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Vol. 107. Issue 4.
Pages 318-328 (May 2016)
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Vol. 107. Issue 4.
Pages 318-328 (May 2016)
Original Article
DOI: 10.1016/j.adengl.2016.02.015
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Skin Cancer Incidence and Mortality in Spain: A Systematic Review and Meta-Analysis
Incidencia y mortalidad del cáncer cutáneo en España: revisión sistemática y metaanálisis
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A. Tejera-Vaquerizoa,
Corresponding author
antoniotejera@aedv.es

Corresponding author.
, M.A. Descalzo-Gallegob, M.M. Otero-Rivasc, C. Posada-Garcíad, L. Rodríguez-Pazosd, I. Pastushenkoe, R. Marcos-Grageraf, I. García-Dovalb,d
a Servicio de Dermatología, Instituto Dermatológico GlobalDerm, Palma del Río, Córdoba, Spain
b Unidad de Investigación, Fundación AEDV, Madrid, Spain
c Servicio de Dermatología, Hospital Universitario Lucus Augusti, Lugo, Spain
d Servicio de Dermatología, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
e Interdisciplinary Research Institute, Université Libre de Bruxelles, Brussels, Belgium
f Institut Català d’Oncologia, Pla Director d’Oncologia, Unitat d’Epidemiologia i Registre de Càncer de Girona (UERCG), Institut d’Investigació Biomèdica de Girona (IdIBGi), Universitat de Girona, Girona, Spain
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Tables (3)
Table 1. Criteria Used to Assess the Methodological Quality of the Studiesa
Table 2. List of Articles Selected in the Systematic Review.
Table 3. Risk of Bias.
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Additional material (1)
Abstract
Introduction and objectives

The aim of this systematic review was to describe the incidence and mortality of basal cell carcinoma, squamous cell carcinoma, melanoma, and Merkel cell carcinoma in Spain.

Material and methods

We performed a search of the MEDLINE and Embase databases and reviewed articles from the Spanish Network of Cancer Registries (REDECAN) and the International Agency for Research on Cancer (IARC). The methodological quality of the studies was evaluated and statistical heterogeneity was measured using the I2 index. A random-effects model was used to perform the meta-analysis because of the heterogeneity of the data.

Results

Thirty-two papers were included in the systematic review. The crude incidence rate for basal cell carcinoma was 113.05 (95% CI, 89.03-137.08) cases per 100000 person-years for the studies based on the registration methodology normally used by registries (in which only 1 tumor with histological confirmation is counted per person). However, the same incidence rate calculated on the basis of clinical and histologic criteria and counting tumors rather than individual patients was 253.23 (95% CI, 273.01-269.45) cases per 100000 person-years. The incidence was 38.16 (95% CI, 31.72-39.97) cases per 100000 person-years for squamous cell carcinoma, 8.76 (95% CI, 7.50-10.02) cases per 100000 person-years for melanoma, and 0.28 (95% CI, 0.15-0.40) cases per 100000 person-years for Merkel cell carcinoma.

Conclusions

The registration methodology normally used by cancer registries probably underestimates the incidence rates of basal cell and squamous cell carcinoma in Spain. The incidence rates of cutaneous melanoma and Merkel cell carcinoma are lower in Spain than in other European countries.

Keywords:
Basal cell carcinoma
Squamous cell carcinoma
Merkel cell carcinoma
Epidemiology
Mortality
Incidence
Review
Meta-analysis
Resumen
Introducción y objetivos

El objetivo de la revisión sistemática es describir la incidencia y mortalidad en España del carcinoma basocelular, carcinoma espinocelular, melanoma y carcinoma de células de Merkel.

Material y métodos

Se realizó una búsqueda en Medline, Embase y revisión de artículos de la Red Española de Registros de Cáncer (REDECAN) y la Agencia Internacional de Investigación sobre el Cáncer (IARC). Se evaluó la calidad metodológica de los estudios. La heterogeneidad estadística se midió usando el estadístico I2. Para el metaanálisis de los datos se empleó un modelo de efectos aleatorios debido a la heterogeneidad de los resultados.

