observations from the Veterans Affairs Topical Tretinoin Chemoprevention Trial
2010; Elsevier BV; Volume: 63; Issue: 6 Linguagem: Inglês
10.1016/j.jaad.2010.02.014
ISSN1097-6787
AutoresKachiu C. Lee, Martin A. Weinstock,
Tópico(s)Nail Diseases and Treatments
ResumoTo the Editor: Keratinocyte carcinoma (KC; basal and squamous cell carcinoma) is the most common malignancy in the United States. Previous cross-sectional analysis found minimal KC-related quality of life (QOL) effects, but the relationship over time between developing KCs and QOL remains unclear.1Weinstock M.A. Lee K.C. Chren M.M. Marcolivio K. Quality of life in the actinic neoplasia syndrome: the VA Topical Tretinoin Chemoprevention (VATTC) Trial.J Am Acad Dermatol. 2009; 61: 207-215Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 2Rhee J.S. Loberiza F.R. Matthews B.A. Neuburg M. Smith T.L. Burzynski M. Quality of life assessment in nonmelanoma cervicofacial skin cancer.Laryngoscope. 2003; 113: 215-220Crossref PubMed Scopus (48) Google Scholar This study examines QOL effects of developing KCs over the course of 36 months. The Veterans Affairs Topical Tretinoin Chemoprevention (VATTC) Trial was a randomized trial of topical tretinoin 0.1% for the prevention of KCs. All subjects had two or more KCs within the previous 5 years, and were free of KCs at baseline.3Weinstock M.A. Bingham S.F. Lew R.A. Hall R. Eilers D. Kirsner R. et al.Topical tretinoin therapy and all-cause mortality.Arch Dermatol. 2009; 145: 18-24Crossref PubMed Scopus (49) Google Scholar Subjects received full-body skin examinations semiannually. QOL was measured at baseline, 12, 24, and 36 months with the Skindex-29,4Chren M.M. Lasek R.J. Flocke S.A. Zyzanski S.J. Improved discriminative and evaluative capability of a refined version of Skindex, a quality-of-life instrument for patients with skin diseases.Arch Dermatol. 1997; 133: 1433-1440Crossref PubMed Google Scholar a skin-specific survey, and with six KC-specific items created using input from clinicians and patients (Table I). The treatment modality of KCs was left to the discretion of each clinical site.Table IKeratinocyte carcinoma–specific items used to access quality of life∗Items were rated on a scale of 1 to 5, with 1 being “never” and 5 being “all the time.”These questions concern your feelings over the past week about the skin condition that has bothered you the most. Circle the answer that comes closest to the way you have been feeling.1. I worry about side effects from skin medication/treatments.2. I am bothered or upset by scars on my face.3. I am bothered by the way my skin condition affects my appearance.4. I am worried about the treatment for my skin condition.5. I am bothered by the persistence/reoccurrence of my skin condition.6. I am worried that my skin condition will spread.∗ Items were rated on a scale of 1 to 5, with 1 being “never” and 5 being “all the time.” Open table in a new tab KC was defined as basal or invasive squamous cell carcinoma (including keratoacanthoma), as determined by central dermatopathology review. Interobserver reliability of these histopathologic diagnoses has been reported.5Jagdeo J. Weinstock M.A. Piepkorn M. Bingham S.F. Reliability of the histopathologic diagnosis of keratinocyte carcinomas.J Am Acad Dermatol. 2007; 57: 279-284Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Analysis was conducted on STATA 8.2 (StataCorp; College Station, TX) using paired/unpaired t tests. All P values were 2-tailed. Of 937 participants enrolled in 5 centers of the trial, 97% were men (mean age, 71 years). Among 799 participants with complete QOL surveys, 382 (48%) developed one or more KC over 36 months. There was no difference in Skindex or KC-item scores in those with new KCs, as compared to their own scores 12 months earlier. In addition, there was no difference in change of QOL scores when comparing those with and without new KCs over each 12-month interval. The only exception was the KC-specific items at the 12-month assessment (Table II); no differences were present at the 24- or 36-month assessment (Table III, Table IV).Table IIQuality of life scores in patients with and without new keratinocyte carcinomas at 12 monthsSkindex score in patients with no new KCs (n = 562)Skindex score in patients with new KCs (n = 176)Skindex domainBaseline12 moChange in QOLBaseline12 moChange in QOLPEmotions15.212.9−2.316.314.8−1.5.5Functioning7.26.2−1.06.56.2−0.3.4Symptoms21.822.10.324.125.81.7.3KC-specific18.714.8−3.918.618.80.2.001KC, Keratinocyte carcinomas; QOL, quality of life. Open table in a new tab Table IIIQuality of life scores in patients with and without new keratinocyte carcinomas at 24 monthsSkindex score in patients with no new KCs (n = 458)Skindex score in patients with new KCs (n = 194)Skindex domain12 mo24 