1066 Research Letters

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1 1066 Research Letters JAM ACAD DERMATOL NOVEMBER 2016 This, coupled with known underreporting by cancer registries, 5 may have altered their incidence in SEER. By using the SEER database, we were able to characterize the nationwide epidemiology of DFSP and Bednar tumors. The gender distribution of the 2 tumors were similar; however, the distribution by age and location on the body were different. Previous studies have found DFSP to be more common in African Americans, 5 and our results suggest Bednar tumors are as well. Ultimately, perhaps the most important clinical characteristic of Bednar tumors is that, like DFSP, they have an excellent prognosis. Walter Liszewski, MD, a Derek Blanchette, MS, b Ashley M. Cunningham, MD, c and Daniel D. Miller, MD a Department of Dermatology, University of Minnesota, a Minneapolis, Division of Biostatistics and Research Design, University of Iowa College of Dentistry, b Iowa City, and Department of Pathology, University of Wisconsin, Madison c Funding source: None. Conflicts of interest: None declared. Correspondence to: Walter Liszewski, MD, 516 Delaware St SE, Mail Code 98, Minneapolis, MN WJLiszewski@gmail.com REFERENCES 1. Kaul R, Kaur N, Dogra SS, Chander B. Variant of dermatofibrosarcoma protuberans: Bednar tumor. Indian J Dermatol. 2015;60: Bogucki B, Neuhaus I, Hurst EA. Dermatofibrosarcoma protuberans: a review of the literature. Dermatol Surg. 2012;38: Gloster HM Jr. Dermatofibrosarcoma protuberans. J Am Acad Dermatol. 1996;35: Kobayashi T, Hasegawa Y, Konohana A, Nakamura N. A case of Bednar tumor. Immunohistochemical positivity for CD34. Dermatology. 1997;195: Criscione VD, Weinstock MA. Descriptive epidemiology of dermatofibrosarcoma protuberans in the United States, 1973 to J Am Acad Dermatol. 2007;56: Family history of cutaneous and noncutaneous malignancies in relation to the risk of keratinocyte carcinoma coupled with another type of cancer: A case-control study To the Editor: For unknown reasons, a personal history of keratinocyte carcinoma (KC) is associated with increased risk for most other malignancies. 1-3 Inherited predisposition may be a contributory factor, 4 in that this association is stronger in those with early age-of-onset KC. 1,2 A positive family cancer history is associated with increased cancer risk. 5 However, skin cancer is usually ignored when investigating family cancer history. This study tested the hypothesis that a family history of skin cancer coupled with noncutaneous malignancy is associated with the cancer-prone phenotype characterized by KC coupled with another type of cancer. This dermatology clinic-based case-control study had 3 study groups: KC coupled with another type of cancer (n ¼ 49), KC only (n ¼ 50), and a cancer-free comparison group (n¼50). Participants were limited to non-hispanic whites and were further matched by gender and age to form matched triads. Patients were interviewed in-person to collect lifestyle and demographic information and family history in firstdegree relatives of skin cancer and cancer other than skin cancer (study questionnaire included as Appendix at Cancer diagnoses were confirmed via medical records. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using conditional logistic regression models. Cancer-free controls were the referent category for the risk of (1) KC only and (2) KC coupled with another type of cancer. The matching resulted in nearly identical mean ages across the 3 study groups (Table I). In dichotomous comparisons (Table II), skin cancer family history was associated with 9-fold elevation in KC risk and an apparent 2.2-fold increased risk of cancers other than KC. However, this latter association disappeared when limited to the comparison of KC coupled with another cancer versus KC alone by removing the cancer-free controls from the denominator (OR 1.0). When family history was categorized into a single 4-level variable and evaluated across the 3 study groups, compared to the control group the associations for a family history of skin cancer coupled with noncutaneous malignancy were strong and nearly identical for both KC only (OR 9.9) and KC coupled with another type of cancer (OR 9.8). Similar ORs were also observed for family history of skin cancer only for both KC only (OR 4.3) and KC coupled with another cancer (OR 6.8) (Table II). Family history of noncutaneous malignancy only was null across all comparisons. Due to sample size constraints, a study limitation, potential confounding variables (nonmatching factors in Table I) were adjusted for singly; these adjustments did not alter the inferences from the results presented in Table II (data not shown).