Resultados

Se incluyeron un total de 32 trabajos en la revisión sistemática. La tasa de incidencia del carcinoma basocelular global cruda fue 113,05 (IC 95%: 89,03-137,08)/100.000 personas-año para los estudios que emplean la metodología de los registros de cáncer (contando un solo tumor por persona y diagnóstico histológico). La tasa de incidencia mediante criterios clínicos e histológicos, y contando tumores en lugar de personas, fue de 253,23 (IC 95%: 273,01-269,45)/100.000 personas-año. La incidencia de carcinoma espinocelular fue de 38,16 (IC 95%: 31,72-39,97)/100.000 personas-año, de 8,76 (IC 95%: 7,50-10,02)/100.000 personas-año para el melanoma y 0,28 (IC 95%: 0,15-0,40)/100.000 personas-año para el carcinoma de células de Merkel.

Conclusiones

La tasa de incidencia del carcinoma basocelular y espinocelular en España está probablemente infraestimada al utilizar el método habitual de los registros. La tasa de incidencia del melanoma cutáneo es baja en comparación con otros países europeos, al igual que la tasa de incidencia del carcinoma de células de Merkel.

Palabras clave:
Carcinoma de células basales
Carcinoma de células escamosas
Carcinoma de células de Merkel
Epidemiología
Mortalidad
Incidencia
Revisión
Metaanálisis
Full Text
Introduction

Skin cancers are divided into 2 categories according to epidemiological and prognostic differences: cutaneous melanoma, and nonmelanoma skin cancer (NMSC). The 2 main types of NMSC are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).

The incidence of cutaneous melanoma continues to rise in Europe, with considerable geographical differences in mortality.1,2 Owing to the higher incidence of NMSC compared to other skin tumors and the difficulty of quantifying the condition,3 NMSC tumors are not consistently reported in cancer registries.

Both cutaneous melanoma and NMSC represent a significant economic burden to the Spanish National Health Service. Thus, it is essential to know the true burden of disease attributable to skin cancer in Spain.

The main objective of this systematic review is to describe the incidence and mortality of skin cancer in Spain, including cutaneous melanoma, BCC, SCC, and Merkel cell carcinoma.

Material and MethodsCriteria for Article InclusionTypes of Studies

We reviewed all the epidemiological studies in the literature that assessed the incidence rate of skin cancer in Spain. To investigate the incidence of melanoma, we reviewed articles that included other forms of cancer, and particularly articles derived from data from population-based cancer registries in Spain.4 For the other types of skin tumors, given the methodological difficulties involved in any assessment of the epidemiology of NMSC, we only reviewed articles that had as their main objective to describe the incidence of any form of NMSC.

Only articles referring to a Spanish population and reporting incidence rates and the corresponding CI (or providing sufficient data to calculate the CI) were finally included. We excluded studies of skin tumors in at risk populations (syndromes, immunocompromized patients, and other special populations, etc.), data on in situ tumors, and data from modeling studies. In the case of different studies dealing with the same population and cancer type, we included only the most recent data.

Search Strategy

Details of the search strategy used are included in the supplementary material (Appendix 1).

The search was not restricted by language or date range.

Electronic Search

On 28 April 2015, we searched the Medline database (via PubMed) and the EMBASE database (via Ovid, 1980-2015).

Other Data Sources

We searched for data published by the Spanish population-based cancer registries and the International Agency for Research on Cancer-World Health Organization in addition to unpublished studies. We also reviewed the primary sources of articles involving secondary analysis of data and sought expert opinion.

Data Collection and Analysis

The articles were divided into 4 groups and screened on the basis of the abstract by 8 reviewers (2 reviewers for each group of articles). If there was a discrepancy between the 2 initial reviewers, the article was reviewed by a third person. Duplicate articles were also excluded. The complete text of the selected articles was then reviewed using the Covidence tool (https://www/covidence.org/).

The PRISMA flow diagram (Fig. 1) shows the results of the search, screening, selection, and inclusion processes.

Figure 1.

PRISMA flow diagram.

(0.28MB).
Data Extraction

Data were extracted by 2 reviewers (IGD and MAD), both of whom had training in epidemiology. When an article included various types of cancer, a separate data form was created for each type. When data were reported jointly they were included under the category NMSC.

Assessment of Methodological Quality

The methodological quality of the studies was assessed using criteria adapted from Lomas et al.3 One point was allocated for each of the 10 criteria (Table 1).