moChange in QOL12 mo24 moChange in QOLPEmotions12.312.5−0.215.916.30.4.9Functioning5.96.20.37.67.90.3.6Symptoms20.921.80.920.8210.2.6KC-specific14.615.91.31818.30.3.2KC, Keratinocyte carcinomas; QOL, quality of life. Open table in a new tab Table IVQuality of life scores in patients with and without new keratinocyte carcinomas at 36 monthsSkindex score in patients with no new KCs (n = 354)Skindex score in patients with new KCs (n = 136)Skindex domain24 mo36 moChange in QOL24 mo36 moChange in QOLPEmotions12.912.5−0.416.817.81.0.3Functioning6.46.2−0.28.7101.3.2Symptoms21.622.11.525.827.71.9.3KC-specific14.313.5−0.819.621.20.6.3KC, Keratinocyte carcinomas; QOL, quality of life. Open table in a new tab KC, Keratinocyte carcinomas; QOL, quality of life. KC, Keratinocyte carcinomas; QOL, quality of life. KC, Keratinocyte carcinomas; QOL, quality of life. At the 12-month assessment, common KC treatments included Mohs micrographic surgery (51%), electrodessication and curettage (28%), and excision (13%). At 24 and 36 months, the proportions were similar. No QOL differences were associated with treatment modality. Tretinoin use was not associated with any of the potential predictors of Skindex score. We did not find any QOL impact associated with development of KCs, with the exception of worse QOL noted on KC items at 12 months. The interpretation of this finding is complicated by the fact that the KC items were not previously validated, and that this isolated association was not confirmed at any other time period, or by any of the standard dimensions of the Skindex. Our study did not find any difference in QOL based on mode of treatment. However, our sample size was not powered for adequate assessment of this clinical question. Previous studies measuring cross-sectional KC-related QOL found minimal associations of KC with QOL, suggesting that available instruments may be insensitive to this skin condition, or that the QOL impact could be minimal for most patients.1Weinstock M.A. Lee K.C. Chren M.M. Marcolivio K. Quality of life in the actinic neoplasia syndrome: the VA Topical Tretinoin Chemoprevention (VATTC) Trial.J Am Acad Dermatol. 2009; 61: 207-215Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 2Rhee J.S. Loberiza F.R. Matthews B.A. Neuburg M. Smith T.L. Burzynski M. Quality of life assessment in nonmelanoma cervicofacial skin cancer.Laryngoscope. 2003; 113: 215-220Crossref PubMed Scopus (48) Google Scholar Our QOL instrument, the Skindex-29, may also be insufficiently sensitive at measuring QOL for KCs. However, it was sufficiently sensitive to detect multiple differences in baseline assessments from this trial.1Weinstock M.A. Lee K.C. Chren M.M. Marcolivio K. Quality of life in the actinic neoplasia syndrome: the VA Topical Tretinoin Chemoprevention (VATTC) Trial.J Am Acad Dermatol. 2009; 61: 207-215Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Based on our findings, we suggest that additional KCs do not present substantial QOL burdens for individuals with multiple previous KCs. Study Chairman's Office: Martin A. Weinstock, MD, PhD (Chair), Kimberly Marcolivio, Providence VAMC Executive Committee: Martin Weinstock, Providence, RI; Stephen Bingham, Perry Point, MD; John DiGiovanna, Providence, RI; Russell Hall, Durham, NC; Mark Naylor, Oklahoma City, OK; J. Richard Taylor, Miami, FL; Julia Vertrees, Albuquerque, NM; Clifton White, Portland, OR Clinical Centers: Durham VAMC: Russell Hall (primary investigator), Navjeet Sidhu-Malik, Deborah Hannah; Hines VAMC: David Eilers (primary investigator), Tehming Liang, Nadia Sakla, Ann Kreuger; Long Beach VAMC: Gary Cole (primary investigator), Edward Jeffes, Terri Labrador; Miami VAMC: J. Richard Taylor (primary investigator), Robert Kirsner (primary investigator), Jonette E. Kerri, Anna G. Falabella; Margarita Givens; Oklahoma City VAMC: Mark Naylor (primary investigator), Mary Beth Benson, Lisa Perry; Phoenix VAMC: James Kalivas (primary investigator), Catherine Yanni, Selma Targovnik, Janet Austin, Susan Collier Cooperative Studies Program Coordinating Center, Perry Point, MD: Joseph F. Collins, ScD; Stephen Bingham; Beverly Calvert; Philip Connor; Colleen Crigler; Dawn Davis; Pat Grubb, Judy Kelly; Gail Kirk, Karen Lawson; Linda Linzy, Lorrine Palmer, Maxine Rhoads Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM: Mike Sather, PhD, FASHP; Erica Copeland; Carol Fye; William Gagne; Patricia Grimes de Naranjo; Chad Messick; Julia Vertrees Dermatopathologists: Michael Piepkorn, Bellevue, WA; Clifton White, Portland, OR Data and Safety Monitoring Board: Robert Lew, Boston, MA; Irwin Braverman, New Haven, CT; Bernard Cole, Lebanon, NH; Richard Kalish, Stony Brook, NY; David McLean, Vancouver, BC; Bruce Harris Thiers, Charleston, SC
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