2 JAM ACAD DERMATOL VOLUME 75, NUMBER 5 Research Letters 1067 Table I. Percentage distributions of selected characteristics of patients with no personal cancer history, personal history of KC only, and personal history of KC coupled with another form of cancer Characteristic No personal history of cancer (n = 50) Personal history of KC only (n = 50) Personal history of KC coupled with other cancer (n = 49) Race/ethnicity* Non-Hispanic white Gender* Female Male Mean age in years (SD)*, y 66 (6.9) 68 (7.4) 68 (7.8) Marital status Not married Married Education Less than college graduate College graduate or greater Mean BMI in kg/m 2 (SD) y 27.6 (5.0) 26.9 (4.2) 27.8 (5.1) Family history of cancer in a firstdegree relative None KC only Other cancer only KC plus another cancer Personal KC histologic type None 100 n/a n/a BCC only n/a SCC only n/a Both BCC and SCC n/a Missing histologic type n/a 4 6 Smoking history Never Ever Average No. alcohol drinks/day None Any Reaction to an hour of sunlight Tan or no change Sunburn Mean hours daily sunlight: teens # $ Mean hours daily sunlight: twenties # $ BCC, Basal cell carcinoma; BMI, body mass index, KC, keratinocyte carcinoma; n/a, not applicable; SCC, squamous cell carcinoma. *Matching factor. y For age and BMI, means rather than percentages are presented. The overall pattern of associations, especially the overall similar associations observed in patients with a personal history of KC only and with KC coupled with another type of cancer, reinforce the known association between a family and personal history of KC but do not support a link between family history of skin cancer and noncutaneous malignancy and the KC cancer-prone phenotype. Thus, these data do not support the hypothesis that a family history of skin cancer coupled with noncutaneous malignancy is specifically linked to risk of KC coupled with another type of cancer. James Small, BS, a Catherine Flanagan, MS, b Kent Armeson, MS, a,b David Perry, MD, PhD, c Richard Marchell, MD, c Bruce Thiers, MD, c and Anthony J. Alberg, PhD, MPH a,b Department of Public Health Sciences, a Hollings Cancer Center, b and Department of

3 1068 Research Letters JAM ACAD DERMATOL NOVEMBER 2016 Table II. Odds ratios (and 95% confidence intervals) for the association between family history of cancer in a first-degree relative and personal history of (1) keratinocyte carcinoma (KC) (dichotomous yes/no), (2) another type of cancer ( yes/no), (3) KC coupled with another type of cancer versus KC only, (4) KC only, and (5) KC coupled with another type of cancer Family history of cancer in a first-degree relative KC vs No-KC (Yes/No) Dichotomous Another type of cancer vs No other type of cancer (Yes/No) KC 1 another type of cancer vs KC only (Yes/No) Personal history Study groups compared with cancer-free controls KC only vs cancer-free controls KC coupled with another type of cancer vs cancer-free controls Keratinocyte carcinoma (KC) * * No 1.0 (referent) 1.0 (referent) 1.0 (referent) 1.0 (referent) 1.0 (referent) Yes 9.0 ( ) 2.2 ( ) 1.0 ( ) 9.6 ( ) 9.1 ( ) Noncutaneous Malignancy No 1.0 (referent) 1.0 (referent) 1.0 (referent) 1.0 (referent) 1.0 (referent) Yes 0.9 ( ) 0.9 ( ) 1.0 ( ) 0.9 ( ) 0.9 ( ) P interaction Combined family history of skin cancer coupled with another type of cancer None 1.0 (referent) 1.0 (referent) 1.0 (referent) 1.0 (referent) 1.0 (referent) KC only 5.7 ( ) 2.7 ( ) 1.5 ( ) 4.3 ( ) 6.9 ( ) Other cancer only 0.9 ( ) 1.1 ( ) 1.3 ( ) 0.6 ( ) 0.9 ( ) KC coupled with another type of cancer 9.7 ( ) 2.1 ( ) 1.1 ( ) 9.9 ( ) 9.8 ( ) All results presented are from conditional logistic regression models. *The cancer-free group is the referent category. Dermatology, c Medical University of South Carolina, Charleston. Funding sources: This study was supported by funding from CTSA NIH Grant UL1 TR to the Medical University of South Carolina, from National Cancer Institute Cancer Center Support Grant (P30 CA38313) to the Hollings Cancer Center, Medical University of South Carolina, and funds from the Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina Conflicts of interest: None declared. Correspondence to: Anthony J. Alberg, PhD, MPH, Hollings Cancer Center, Medical University of South Carolina, 68 President Street, MSC 955, Charleston, SC, alberg@musc.edu REFERENCES 1. Wheless L, Black J, Alberg AJ. Nonmelanoma skin cancer and the risk of second primary cancers: a systematic review. Cancer Epidemiol Biomarker Prev. 2010;19: Ong EL, Goldacre R, Hoang U, Sinclair R, Goldacre M. Subsequent primary malignancies in patients with nonmelanoma skin cancer in England: a national record linkage study. Cancer Epidemiol Biomarker Prev. 2014;23: Alberg AJ, Fischer AH. Is a personal history of nonmelanoma skin cancer associated with increased or decreased risk of other cancers? Cancer Epidemiol Biomarkers Prev. 2014;23: Ruczinski I, Jorgensen TJ, Shugart YY, et al. A population-based study of DNA repair gene variants in relation to non-melanoma skin cancer as a marker of a cancer-prone phenotype. Carcinogenesis. 2012;33: Risch NJ, Whittemore AS. Genetic concepts and methods in epidemiologic researchin: Schottenfeld D, Fraumeni Jr JF, eds. Cancer Epidemiology and Prevention. 3rd ed. New York, NY: Oxford University Press; 2006: Successful use of a modified Goeckerman regimen in the treatment of chronic severe atopic dermatitis: A prospective pilot study To the Editor: Atopic dermatitis (AD) is a chronic inflammatory dermatosis that affects up to 25% of children and 2-3% of adults. 1 A significant proportion of patients with AD remain undertreated, especially patients with severe AD. In this prospective pilot study, 5 patients with chronic severe AD were treated with an outpatient modified Goeckerman regimen at the University of