Table 1.

Criteria Used to Assess the Methodological Quality of the Studiesa

Internal validity 
Data collection 
1. Did the study directly sample the population, as opposed to using data from registries? 
Description of methods 
2. Is the method of counting tumors stated (number of tumors or number of patients)? 
3. Does this study specify whether the data relate to primary tumors? 
4. Is there histological confirmation? 
Reporting of incidence rates 
5. Were separate rates reported for different types of tumors? 
6. Are gender-specific incidence rates reported? 
7. Were the rates stratified by age? 
8. Were the rates age standardized? 
9. Were confidence intervals reported or can they be calculated (based on standard error or number of tumors and population)? 
 
External validity 
10. Were the data standardized to a major population (European, world, USA)? 
a

One point is assigned for each positive response. The maximum score is 10.

Data Synthesis, Heterogeneity, and Subgroup Analysis

Meta-analysis of the data was performed using a random effects model. The following values were calculated for each tumor type: incidence, standardized incidence (direct and using the same standard), and mortality rate (only for melanoma and NMSC). The analyses were performed by separating these rates using clinical and/or histological criteria. A separate analysis was performed on the more recent data collected in the last 11 years. The data were analyzed using the Stata 14 software package (StataCorp. 2015. Stata Statistical Software: Release 14).

Results

The search strategy identified 1694 articles. Of these, 89 were selected on the basis of a reading of the abstract. After a review of the full texts, 17 were selected for analysis. To these we added a further 15 articles identified by the search of the “gray literature” outside of PubMed and EMBASE. In total, 32 studies were included in the review (Fig. 1).

The selected studies, which are listed in Table 2, analyze data from different provinces, regions, or the whole country relating to the period from 1989 to 2015.

Table 2.

List of Articles Selected in the Systematic Review.

