gms | German Medical Science

Introduction: Skin cancer is already the most common cancer today. At the moment, ICD10:C44 (basal cell/squamous cell carcinoma of the skin) is diagnosed in 200,000–240,000 Germans per year. This corresponds to an increase by 80% in the last 7 years. Due to the patients’ differences in health insurance status, the numbers in the out-patient area can only be estimated. Since skin carcinomas occur in older persons, demographic change will cause further increases of the disease figures. Though the face, frontal scalp and neck make up only 9% of the body surface, more than 80% of the skin carcinomas are located there. This is a challenge for dermato- and ENT-surgeons alike. Therapeutically, the in-sano-excision of the skin tumour, histographically controlled surgery with systematic histological 3D excision-edge examination and skin defect closure by advancement or near-distance flap is the state of the art. In the face, skin defect closures by split skin or full thickness grafts are clearly the method of 2nd choice. Consistent histographically controlled surgery essentially contributes to reducing the rate of recurrence.

Optimal healing and scarring requires observation of the relaxed skin tension lines (RSTL) when making the incision in the skin. Their course depends on age, nutritional and general condition. In the face, the RSTL usually follow the muscles used for facial expressions.

Material and methods: The Genesis online database provided precise data on patients who were treated for ICD10:C44 in German hospitals from 2000–2013. Both patients discharged from hospital and the patients who died in hospital with ICD10:C44 as the underlying disease leading to death were included. For comparative examinations, the age and gender of the patients were analysed. The elderly were classified according to a graduation common in gerontology: 65–74 years = young elderly, 75–84 years = older elderly, 85 years and older = very elderly.

Results: In 2000, 34,811 patients were treated in-patient for ICD 10:C44. By 2013, this number had risen to 70,357 patients. The patient number has therefore doubled in 14 years. A hospital stay (= 1 DRG case) was usually connected to surgery. The average time in hospital in 2013 was 5.2 days. Subject to adequate therapy, C44 is a local disease with a very good prognosis. Only approx. 0.5% of the patients treated in hospital died of this diagnosis. 82% of the patients were at least 65 years old (37% n= 26,592 75–84 years, 27% n= 18,443 65–74 years, 18% n= 12,811 85 years and older). All in all, the gender ratio was balanced. A peak was found in post-menopausal women. ICD10:C44 was particularly common in older male elderly and very elderly.

The therapy concept for older patients was not generally different from that for younger patients. However, a high comorbidity had to be considered. Patients often took oral coagulants that, according to the guidelines, could only be discontinued on the day of surgery. During surgery, subtle staunching of blood and sufficient drainage had to be observed for this reason. Due to an increase of cognitive impairment after general anaesthesia in the elderly, local anaesthesia was used where possible.

Discussion: According to the projection of the Federal Statistical Office, Germany will have only 67.7 M residents in 2060. As compared to this, Germany still had 80.8 M residents in 2013. At a concurrent reduction of the overall population, an increase of the above-65-year-olds by 30–35% by 2060 is forecasted. Demographic change will cause increase of skin carcinomas by 38% by 2040, and then form a plateau on this level. Cohort effects are still unconsidered here.

In 2015, 5,380 ENT doctors (3,839 out-patient, 1,541 in-patient) and 4,553 dermatologists (3,551 outpatient, 1,002 in-patient) worked in Germany. This meant an increase by 3% in ENT and by 1.7% in dermatology as compared to the prior year. This increase in specialists and the number of annual graduates who successfully completed their studies of medicine will not be sufficient to cover the rising demand in medical care for ICD10:C44. It will be impossible to ensure skin cancer screening, which statutory health insurance has paid for every two years since 2008. It is doubtful that surgical treatment of patients with skin cancer can be performed in a timely manner and correctly without corrective political decisions, e.g. by increase of the matriculation numbers for medicine by at least 10%.

Although more than 80% of the skin carcinomas were located in the face (nose/ear), only approx. 7% of the surgeries took place in an ENT facility. In the patients’ interest, dermatosurgery in the face is to be viewed as an interdisciplinary task between dermatologists and ENT specialists. Cooperation between dermatologists and ENT specialists is required in case of tumour-related cartilage and bone filtration. In particular ENT specialists with the additional designation of plastic surgeon are experts in this. ENT doctors working in the out-patient area should assess the skin of the face and neck, even when they are consulted by the elderly for other reasons.