VOLUME 38 | ISSUE 1 | JANUARY-FEBRUARY 2018

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Nonmelanoma skin cancer in Saudi Arabia: single center experience

Sarah Abdullah AlSalman,a Tuqa Morad Alkaff,b Tariq Alzaid,c Yousef Binamerd

From the aKing Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; bCollege of Medicine, King Khaled University Hospital, King Saud University, Riyadh, Saudi Arabia; cDepartment of Pathology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; dDeperatment of Dermatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia 

How to cite this article:

Alsalman S, Alkaff TM, Alzaid T, Binamer Y. Nonmelanoma skin cancer in Saudi Arabia: single center experience. Ann Saudi Med 2018; 38(1): 42-45.

Abstract

BACKGROUND: Skin cancer is the most common cancer worldwide; one in every three diagnosed malig.nancies is a skin cancer. However, skin cancer is rarely reported in Saudi Arabia so we conducted this study to highlight these underreported neoplasms.

 

OBJECTIVES: Determine the prevalence and patterns of basal cell carcinoma (BCC) and primary squamous cell carcinoma (SCC), the most common types of nonmelanoma skin cancer (NMSC) with respect to age, sex, and anatomic location and to identify potentially associated risk factors.

 

DESIGN: Retrospective, descriptive medical record review.

 

SETTING: A tertiary care centre.

 

PATIENTS AND METHODS: We did a retrospective chart review of all patients diagnosed with basal cell carcinoma and primary squamous cell carcinoma between 2003-2016.

 

MAIN OUTCOME MEASURES: Prevalence and pattern of BCC and SCC with respect to age, sex, and anatomic location. 

 

RESULTS: Of 593 cases identified, 279 patients were diagnosed with BCC or SCC or both in a few cases. The mean age at diagnosis was 59 (19.5) years. Sixty-two percent of the patients were males. However, 24.3% (n=68) of skin cancers occurred in patients younger than 50 years. The frequency of BCC and SCC was 50.2% and 44.8%, respectively. The head and neck was the most common location (79.6%). In patients younger than 50 years, xeroderma pigmentosum and previously treated solid malignancies were the major factors.

 

CONCLUSIONS: BCC and SCC are uncommon but not rare. However, skin cancers are underreported in in our population. NMSC in individuals younger than 50 years of age requires more careful evaluation of possible risk factors.

 

LIMITATIONS: Retrospective in a single tertiary care setting. 

 


INTRODUCTION


Skin cancer has become one of the most frequent malignancies worldwide, with one in every three cancers diagnosed as skin cancer.1 The majority of such cancers are either malignant melanoma (MM) or nonmelanoma skin cancer (NMSC); the latter encompasses mostly basal cell carcinoma (BCC) and primary squamous cell carcinoma (SCC).2 Generally NMSC is BCC or SCC unless otherwise specified. According to the World Health Organization, between 2 to 3 million NMSCs and 132000 MMs are diagnosed annually worldwide.1 In our region, the latest Saudi Cancer Registry revealed that this disease was ranked the ninth most common among both sexes, accounting for 3.2% of all newly diagnosed cases in the year 2010.3 The five regions with the highest age-specific rates (ASR) were Riyadh at 4.4/100 000, Tabuk at 4.3/100 000, Jazan at 3.8/100 000, the Eastern region at 3.6/100 000, and the Northern and Qassim regions at 3.4/100 000 each.3 

 

Many factors play a role in the cause of NMSC, including environmental (ultraviolet radiation, ionizing radiation, and chemicals such as arsenic and polyaromatic hydrocarbons) and host factors (genetic vulnerability, age, sex, presence of precursor lesions, and pre-existing medical conditions).2,4,5 Saudi Arabia is located in low northern latitudes, and has high sun exposure.5 Precise population-based studies of the prevalence, patterns, and risk factors for skin cancer are essential for the evaluation of the disease burden and development of prevention strategies. 


 

Patients and Methods

We conducted a retrospective chart review of all pa.tients diagnosed with BCC or primary SCC or both between 2003-2016 after the approval of the Office of Research Affairs (RAC# 2161207). Demographic data were extracted from records as well as tumor location, clinical and histological variants and possible risk factor. Only patients with BCC or primary SCC were included. IBM SPSS software (version 22) was used for this descriptive analysis. 

