Body site distribution of skin cancer, pre-malignant and common benign pigmented lesions excised in general practice
Body site distribution of skin cancer, pre-malignant
and common benign pigmented lesions excised in
general practicePhilippa H. YoulUniversity of Queensland
Monika JandaQueensland University of Technology
Joanne F. AitkenUniversity of Queensland
Chris B. Del MarBond University
, [email protected]
David C. WhitemanQueensland Institute of Medical Research
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Recommended CitationPhilippa H. Youl, Monika Janda, Joanne F. Aitken, Chris B. Del Mar, David C. Whiteman, and PeterD. Baade. (2011) "Body site distribution of skin cancer, pre-malignant and common benignpigmented lesions excised in general practice" British journal of dermatology,
165 (1), 35-43: ISSN0007-0963.
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Philippa H. Youl, Monika Janda, Joanne F. Aitken, Chris B. Del Mar, David C. Whiteman, and Peter D. Baade
This journal article is available at [email protected]
Body site distribution of skin cancer, pre-malignant and common benign pigmented lesions
excised in general practice Running head:
Body site distribution of skin lesions excised in general practice Authors:
P.H. Youl 1,2, M Janda3, J.F. Aitken 1,2, C.B Del Mar, 4 D.C. Whiteman5, P.D. Baade 1,3
1 Viertel Centre for Research in Cancer Control, Cancer Council Queensland, Australia
2 School of Population Health, University of Queensland, Australia
3 School of Public Health, Queensland University of Technology, Australia
4 School of Medicine, Bond University, Queensland, Australia
5 Queensland Institute of Medical Research, Australia
Viertel Centre for Research in Cancer Control
Cancer Council Queensland
PO Box 201
Spring Hill Qld Australia 4004
Tel: + 61 7 3634 5301
Fax: + 61 7 3259 8527
Word Count: 2,956
References: 27 Funding:
This research was funded by National Health and Medical Research Council Project
Grant 339100. Conflict of interest:
None to declare What's already known about this topic?
• Skin cancer is the most common malignancy worldwide.
• Patients frequently present to general practitioners (GPs) with skin lesions they are
• They often exert pressure on their GPs to excise lesions.
What does this study add?
• Nearly two-thirds of lesions excised in primary care are for skin cancer.
• After adjusting for surface area the density of malignant and pre-malignant skin lesions is
highest on the more chronically sun exposed body sites.
• Women and younger patients are significantly more likely to exert pressure to excise a
benign pigmented lesion.
Concern about skin cancer is a common reason for people from predominantly fair-
skinned populations present to primary care doctors.
To examine the frequency and body site distribution of malignant, pre-malignant and
benign pigmented skin lesions excised in primary care.
This prospective study conducted in Queensland, Australia, included 154 primary care
doctors. For all excised or biopsied lesions, doctors recorded the patient's age and sex, body site,
level of patient pressure to excise, and the clinical diagnosis. Histological confirmation was
obtained through pathology laboratories.
Of 9,650 skin lesions, 57.7% were excised in men and 75.0% excised in patients ≥ 50
years. The most common diagnoses were basal cell carcinoma (BCC) (35.1%) and squamous cell
carcinoma (SCC) (19.7%). Compared to the whole body, highest densities for SCC, BCC and
actinic keratoses were observed on chronically sun exposed areas of the body including the face in
men and women, the scalp and ears in men, and the hands in women. The density of BCC was also
high on intermittently or rarely exposed body sites. Women, younger patients and patients with
melanocytic naevi were significantly more likely to exert moderate/high levels of pressure on the
doctor to excise.
More than half excised lesions were skin cancer which mostly occurred on the more
chronically sun exposed areas of the body. Information on the type and body site distribution of
skin lesions can aid in diagnosis and planned management of skin cancer and other skin lesions
commonly presented in primary care.
Skin cancer is the most common malignancy in fair-skinned populations around the world. It is
estimated that 434,000 people were diagnosed with non-melanoma skin cancer (NMSC) in 2008 in
Australia, and nearly 84,500 individuals were diagnosed with NMSC in 2007 in the United
Kingdom (UK)Rates of NMSC and melanoma continue to rise in countries with predominantly
The diagnosis and management of common skin lesions represents a significant workload for
General Practitioners (GPs). The UK has a similar two-tiered health service system to Australia,
whereby the GP is the initial point of contact for most patients. In Australia, GPs bill for patient
consultations and procedures through a universal health insurance scheme (Medicare), while GPs in
the UK work under national health service contracts (General Medical Services Contract)linked
Unlike specialist settings where patients are usually referred following an initial consultation in
primary care, patients commonly present to GPs with a diverse range of skin lesions. In Australia
about half of excised lesions are NMSC. Other common diagnoses include actinic (solar)
keratoses, thought to be a form of in situ
SCC which in some cases can develop into invasive SCC,
and benign pigmented lesions such as melanocytic and dysplastic naevi and seborrhoeic
keratosisOverall about 90% of pigmented lesions seen in general practice are melanocytic naevi.