4 JAM ACAD DERMATOL VOLUME 75, NUMBER 5 Research Letters 1068.e1 SCAN QUESTIONNAIRE Research Staff: Date: / / Study ID: BACKGROUND CHARACTERISTICS We would first like to gather some basic background information about you. 1. What is your date of birth? / / What is your age? Years 2. What is your gender? Male Female 3. Are you Hispanic? 4. Which of these groups best describes you? Caucasian or White American Indian or Alaskan Native African American or Black Pacific Islander Asian Other 5. What is your current marital status? Married, or living as married with a partner Separated Widowed Never married 6. What is the highest level of school you have completed? 8th grade or less Some high school High school graduate or GED Some college College graduate or beyond 7. What is your employment status? Employed Disabled, unable to work Homemaker Unemployed Retired Student Other, SPECIFY: 8. What has been your usual occupation or job e the job you have worked at the longest? ( for example, carpenter, executive, salesman, foreman, waitress, truck driver) Job/occupation Years in this job In your work, did you spend more time (check one) Indoors Outdoors 9. What is your height? Feet: Inches: 10. What is your weight? Pounds 11. In general, would you say your physical health is: Poor Fair Good Very Good Excellent

5 1068.e2 Research Letters JAM ACAD DERMATOL NOVEMBER 2016 LIFESTYLE FACTORS We would like to ask some questions regarding your everyday lifestyle. 12. How many days per WEEK do you do MODERATE physical activity for at least 30 minutes at a time? (Moderate physical activity is any activity that causes an increase in breathing or heart rate) 0 days 1-2 days 3-4 days 5-7 days 13. On average, how many fruits and/or vegetables do you eat in a DAY? ne 1-2 fruits and/or vegetables 3-4 fruits and/or vegetables 5 or more fruits and/or vegetables 14. On average, how much alcohol do you drink in a DAY? (Alcohol includes beer, wine, and hard liquor) ne Less than one drink per day One drink per day Two drinks per day Three or more drinks per day 15. Do you take any of the following vitamins or supplement forms? Yes No Multivitamin Calcium supplement Mineral supplement Single vitamins (e.g. vitamin A, vitamin C, vitamin D) Any other herbal or natural supplements 16. How often do you take aspirin or any other non-steroidal anti-inflammatory drugs? (e.g. Advil, Aleve, Bayer, Tylenol) t at all Less than every other day Every other day Why? Once a day or more (e.g. headache, back pain, heart health etc.) 17. Have you smoked at least 100 cigarettes in your entire life? NOTE: 5 packs5100 cigarettes /(If no, please proceed to question 24) 18. How old were you when you first started to smoke cigarettes? (Age) 19. Do you now smoke cigarettes every day, some days, or not at all? t at all /(If not at all, please proceed to question 22) Every day Somedays 20. On average, how many cigarettes do you smoke per day? (Exact number)

6 JAM ACAD DERMATOL VOLUME 75, NUMBER 5 Research Letters 1068.e3 21. In total, for how many years have you smoked cigarettes? (Years) 22. When you used to smoke, on average, how many cigarettes did you smoke per day? (Exact number) 23. When you used to smoke, in total, how many years did you smoke cigarettes? (Years) PERSONAL CANCER HISTORY We would like to ask you some questions about your history of cancer. 24. Have you ever been told by a doctor that you have skin cancer? Don t know 24a. If yes, what kind of skin cancers have you had? Basal cell carcinoma Date of Diagnosis (month/year) / / If yes, how many? Don t know Squamous cell carcinoma Date of Diagnosis (month/year) / / If yes, how many? Don t know Melanoma Date of Diagnosis (month/year) / / If yes, how many? Don t know 25. Have you ever been told by a doctor that you have had cancer other than skin cancer? /(If no, proceed to question 26) /What kind(s) of cancer (e.g., breast, lung, colon, prostate)? List as many as apply Location of treatment Facility name Facility name Facility name City and Adress City and Adress City and Adress Treating physician Name Name Name Date of Diagnosis / / / (Month/Year) (Month/Year) (Month/Year) 25a. SCAN Study Group One Two Three FAMILY HISTORY OF CANCER We would like to ask some questions regarding any history of cancer within your family. 26. Counting only blood relatives, have any of your parents or brothers and sisters ever had skin cancer? / 26a. If yes, how many relatives have had skin cancer? One Two [5 3 Don t know