Authors  Journal  Title  Year  Geographic Area 
Ardanaz et al.5  An Sist Sanit Navar  [Incidence and mortality due to cancer in Navarre, 1998-2002. Trends in the last 30 years]  2007  Navarrea 
Bielsa et al.6  Br J Dermatol  Population-based incidence of basal cell carcinoma in a Spanish Mediterranean area  2009  Barcelona 
Cayuela et al.7  Br J Dermatol  Has mortality from malignant melanoma stopped rising in Spain? Analysis of trends between 1975 and 2001  2005  Spain 
Clèries et al.8  Clin Trans Oncol  Time trends of cancer incidence and mortality in Catalonia during 1993-2007  2014  Girona, Tarragonaa 
Fernández-Canedo et al.9  Piel  Epidemiología del melanoma en una población multicultural mediterránea  2014  Malaga 
Larrañaga et al.10  Gacet Sanit  Incidencia del cáncer en Guipúzcoa (1998-2002 y tendencias desde 1986  2008  Guipúzcoa 
Marcos-Gragera et al.11  MedClin  Incidencia del cáncer en Cataluña, 1998-2002  2008  Tarragona, Gironaa 
Marcos-Gragera et al.12  J Eur Acad Dermatol Venereol  Rising trends in incidence of cutaneous malignant melanoma and their future projections in Catalonia, Spain: Increasing impact or future epidemic?  2010  Tarragona, Gironaa 
Montero Pérez et al.13  Aten Primaria  [Importance of skin cancer (non-melanoma): A study of 89 cases]  1989  Cordoba 
Ocaña-Riolaet al.14  Eur J Epidemiol  Population-based study of cutaneous malignant melanoma in the Granada province (Spain), 1985-1992  2001  Granadaa 
Puig et al.15  Acta Dermato-Venereologica  Melanoma incidence increases in the elderly of Catalonia but not in the younger population: Effect of prevention or consequence of immigration?  2015  Catalonia 
Revenga Arranz, et al.16  J Eur Acad Dermatol Venereol  Descriptive epidemiology of basal cell carcinoma and cutaneous squamous cell carcinoma in Soria (north-eastern Spain) 1998-2000: A hospital-based survey  2004  Soria 
Rubio Ruiz et al.17  Med Clin (Barc)  Estudio epidemiológico y clínico del melanoma maligno cutáneo en el área sanitaria de León  1991  León 
Verdecchia et al.18  Ann Oncol  A comparative analysis of cancer prevalence in cancer registry areas of France, Italy and Spain  2002  Basque Country, Mallorca, Navarre, Tarragonaa 
Vergara Ugarriza19  Neoplasia  Incidencia de cáncer en la población de Zaragoza  1995  Zaragoza 
Vilar-Coromina et al.20  Med Clin (Barc)  Cáncer cutáneo distinto de melanoma: tendencia de la incidencia poblacional en Girona, 1994-2007  2011  Gironaa 
Vilar-Coromina et al.21  Med Clin (Barc)  Carcinoma de células de Merkel cutáneo: incidencia y supervivencia poblacional, 1995-2005  2009  Gironaa 
Forman et al.22  http://ci5.iarc.fr  Cancer incidence in five continents, Vol. X (electronic version)  2013  Albacetea 
Forman et al.22  http://ci5.iarc.fr  Cancer incidence in five continents, Vol. X (electronic version)  2013  Asturiasa 
Forman et al.,22  http://ci5.iarc.fr  Cancer incidence in five continents, Vol. X (electronic version)  2013  Basque Country a 
Forman et al.22  http://ci5.iarc.fr  Cancer incidence in five continents, Vol. X (electronic version)  2013  Canary Islandsa 
Forman et al.22  http://ci5.iarc.fr  Cancer incidence in five continents, Vol. X (electronic version)  2013  Ciudad Reala 
Forman et al.22  http://ci5.iarc.fr  Cancer incidence in five continents, Vol. X (electronic version)  2013  Cuencaa 
Forman et al.22  http://ci5.iarc.fr  Cancer incidence in five continents, Vol. X (electronic version)  2013  Gironaa 
Forman et al.22  http://ci5.iarc.fr  Cancer incidence in five continents, Vol. X (electronic version)  2013  Granadaa 
Forman et al.22  http://ci5.iarc.fr  Cancer incidence in five continents, Vol. X (electronic version)  2013  La Riojaa 
Forman et al.22  http://ci5.iarc.fr  Cancer incidence in five continents, Vol. X (electronic version)  2013  Mallorcaa 
Forman et al.22  http://ci5.iarc.fr  Cancer incidence in five continents, Vol. X (electronic version)  2013  Murciaa 
Forman et al.22  http://ci5.iarc.fr  Cancer incidence in five continents, Vol. X (electronic version)  2013  Navarrea 
Forman et al.22  http://ci5.iarc.fr  Cancer incidence in five continents, Vol. X (electronic version)  2013  Tarragonaa 
Cabanes et al.23  Instituto de Salud Carlos III  La situación del cáncer en España, 1975-2006  2009  Spain a 
Pujol et al.24  Informe  Proyecto Incaces  2007  Malaga, La Coruña, Barcelona, Madrid 
a

Data taken from a population-based cancer registry.

The score for methodological quality ranged from 2 to 9 points. Twenty-four studies (75%) achieved a high quality score, but none achieved the maximum score of 10. Most of the studies (84.8%) included histological confirmation. (Table 3)

Table 3.

Risk of Bias.