An understanding of patterns and the distribution of skin lesions can provide aetiological clues and
may help inform possible diagnosis and appropriate management. Previous studies examining body
site distribution of common skin lesions have primarily relied on retrospective data obtained
through pathology services and/or extraction of data from medical recordsIn contrast the
present study was conducted prospectively in primary care surgeries, thus reflecting typical day-to-
day clinical practice presentations.
The aim of this study was to examine and report on the frequency and body site distribution of
common skin lesions presenting to, and excised in, primary care following a skin examination, the
degree of pressure by patients to excise, and factors that influence patient pressure to excise a
Materials and Methods
The study methodology has been described in detail previously.Briefly, the study included 154
primary care doctors located in South-East Queensland, Australia. Participating doctors recorded
the details of all consultations involving a skin examination over a specified time period including:
patient's age and sex; type of skin examination (whole-body, part-body, specific lesions); and who
initiated the examination (doctor, patient as primary reason for consultation or patient as the
secondary reason for consultation). For excised or biopsied lesions, doctors also recorded the body
site; degree of patient pressure to excise (on a scale of 1 to 5 with 1 being 'no pressure' and 5 being
'pressure was only reason for excision'); and the clinical diagnosis. Trained research personnel
extracted information from histopathology reports including body site and histological diagnosis.
Diagnoses were grouped into eight major categories including: melanoma (including Hutchinson's
Melanotic Freckle); squamous cell carcinoma (SCC) (including keratoacanthoma and Bowen's
disease); basal cell carcinoma (BCC); actinic keratosis; dysplastic naevi; melanocytic naevi; other
benign pigmented lesions (such as seborrhoeic keratosis, lentigo, lichenoid keratosis); and other
benign non-pigmented lesions (cysts, warts, skin tags). Due to the variety of diagnoses for other
benign non-pigmented lesions it was not possible to appropriately combine them into one category,
so they were excluded from this analysis (n=1,771 [15.5%]). Where a lesion was given multiple
diagnoses a malignant diagnosis was selected as the primary diagnosis.
Ethical approval was obtained from the Behavioural and Social Sciences Ethical Review Committee
of the University of Queensland.
The analysis included only those lesions for which information was available on exact body site,
age, sex and histology (n=9,650 [(96.8%]). Body-sites were categorised as: scalp; face; ear; neck;
upper arm/shoulders; forearm; hand; chest/abdomen; back; buttocks; thigh; lower leg and foot.
Logistic regression analyses were used to examine differences in the frequency distributions of
histological diagnosis by sex and age group (< 50 and ≥ 50 years) and to examine differences in the
body site distribution for each histological type by sex and age group with analyses adjusted for
clustering by doctor and patient. To account for surface area of the skin at each body site relative to
the whole body, relative tumour densities (RTD) were calculated by dividing the proportion of
lesions at a specific site by the average proportion of skin surface area at that site using the formula
suggested by Pearland the estimated proportion of surface area suggested by Lund and
Browder.For example according to Lund and Browder the back is equivalent to 13% of the body
thus if 48 of 152 melanomas occurred on the back then the RTD of melanoma on the back=
(48/152)/0.13=2.43. RTD's were transformed and graphed using a log scale to better reflect the
differences in densities compared to the overall body density of 1. Body sites with no lesions were
not graphed. Logistic regression analysis was used to analyse factors related to moderate to high
levels of pressure to excise benign pigmented lesions. Variables that showed significant bivariate
associations or were known or suspected confounders were included in the model. A stepwise
selection approach was implemented based on the likelihood ratio of each successive model, and a
significance level of 0.05 was used for the final model and was adjusted for clustering of patients
and doctors. All analyses were performed using Stata Statistical Software, version 10.1 (Statacorp
LP, College Station, Tex).
Of 9,650 lesions excised in 7,133 patients, 57.7% were excised in men and 75.0% excised in
patients 50 years and over. The most common diagnoses were BCC (35.1%), SCC (17.7%) and
actinic keratoses (14.8%). Just under 11% were melanocytic naevi, 6.2% were dysplastic naevi and
1.6% were melanoma (Table 1).