7 1068.e4 Research Letters JAM ACAD DERMATOL NOVEMBER Counting blood relatives, have any of your parents or brothers and sisters ever had cancer other than skin cancer? / Don t know 27a. If yes, how many relatives have had cancer other than skin cancer? One Two [5 3 SKIN AND SUN EXPOSURE We would like to ask some questions related to your skin and sun exposure. 28. How would you describe your complexion? Very fair Fair Medium Light brown Medium brown Dark brown 29. If you spent an hour in the mid-day sun for the first time without sunscreen, which of these reactions best describes what would happen to your skin? Blistering sunburn Sunburn without blisters Mild sunburn that becomes a tan Tan or darken with no sunburn change in skin color 30. What is the natural color of your eyes? Blue Green Hazel Light brown Dark brown Other color, SPECIFY: 31. How much freckling do you have on your face? ne Small amount Large amount Almost all 32. Have you ever had a blistering sunburn? (If no, proceed to question 33) 32a. How old were you the first time you got a blistering sunburn? Under 5 years old 5 e 14 years old 15 e 24 years old 25 e 39 years old 40 e 64 years old 65 years or older

8 JAM ACAD DERMATOL VOLUME 75, NUMBER 5 Research Letters 1068.e5 32b. How old were you the last time you got a blistering sunburn? Under 5 years old 5 e 14 years old 15 e 24 years old 25 e 39 years old 40 e 64 years old 65 years or older 32c. How many blistering sunburns have you gotten in your life? 1or2 3or4 5 e 9 10 e or more 33. Have you ever used a solar blanket or a reflector? 34. Have you ever used a sunlamp or tanning booth? (If no, proceed to question 35) 34a. How old were you the first time you used a sunlamp or tanning booth? Under 5 years old 5 e 14 years old 15 e 24 years old 25 e 39 years old 40 e 64 years old 65 years or older 34b. How old were you the last time you used a sunlamp or tanning booth? Under 5 years old 5 e 14 years old 15 e 24 years old 25 e 39 years old 40 e 64 years old 65 years or older 34c. During periods when you used a sunlamp or tanning booth, how many minutes did you usually use them each time? 5 minutes or less 6 e 10 minutes 11 e 20 minutes 21 e 30 minutes 31 e 40 minutes 41 minutes or longer 34d. In total, how many times have you used a sunlamp or a tanning both? Less than 10 times 10 e 50 times More than 50 times 35. During the summer, how many days per week do you go outside in direct sunlight for 60 minutes or more? Never 1 day per week or less 2 e 3 days per week 4 e 5 days per week 6 e 7 days per week

9 1068.e6 Research Letters JAM ACAD DERMATOL NOVEMBER When you go out into the sun, do you use sunscreen (or lotions containing sunscreen)? Never (If never, proceed to question 37) e rarely e sometimes e often or always I do not go out in the sun 36a. When you use sunscreen, what SPF level do you usually use? 15 or less N/A I do not go out in the sun 36b. On days you use sunscreen, do you ever put on more (reapply) sunscreen? N/A I do not go out in the sun 37. Do you protect your skin exposure with clothing (hat, long sleeves, long pants, umbrella)? Never e rarely e sometimes e often or always Please answer the following questions about your exposure to the sun at different periods of your life. When we refer to mid-day sun, it means those hours when the sun is more than halfway up in the sky. For most of the United States, that would be between the hours of 10 AM and 4 PM Daylight Savings Time. 38. On a typical weekday in the summer, about how many hours did you generally spend in the mid-day sun when you were in your. Teens? Twenties? Thirties? Past 10 years? ormore 9ormore 9ormore 9ormore 39. On a typical weekend day in the summer, about how many hours did you generally spend in the mid-day sun when you were in your. Teens? Twenties? Thirties? Past 10 years? ormore 9ormore 9ormore 9ormore

10 JAM ACAD DERMATOL VOLUME 75, NUMBER 5 Research Letters 1068.e7 40. How many months a year did you usually have a tan when you were in your... Teens? Twenties? Thirties? Past 10 years? ormore 9ormore 9ormore 9ormore FASTING 41. Did you fast overnight prior to your appointment today? 41a. If not, please list everything you ate and drank today? Thank you very much for taking part in this study, your cooperation is greatly appreciated. We are now finished with the survey portion of the study.