Author  Sample  Specifies Unit of Analysis  Separates Primary Tumors  Histological Confirmation  Rates by Tumor Type  Rates by Sex  Rates by Age  Age Standardized  95% CI Included  Direct Standardization  Total 
Fernandez-Canedo, 20149  No  No  No  Yes  Yes  No  No  No  No  No 
Montero Pérez, 198913  No  Yes  No  Yes  Yes  No  No  No  No  No 
Rubio Ruiz, 199117  No  No  No  Yes  Yes  Yes  No  No  No  No 
Verdecchia, 200218  No  No      Yes  No  Yes  No  Yes  No 
Cayuela, 20057  No  No    No  Yes  No  No  Yes  Yes  Yes 
Cabanes, 200923  No  No  No  No  Yes  Yes  No  Yes  No  Yes 
Clèries, 20148  No  No    Yes  Yes  Yes  No  Yes  No  Yes 
Larrañaga, 200810  No  No  No  Yes  Yes  Yes  No  Yes  No  Yes 
Ardanaz, 20075  No  No  No  Yes  Yes  Yes  Yes  Yes  No  Yes 
Ocaña-Riola, 200114  No  No  No  Yes  Yes  Yes  No  Yes  Yes  Yes 
Puig, 201515  No  No  No  Yes  Yes  Yes  Yes  Yes  No  Yes 
Marcos-Gragera, 200811  No  Yes    Yes  Yes  Yes  No  Yes  Yes  Yes 
Marcos-Gragera, 201012  No  Yes    Yes  Yes  Yes  No  Yes  Yes  Yes 
Forman, 2013. Albacete22  No  Yes  Yes  Yes  No  Yes  No  Yes  Yes  Yes 
Forman, 2013. Asturias22  No  Yes  Yes  Yes  No  Yes  No  Yes  Yes  Yes 
Forman, 2013. Basque Country22  No  Yes  Yes  Yes  No  Yes  No  Yes  Yes  Yes 
Forman, 2013. Canary Islands22  No  Yes  Yes  Yes  No  Yes  No  Yes  Yes  Yes 
Forman, 2013. Ciudad Real22  No  Yes  Yes  Yes  No  Yes  No  Yes  Yes  Yes 
Forman, 2013. Cuenca22  No  Yes  Yes  Yes  No  Yes  No  Yes  Yes  Yes 
Forman, 2013. La Rioja22  No  Yes  Yes  Yes  No  Yes  No  Yes  Yes  Yes 
Forman, 2013. Mallorca22  No  Yes  Yes  Yes  No  Yes  No  Yes  Yes  Yes 
Forman, 2013. Murcia22  No  Yes  Yes  Yes  No  Yes  No  Yes  Yes  Yes 
Bielsa, 20096  No  Yes  No  No  Yes  Yes  Yes  Yes  Yes  Yes 
Revenga Arranz, 200416  No  Yes  Yes  Yes  Yes  Yes  Yes  Yes  No  Yes 
Vergara Ugarriza, 199519  No  Yes  Yes  Yes  Yes  Yes  No  Yes  Yes  Yes 
Vilar-Coromina, 201120  No  Yes  Yes  Yes  Yes  Yes  No  Yes  Yes  Yes 
Forman, 2013. Girona22  No  Yes  Yes  Yes  Yes  Yes  No  Yes  Yes  Yes 
Forman, 2013. Granada22  No  Yes  Yes  Yes  Yes  Yes  No  Yes  Yes  Yes 
Forman, 2013. Navarre22  No  Yes  Yes  Yes  Yes  Yes  No  Yes  Yes  Yes 
Forman, 2013. Tarragona22  No  Yes  Yes  Yes  Yes  Yes  No  Yes  Yes  Yes 
Vilar-Coromina, 200921  No  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes 
Pujol, 200724  No  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes 
Basal Cell Carcinoma

The overall incidence for BCC in the meta-analysis was 113.05 (95% CI, 89.03-137.08) cases per 100000 person-years for the studies based on the registration methodology normally used by registries (in which only 1 tumor with histological confirmation is counted per person) (Fig. 2). Only 1 study calculated the incidence using both clinical and histological criteria and counting tumors rather than patients, reporting an incidence of 253.23 (95% CI, 273.01-269.45) cases per 100000 person-years.6 The incidence rates for these studies standardized to the world population are shown in Fig. 1, Appendix 1.

Figure 2.

Incidence rate for basal cell carcinoma. All ages.

(0.27MB).
Squamous Cell Carcinoma

The overall incidence rate for SCC was 38.16 (95% CI, 29.82-46.49) cases per 100000 person-years in the meta-analysis (Figs. 2 and 3). The incidence rate standardized to the world population is shown in Figure 2, Appendix 1.

Figure 3.

Incidence of squamous cell carcinoma. All ages.

(0.22MB).

The mortality rate for NMSC was reported in 2 studies: 1 based on data from Navarre,5 with a mortality rate of 0.90 (95% CI, 0.54-1.25) cases per 100000 person-years; and the other on data for Spain as a whole, with a mortality rate of 1.10 (95% CI, 1.00-1.20) cases per 100000 person-years (Fig. 3, Appendix 1). Only the Navarre study reported the mortality rate standardized to the world population (Fig. 4, Appendix 1).

