Maureen Salamon

September 17, 2017

GENEVA — Dermatologists may be tempted to overtreat patients with minor skin cancers such as basal cell carcinomas, or prescribe patented drugs offering no advantage to generics, because these approaches benefit them financially, according to a symposium focusing on controversies in dermatology.

Financial ties between dermatologists and pharmaceutical companies are rife in the specialty, but these relationships inevitably promote using more costly procedures and less-optimal drugs than are warranted, said Tamar Nijsten, MD, PhD, from Erasmus Medical Center in Rotterdam, the Netherlands.

"I like games, but often if I don't understand what's going on in a game, I follow the principle of 'follow the money,' " Dr Nijsten said. "We've seen a rise in every [ultraviolet]-related type of skin cancer. For physicians, it's very profitable because we do procedures, and procedures cost money."

Dr Nijsten's remarks were part of a presentation entitled "Inconvenient Truths in Skin Cancer Care," given here at the 26th European Academy of Dermatology and Venereology (EADV) Congress.

As chair of the European Dermato-Epidemiology Network, Dr Nijsten's research has largely focused on the epidemiology and related aspects of different skin diseases, but with an emphasis on skin cancer.

We've seen a rise in every ultraviolet-related type of skin cancer. For physicians, it's very profitable. Dr Tamar Nijsten

Dermatologists often default to expensive Mohs micrographic surgery to treat primary basal cell carcinomas in particular, he said, despite evidence that a specific lesion is nonaggressive. Instead, curettage, excision, cryotherapy, or even topical creams should be considered before resorting to Mohs.

Guidelines such as those issued by the American Academy of Dermatology as part of the Choosing Wisely campaign to reduce unnecessary healthcare attempt to lead dermatologists to this conclusion, he said. One American Academy of Dermatology statement specifically cautions, "Do not treat uncomplicated, non-melanoma skin cancer less than 1 cm in size on the trunk and extremities with Mohs micrographic surgery."

Choosing Wisely

Research analyzing skin cancer pathology reports in the Netherlands showed that dermatologists were actually more effective at completely excising basal cell carcinomas than plastic surgeons, who often charge much more for the same procedure, Dr Nijsten pointed out.

"I think, regarding Mohs surgery, it really requires a mind shift," Dr Nijsten told Medscape Medical News. "In reality, Mohs is very effective surgery in selective cases, for any type of skin cancer or basal cell carcinoma, but it's only cost-effective in select cases. It should be reserved for those indicated at high risk."

Another controversy in skin cancer care, Dr Nijsten said, is "evergreening," a strategy pharmaceutical companies may use to prolong a drug staying on patent, costing more and preventing competition. Tactics used to extend a drug include slightly changing its formulation without any evidence the tweak improves benefits to patients, or creating a new indication, such as an orphan disease or different condition.

Dermatologists need to be wary of being complicit with evergreening, he said, even tacitly.

We should circumscribe Mohs surgery to the most complicated basal cell carcinomas that are recurring once, and skip most surgeries for primary tumors. Dr Rafael Botella-Estrada

"When you start introducing a new topical treatment with slightly changed formulations or concentrations, for example, it increases profits for the pharmaceutical industry," Dr Nijsten said. "Lots of doctors have financial relationships with pharmaceuticals, so they start using new formulations where there's no evidence it's better or worse than the old."

One of the most intimidating skin cancer controversies is the growing ability of high-tech imaging, combined with artificial intelligence, to diagnose malignant melanoma and other skin cancers more reliably than dermatologists, Dr Nijsten explained.

Automated analyses of features in dermoscopic skin lesion images, such as shape, color, size, and border irregularity, are being blended with artificial intelligence software and decision support systems in research evaluating how the technology fares in capturing early-stage skin cancers. Results are indicating this technology can produce highly accurate diagnoses that may eventually negate the need for dermatologists' years of experience and skill, he said.

"Now computers can start to learn," he said. "In the end, this will be the real deal."

Asked to comment on the presentation, Rafael Botella-Estrada, MD, from the University of Valencia in Spain, told Medscape Medical News that Dr. Nijsten's message was valuable because "we are confronted with many of these controversies and biases" in daily practice.

"I'm going to be motivated to slightly change some my approaches to some of topics he mentioned," Dr Botella-Estrada said, noting that pathologists at his facility often interpret Mohs patients' biopsy slides at a greater cost than if dermatologists performed the task, with equal efficacy.

"We should circumscribe Mohs surgery to the most complicated basal cell carcinomas that are recurring once, and skip most surgeries for primary tumors," he added.

Dr Nijsten reports financial relationships with Bristol-Myers Squibb, Galderma, Leo Pharma, Meda Pharma, and Roche. Dr Botella-Estrada Smith reports financial ties with Novartis, Leo Pharma, and Janssen Biotech.

26th European Academy of Dermatology and Venereology (EADV) Congress. Presented September 16, 2017.

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