BCC was more common in men (39.4% of lesions) than women (29.3%), (p < 0.001). Nearly 14%
of lesions excised in women were melanocytic naevi compared to 8.2% in men (p < 0.001). Nearly
two-thirds (63.1%) of excised lesions in patients
≥ 50 years were malignant (melanoma, SCC or
BCC) compared to just over one-third (36.1%) for those < 50 years (p < 0.001). Melanocytic lesions
were more commonly excised in younger patients (30.6% of all lesions) compared to older patients
(p < 0.001) (Table 1).
Distribution of histological diagnoses by gender and age group according to body site
Melanoma was more frequently diagnosed on the back and upper arm in men (37.0% and 21.0%,
respectively) and on the upper arm, back and lower legs in women (23.1%, 21.1% and 17.3%,
respectively) (Table 2). SCC was more commonly excised on the face in both men and women
(23.2% and 27.0%, respectively), however men had significantly more SCCs excised from the scalp
and ears (p < 0.001). The body site distribution of dysplastic and melanocytic naevi was similar to
that for melanoma with most lesions excised from the back for both men and women. Women had
more benign pigmented lesions excised from the face and men had more lesions excised from the
Melanoma was almost twice as prevalent on the forearm in those aged < 50 years compared to
patients ≥ 50 years (16.7% and 8.7% respectively). SCC was more commonly excised on the face in
both age groups, followed by the hand (16.9%) and forearm (15.6%) for patients < 50 years, and the
lower leg (21.6%) and forearm (13.7%) for patients
≥ 50 years. More than half of dysplastic naevi
were excised from the back for both age groups. Younger patients had significantly more
melanocytic naevi excised from their chest/abdomen than older patients (16.9% and 8.0%,
respectively) (Table 3).
Adjusting for surface area
Figs 1 and 2 illustrate the relative tumour density (RTD) of malignant and pre malignant lesions,
and the most common benign pigmented lesions excised or biopsied for men and women and by age
group according to body site plotted on a log scale.
Malignant and pre-malignant lesions excised in males and females
In men, the density of melanoma was five times as high on the face and four times as high on the
ears compared to the body as a whole (RTD=5.0 and 4.0, respectively) and nearly three times
higher for sites such as the neck, upper arm/shoulders and back (Fig1). For BCC, SCC and actinic
keratosis the density of lesions was 12 to 15 times higher on the face and ears compared to the
whole body. The RTD for BCC on the upper arm/shoulder (1.6) and the back (1.9) were more than
double that observed for SCCs at the same sites (0.4 and 0.9 respectively). However the density of
malignant and pre-malignant lesions was very low on sites such as the chest/abdomen and thigh.
In women, the density of excised melanoma was four times higher on the face and three times
higher on the neck and upper arm/shoulders compared to the whole body. For SCC, BCC and
actinic keratosis the density of lesions was 11 to 17 times higher on the face compared to the whole
body (11.3; 12.8 and 17.5, respectively). High relative densities of SCC and actinic keratosis were
observed on the hands (2.2 and 2.3, respectively). The density of lesions was low for the
chest/abdomen and the thigh.
Benign pigmented lesions excised in males and females
In men, the density of dysplastic naevi was over four times higher on the back (4.3) compared to the
whole body. The RTD of melanocytic naevi excised from the face was 4.9, 3.5 for the ears and 3.0
for the back. For benign pigmented lesions, extremely high RTDs were observed on chronically sun
exposed sites such as the face (7.7), ears (5.7) and neck (2.6). For women, the density of dysplastic
naevi was nearly four times higher on the back (3.7) compared to the whole body. The highest
density of melanocytic naevi were observed on the face (5.5) and ear (3.5). The density of benign
pigmented lesions was over 10 times higher on the face than the whole body, whereas these lesions
were only rarely excised from the lower body.
Malignant and pre-malignant lesions by age group
In patients < 50 years the density of excised melanoma was highest on the face (RTD=3.4), upper
arm/shoulders (3.0) and back (2.7) compared to the body as a whole. For SCC, BCC and actinic
keratosis RTD's were nine to 15 times higher on the face. The RTD of SCC and actinic keratosis
were three times higher on the hand (3.4 and 3.3, respectively) compared to the whole body. For
patients 50 years or more, the RTD of excised melanoma was highest on the face (5.1) and then the
ears (3.5) and neck (3.3). The RTD's for SCC, BCC and actinic keratosis were all nine to 12 times
higher for the more chronically exposed body-sites such as the face and ear (Fig 2).