Melanoma

Melanoma has been the subject of more studies than any other skin cancer (n = 24). The meta-analysis yielded a crude incidence rate of 8.82 (95% CI, 7.59-10.04) cases per 100000 person-years (Fig. 4). Of the studies in which the diagnosis of melanoma was confirmed histologically, the study reporting the highest incidence rate was in Marbella (Malaga) between 2002 and 2011, with a rate of 17.53 (95% CI, 15.64-19.41) cases per 100000 person-years.9 The lowest incidence was reported in Zaragoza19 in 1986, with 3.63 (95% CI, 2.33-4.92) cases per 100000 person-years. The only study based on both clinical and histological confirmation reported an incidence rate in Guipúzcoa of 10.15 (95% CI, 9.08-11.23) cases per 100000 person-years for the period from 1998 to 2002.10 Based on both histological and clinical data, Cabanes et al.23 calculated a crude incidence rate for Spain in 2006 of 1.90 (95% CI, 1.77-2.03), but in a study with an high risk of bias. The data standardized to the world population are shown in Figure 5, Appendix 1.

Figure 4.

Incidence of melanoma. All ages.

(0.56MB).

The overall crude mortality rate for melanoma was 2.17 (95% CI: 1.78-2.55) cases per 100000 person-years for studies based on histological diagnoses in the provinces of Navarre,5 Girona,8 and Tarragona12 (Fig. 6, Appendix 1). Cayuela et al.,7 who analyzed data from death certificates, identified a crude mortality rate for Spain in 2001 of 1.82 (95% CI, 1.69-1.95) cases per 100000 person-years. The mortality rates for melanoma standardized to the world population are shown in Figure 7, Appendix 1.

Merkel Cell Carcinoma

In the only study that has reported the incidence rate for Merkel cell carcinoma in Spain the data are from the province of Girona and the crude incidence rate was 0.28 (95% CI, 0.15-0.4) cases per 100000 person-years, with a rate standardized to the world population of 0.12 (95% CI, 0.04-0.2) cases per 100000 person-years.21 None of the studies in the literature analyzed the mortality rate for this tumor.

Analysis of the Most Recent Studies

In the meta-analysis for the studies published in the last 11 years, which represent the most recent data (1998-2000 and later), overall incidence rates were 118.22 (95% CI, 90.25-146.2) for BCC, 42.33 (95% CI, 30.67-49.78) for SCC, and 9.72 (95% CI, 8.91-10.52) for melanoma.

Discussion

The present systematic review included 32 studies on the incidence and mortality of skin cancer in Spain. This is the largest review on this subject to date.

The main objective of this review was to determine the burden of disease attributable to skin cancer in order to ensure adequate planning of available resources. The work was carried out as part of the White Book on Skin Cancer being prepared by the Foundation of the Spanish Academy of Dermatology and Venereology (FAEDV). In this discussion we will focus on the crude incidence rate, since the primary objective of age-standardized incidence rates is to allow comparison between groups with differing age structures, but such rates are less useful for planning purposes.

The results for BCC differ depending on the method used to calculate incidence. The overall crude incidence rate in Spain was 113.05 cases per 100000 person-years when only histologically confirmed tumors were included and only the first tumor for each patient was counted (the usual methodology used by cancer registries). However, when the primary objective is to evaluate the demand for the care of BCC it is preferable to also include tumors not confirmed histologically and all the tumors occurring in any patient. The only study that used this methodology was carried out in the Barcelonès Nord area and reported a crude incidence rate of 253.23 cases per 100000 person-years,6 more than twice the rate estimated by earlier studies. It is likely that this figure more reliably represents the real need for care.

The incidence rate of the meta-analysis standardized to the world population was 55.87 cases per 100000 person-years, similar to rates reported for Scotland, United Kingdom, and Germany, and much lower than the rate reported for Finland.3

The crude incidence rate for SCC was 38.16 (95% CI, 29.82-46.49) cases per 100000 person-years. As this result was also obtained using the methodology typical of registries, it is very likely that it underestimates the need for care.