 

 

Results

Of 279 patients with NMSC diagnosed between 2000 and 2016 in our institution, 62 percent were male, and the male-to-female ratio was 1.6:1. The majority of patients (82.4%, n=230) were Saudi nationals, and their cities of original residence were in the central (43.7%, n=122), western (22.2%, n=62), northern (6.1%, n=17), eastern (5.4%, n=15, and southern (2.9%, n=8) parts of the country. The mean (SD) age at diagnosis was 59.1 (19.6) years. The frequency of BCC was 50.2% while that of SCC was 44.8% (Table 1). Most of pa.tients were diagnosed in the 6th to 7th decade of life (43.7%) (Figure 1) and most were males (Table 2). Most (79%) of tumors were in the head and neck region; 16.9% over the nose and 9.7% on the scalp, followed by the lower extremities (7.2%), trunk (6.5%), upper extremities (4.3%), and anogenital region (2.2%). The most common type of BCC was nodular, while a moderately differentiated SCC was the most common (Tables 3 and 4). Twenty-four percent of the patients were younger than 50 years of age (n=68) and the primary risk factor in those patients was xeroderma pigmentosum (n=21). No risk factors were identified in 26 (38.2%) under the age of 50 (Table 5). Most (88.9%) patients underwent surgical treatment and 9.4% received radiation either alone or in combination (Table 6). 

 

 

Discussion

The incidence of skin cancer differs markedly according to race and geographical location. In the United States, where skin cancer is the most common cancer, 34–45% occurs in Caucasians, 4–5% in Hispanics, 2–4% in Asians, and 1–2% in African Americans.6,7 On the other hand, the rate of cutaneous cancer is highest in Australia, where NMSC occurs in 1–2% of the population.8 Populations with darker skinned individuals have less NMSC due to melanocyte photoprotection.9,10 BCC is frequently reported in Caucasians, Hispanics, Chinese Asians and Japanese, but is less frequent in Africans.11,12 Conversely, SCC is the most common skin cancer in Asians Indians and Africans.13-15 Our study revealed 279 cases of NMSC in our study population; BCC was observed in 140 (50.2%) and SCC in 125 (44.8%) patients, which is consistent with other studies in other populations as well as in Saudi Arabia except for a study which was conducted in the South region (Asir) that showed SCC is more common.16-18 The BCC:SCC ratio in our study was 1.12:1, which is similar to most previously published studies in Saudi Arabia. However, Alzolibani et al, reported that BCC is three times more common than SCC.19 The results of NMSC among different studies done in Saudi Arabia is shown in Table 7. The mean age at diagnosis in these studies was 59 (19) (range 7- 96) years, while the mean (SD) ages of the cases diagnosed as BCC and SCC in our study were 58 (19) and 60 (20) years, respectively. NMSC was mainly observed in patients from the central region, which may be attributable to the location of the hospital in Riyadh. 

 

The incidence of skin cancer in patients younger than 50 years is infrequent and necessitates looking into risk factors, e.g. xeroderma pigmentosum (XP) and epidermolysis bullosa (EB).20 In our study population most of patients with a risk factor have XP and this represent a referral bias to our center. 

 

Our study included some limitations. Mainly, it was retrospective in nature, and data were obtained from patient medical record. In conclusion, the most common type of skin cancer is BCC followed by SCC. The head and neck is the predominant lesion location and skin cancer below the age of 50 requires further investigation to exclude any possible risk factor.

 

 

References

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2. Alonso FT, Garmendia ML, Bogado M. Increased skin cancer mortality in Chile beyond the effect of ageing: Temporal analysis  1990 to 2005. Acta dermato-venereologica. 2010 Feb 15;90(2):141-6. 

3. Saudi Cancer Registry, cancer incidence report, Saudi Arabia, 2010. 

4. Arora A, Attwood J. Common skin can.cers and their precursors. Surgical Clinics of North America. 2009 Jun 30;89(3):703-12. 

