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The Burden of Skin Cancer in the Military Health System, 2017-2022

IN PARTNERSHIP WITH THE ASSOCIATION OF MILITARY DERMATOLOGISTS
Cutis. 2024 May;113(5):200-204,215,E5-E6 | doi:10.12788/cutis.1015
May 6, 2024|Cutis
Kathleen R. Krivda, MD;Nora L. Watson, PhD;Willis H. Lyford, MD;Nicholas F. Logemann, DO
Author and Disclosure Information

Drs. Krivda, Watson, and Logemann are from Walter Reed National Military Medical Center, Bethesda, Maryland. Drs. Krivda and Logemann are from the Department of Dermatology, and Dr. Waston is from the Department of Research Programs. Dr. Lyford is from the Department of Dermatology, Naval Medical Center San Diego, California.

The authors report no conflict of interest.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Army, the Department of the Navy, the Department of Defense, or the US Government.

The eTables are available online at www.mdedge.com/dermatology.

Correspondence: Kathleen R. Krivda, MD, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889 (kathleen.r.krivda.mil@health.mil).

PRACTICE POINTS

  • Study data showed an overall decreasing prevalence of skin cancer in the Military Health System (MHS) from 2019 to 2021, possibly attributable to underdiagnosis resulting from the COVID-19 pandemic. Providers should be mindful of this trend when screening patients who have experienced interruptions in care.
  • An overall increased prevalence of skin cancer was noted in the military beneficiary population compared with publicly available civilian data—and thus this diagnosis should be given special consideration within this population.

Ethics—This study was conducted as part of a study using secondary analyses of de-identified data from the M2 database. The study was reviewed and approved by the Walter Reed National Military Medical Center institutional review board.

Temporal trends in direct care visits from 2017 to 2022 for selected skin cancer diagnoses by beneficiary category.
FIGURE 1. Temporal trends in direct care visits from 2017 to 2022 for selected skin cancer diagnoses by beneficiary category. Diagnosis was defined by the presence of a relevant International Classification of Diseases (ICD) code in any ICD position.

Results

Encounter data were analyzed from a total of 5,374,348 visits between DC and PC over the study period for each cancer type of interest. Figures 1 and 2 show temporal trends in DC visits compared with PC visits in each beneficiary category. The percentage of total DC visits subsequently declined each year throughout the study period, with percentage decreases from 2017 to 2022 of 1.45% or 8200 fewer visits for MM, 3.41% or 7280 fewer visits for BCC, and 2.26% or 3673 fewer visits for SCC.

Temporal trends in purchased care visits from 2017 to 2022 for selected skin cancer diagnoses by beneficiary category.
FIGURE 2. Temporal trends in purchased care visits from 2017 to 2022 for selected skin cancer diagnoses by beneficiary category. Diagnosis was defined by the presence of a relevant International Classification of Diseases (ICD) code in any ICD position.

When stratified by beneficiary category, this trend remained consistent among dependents and retirees, with the most notable annual percentage decrease from 2019 to 2020. A higher proportion of younger adults and active-duty beneficiaries was seen in DC relative to PC, in which most visits were among retirees and others (primarily dependents of retirees, survivors, and Guard/Reserve on active duty, as well as inactive Guard/Reserve). No linear trends over time were apparent for active duty in DC and for dependents and retirees in PC. eTable 1 summarizes the demographic characteristics of MHS beneficiaries being seen in DC and PC over the study period for each cancer type of interest.

Number of Visits With a Skin Cancer Diagnosis by Year and Patient Demographic Characteristicsa

The Table shows the period prevalence of skin cancer diagnoses within the MHS beneficiary population from 2017 to 2022. These data were further analyzed by MM, BCC, and SCC (eTable 2) and demographics of interest for the year 2022. By beneficiary category, the period prevalence of MM was 0.08% in active duty, 0.06% in dependents, 0.48% in others, and 1.10% in retirees; the period prevalence of BCC was 0.12% in active duty, 0.07% in dependents, 0.91% in others, and 2.50% in retirees; and the period prevalence of SCC was 0.02% in active duty, 0.01% in dependents, 0.63% in others, and 1.87% in retirees. By sponsor branch, the period prevalence of MM was 0.35% in the army, 0.62% in the air force, 0.35% in the marine corps, and 0.65% in the navy; the period prevalence of BCC was 0.74% in the army, 1.30% in the air force, 0.74% in the marine corps, and 1.36% in the navy; and the period prevalence of SCC was 0.52% in the army, 0.92% in the air force, 0.51% in the marine corps, and 0.97% in the navy.

Period Prevalence of Skin Cancer Diagnoses in the MHS

Period Prevalence of MM, BCC, and SCC Diagnoses in the MHS

Comment

This study aimed to provide insight into the burden of skin cancer within the MHS beneficiary population and to identify temporal trends in where these beneficiaries receive their care. We examined patient encounter data from more than 9.6 million MHS beneficiaries.

The utilization of ICD codes from patient encounters to estimate the prevalence of nonmelanoma skin cancer (NMSC) has demonstrated a high positive predictive value. In one study, NMSC cases were confirmed in 96.5% of ICD code–identified patients.5 We presented an extensive collection of epidemiologic data on BCC and SCC, which posed unique challenges for tracking, as they are not reported to or monitored by cancer registries such as the Surveillance, Epidemiology, and End Results (SEER) Program.6

MHS Compared to the US Population—A study using the Global Burden of Disease 2019 database revealed an increasing trend in the incidence and prevalence of NMSC and melanoma since 1990. The same study found the period prevalence in 2019 of MM, SCC, and BCC in the general US population to be 0.13%, 0.31%, and 0.05%, respectively.7 In contrast, among MHS beneficiaries, we observed a higher prevalence in the same year, with figures of 0.66% for MM, 0.72% for SCC, and 1.02% for BCC. According to the SEER database, the period prevalence of MM within the general US population in 2020 was 0.4%.8 That same year, we identified a higher period prevalence of MM—0.54%—within the MHS beneficiary population. Specifically, within the MHS retiree population, the prevalence in 2022 was double that of the general MHS population, with a rate of 1.10%, underscoring the importance of skin cancer screening in older, at-risk adult populations. Prior studies similarly found increased rates of skin cancer within the military beneficiary population. Further studies are needed to compare age-adjusted rates in the MHS vs US population.9-11

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