The incidence rate standardized to the world population based on the results of the meta-analysis of available studies was 13.38 per 100000 person-years. These incidence rates are relatively low when compared to those of countries such as Germany and Slovakia, and are lower than countries such as Sweden, Switzerland and Wales.3

The mortality rate for NMSC is low, and predominantly associated with SCC, particularly because of the existence of a high-risk subgroup.25

In the case of melanoma, the crude incidence rate upon meta-analysis was 8.82 cases per 100000 person-years. Differences can be observed between the results obtained several decades ago, 3 to 4 cases per 100000 person-years,14,17–19 and those reported by studies carried out in the 1990s and later, with rates of 7 cases per 100000 person-years and higher.8,12,15,22,24,26 These differences may reflect an increase in the incidence of melanoma27 and the greater risk of bias in older studies. Of particular interest is the study by Fernández-Canedo et al.,9 who reported a high incidence rate of 17.56 cases per 100000 person-years in a study of Marbella in the province of Malaga. This result is attributed to the high proportion of people from central and northern Europe in the population of the study area.

The standardized incidence rate in Spain is low compared to other European countries, reflecting the recognized difference in Europe between north and south and between east and west, with a rate that varies from 6 cases per 100000 person-years in eastern Europe to 10 in southern Europe and up to 19 in northern Europe.28 The incidence rate in Spain is much lower than the more than 20 cases per 100000 person-years reported in the USA,29 and more than 60 reported for New Zealand and Australia.30

On the basis of the only 3 studies available, the crude mortality rate upon meta-analysis was 2.17 cases per 100000 person-years.5,8,12 While relatively low at present, this rate may continue to increase in coming years, particularly in the older population.7,12 Such an increase would be in contrast to the trend in more northern European countries, where the mortality rates have tended to plateau and even decrease. Among the reasons for this difference are the fact that the Spanish population is older and that melanomas occurring at a later age tend to be thicker and have a more aggressive phenotype.31

Finally, in the only study on Merkel cell carcinoma, Vilar-Coromina et al.21 reported an incidence rate for this tumor of 0.28 cases per 100000 person-years calculated on the basis of data from the Cancer Registry in the province of Girona. This rate is similar to that obtained in similar studies in Denmark32 and Finland,33 but lower than that reported in Australia, where the incidence rate adjusted to the US population is 0.8 cases in western Australia and 1.6 cases per 100000 person-years in north-eastern Australia (Queensland), rates 10 times those reported in European studies.34 This epidemiological difference is probably explained by the difference in population phenotype and levels of exposure to ultraviolet radiation.35

The present systematic review provides a good account of the incidence and mortality of skin cancer in Spain in recent years. The study has, however, a number of limitations. The main limitation of the study is that most of the data on which it is based were obtained using the methodology generally used by cancer registries, which is appropriate for the study of etiological factors but tends to underestimate the need for care, especially in the case of BCC, in which patients often present multiple tumors and are treated without histological confirmation. In light of our results, the approximate underestimation could be 50%. Other limitations of the review are that the studies analyzed do not cover the whole population of Spain or all reported tumors (no data are included on neural, hematolymphoid, adnexal, or soft tissue tumors), and that the data refer to different time periods. Finally, not all the studies based on data from cancer registries explicitly stated that in situ tumors were excluded, but such an exclusion was assumed for the purposes of this analysis.

In conclusion, the data indicate that BCC and SCC are very common tumors in Spain. At least in the case of BCC, the need for care is higher than the level that could be determined from registry data. The incidence rate for cutaneous melanoma in Spain is low compared to other European countries. Finally, the incidence rate for Merkel cell carcinoma is low and similar to that reported for other countries in Europe.

Ethical DisclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this investigation.

Confidentiality of data

The authors declare that no private patient data are disclosed in this article.

Right to privacy and informed consent

The authors declare that no private patient data are disclosed in this article.

Funding

This work was funded by the AEDV Foundation and forms part of the White Paper on Skin Cancer in Spain.

Conflict of Interests

The authors declare that they have no conflicts of interest.

Acknowledgments

The Spanish Network of Cancer Registries (REDECAN) collaborated in the preparation of this article.

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Please cite this article as: Tejera-Vaquerizo A, Descalzo-Gallego MA, Otero-Rivas MM, Posada-García C, Rodríguez-Pazos L, Pastushenko I, et al. Incidencia y mortalidad del cáncer cutáneo en España: revisión sistemática y metaanálisis. Actas Dermosifiliogr. 2016;107:318–328.

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