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6. Bradford PT. Skin cancer in skin of color. Dermatology nursing/Dermatology Nurses’ Association. 2009 Jul;21(4):170. 

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8. Australian Institute of Health and Welfare, 2012. Cancer is Australia: an overview 2012. AIHW cat no. 70. 

9. Scotto J, Kopf AW, Urbach F. Non?melanoma skin cancer among caucasians in four areas of the United States. Cancer. 1974 Oct 1;34(4):1333-8. 

10. Halder RM, Bridgeman?Shah S. Skin cancer in african americans. Cancer. 1995 Jan 15;75(S2):667-73. 

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12. Gloster HM, Neal K. Skin cancer in skin of color. Journal of the American Academy of Dermatology. 2006 Nov 30;55(5):741-60. 

13. Kikuchi A, Shimizu H, Nishikawa T. Clinical and histopathological characteristics of basal cell carcinoma in Japanese pa.tients. Archives of dermatology. 1996 Mar 1;132(3):320-4. 

14. Mona A, Amal K. Ultraviolet carcinogen-esis in nonmelanoma skin cancer. Part I: in.cidence rates in relation to geographic loca.tions and in migrant populations. SKINmed: Dermatology for the Clinician. 2004 Jan 1;3(1):29-35. 

15. Halder RM, Ara CJ. Skin cancer and photoaging in ethnic skin. Dermatologic clinics. 2003 Oct 31;21(4):725-32. 

16. Khan AR, Hussain NK, Abdulaziz AS, Malatani T, Sheikha AA. Pattern of cancer at Asir central hospital, Abha, Saudi Arabia. Skin. 1991 Nov;62:14-6. 

17. Mufti ST. Pattern of skin cancer among Saudi patients who attended King AbdulAziz University Hospital between Jan 2000 and Dec 2010. Journal of the Saudi Society of Dermatology & Dermatologic Surgery. 2012 Jan 31;16(1):13-8. 

18. Bahamdan KA, Morad NA. Pattern of malignant skin tumors in Asir region, Saudi Arabia. Annals of Saudi medicine. 1993 Sep;13(5):402-6. 

19. Alzolibani AA, Al Shobaili HA, Al Ro.baee A, Khan A, Haque IU, Rao NS, et al. Clinical and histopathologic characteristics of skin malignancies in Qassim Region, Saudi Arabia. International journal of health sciences. 2013 Jan;7(1):61. 

20. Markey AC, Lane EB, Macdonald DM, LEIGH IM. Keratin expression in basal cell carcinomas. British Journal of Dermatology. 1992 Feb 1;126(2):154-60. 

21. Al-Dawsari NA, Amra N. Pattern of skin cancer among Saudi patients attending a tertiary care center in Dhahran, Eastern Prov.ince of Saudi Arabia. A 20-year retrospective study. International journal of dermatology. 2016 Dec 1;55(12):1396-401. 

22. Bahamdan KA, Morad NA. Pattern of malignant skin tumors in Asir region, Saudi Arabia. Ann Saudi Med. 1993 Sep;13(5):402.6. PubMed PMID: 17590717. 

23. Al-Maghrabi JA, Al-Ghamdi AS, Elha.keem HA. Pattern of skin cancer in Southwestern Saudi Arabia. Saudi medical journal. 2004;25(6):776-9. 

24. Mufti ST. Pattern of skin cancer among Saudi patients who attended King AbdulAziz University Hospital between Jan 2000 and Dec 2010. 

25. Al Aboud KM, Al Hawsawi KA, Bhat MA, Ramesh V, Ali SM. Skin cancers in Western Saudi Arabia. Saudi Med J. 2003 Dec 1;24(12):1381-7. 

26. Alzolibani AA, Al Shobaili HA, Robaee AA, et al. Clinical and histopathologic characteristics of skin malignancies in Qassim Region, Saudi Arabia. International Journal of Health Sciences. 2013;7(1):61-65. 

27. Alakloby OM, Bukhari IA, Shawarby MA. Histopathological pattern of non melanoma skin cancers at king fahd hospital of the university in the eastern region of Saudi Arabia during the years 1983–2002. Cancer Ther. 2008;6:303-6. 

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