Benign pigmented lesions by age group
Compared to the body as a whole, the density of dysplastic naevi were more than four times higher
on the back for both younger and older patients (Figure 4). For younger patients the RTD of excised
melanocytic naevi was three to four times higher on the face (4.3) and ears (3.5) and more than
twice as high on the back (2.4). In older patients, the density of excised melanocytic naevi and
other benign pigmented lesions was seven to eight times higher on the face and three to four times
higher on the ears compared to the body as a whole. The density of benign pigmented lesions was
low for sites such as the thigh and lower leg in both age groups.
Pressure from the patient to excise or biopsy skin lesions
We examined the degree of patient pressure to excise benign pigmented lesions (n=2,644). Overall,
just over one-third (36.4%) of patients exerted a moderate to high degree of pressure on the doctor
to excise a skin lesion and this was more common in women. Moderate to high pressure to excise
was recorded for nearly 50% of benign pigmented lesions on the head and neck compared to 29%
of lesions on the lower limbs. In multivariate analysis, factors positively associated with a moderate
to high degree of pressure to excise included being female, being aged 30 to 49 years, having a
lesion on the head or neck, having a melanocytic naevus and undergoing a part-body examination or
a check of specific lesions (Table 4).
This study examined the site and histological distribution of skin lesions excised or biopsied in
primary care practice. Nearly two-thirds of lesions were malignant or pre-malignant. BCC
accounted for over one-third and nearly two-thirds of all skin cancer diagnoses. The ratio of BCC to
SCC was about 2 to 1 and this is in keeping with other studies in high incidence populationsIn
populations at higher latitudes and lower risk, the occurrence of BCC can be up to five-fold higher
than SCCExcision of any type of skin cancer was approximately 40% more common in men
than women (M:F ratio=1:0.6) and about 80% more common in patients over the age of 50 years
compared to younger patients.
Compared to the whole body, five sites in men had a higher than average density of melanoma
(ears, face, neck, back, upper arm/shoulders) and six sites in women (face, neck, upper
arm/shoulders, forearm, back and lower legs). Although our findings are based on a relatively small
number of melanomas (n=152), they are consistent with other published studiesThere is now
growing evidence that the relationship between melanoma and patterns of sun exposure varies
according to age, site, and morphology. For example, melanoma that occurs on more chronically
sun exposed sites such as the face, and head and neck region is more likely to be associated with
older age as we have found in this study, while melanoma occurring on intermittently exposed sites
such as the trunk and upper limbs is more likely to be associated with onset at an earlier age
The relative densities of BCC and SCC for the more chronically sun exposed sites such as face, ears
and scalp (in men) were high and followed a similar pattern to that reported in other studies both in
high and low risk populationskin lesions excised on other chronically sun exposed sites
such as the forearm and hand were significantly more likely to be SCC or actinic keratosis than
BCC. Interestingly men were around 30% less likely to have such a lesion excised from their hand
compared to women. A similar differential was found for the lower leg, with men around 20% less
likely to have a lesion excised from the lower leg compared to women.
The density of actinic keratosis followed a similar pattern to SCC. This is not surprising given that
actinic keratosis is considered by some to be a precursor to SCC, or at the very least a risk factor
Studies have reported 60% of incidental SCCs developed from an existing actinic keratosis,while
others report nearly three-quarters of SCCs were contiguous with an actinic keratotic lesi
Excisions or biopsy of benign pigmented lesions accounted for more than one-third of all lesions in
this population group with melanocytic naevus accounting for the majority. Compared to the body
as a whole, the density of excised melanocytic naevi followed a similar distribution to that of
melanoma and was highest on the face in both men and women. This is likely to reflect both the
known correlation between the development of melanocytic naevi and sun exposure, and the ready
visibility to the patient of any apparent changes
Consistent with this, patient pressure to excise benign pigmented lesions was greater for lesions
located on the head and neck. Younger patients, females and those presenting for examinations of
specific lesions were more likely to exert pressure on doctors and this may suggest that cosmetic
concerns contribute to high pressure to excise. In this study patients were significantly more likely
to exert pressure to excise a melanocytic naevi, despite the doctor rating the chance of malignancy
Implications for clinical practice
Diagnosing and managing suspicious skin lesions is a common part of primary care practice and an
understanding of the pattern and body site distribution can help inform clinical practice. The
consistent finding that melanoma does occur on intermittently or rarely exposed sites highlights the
importance of whole-body skin examination. Similarly, we found over one-third of NMSC occurred
on intermittently sun exposed sites such as the trunk and upper arms and this pattern was more
pronounced for patients under the age of 50 years. Recent results from a large population-based
melanoma case-control study found the risk of being diagnosed with thicker melanoma (> 0.75mm)
was reduced by 14% for patients who had undergone a whole-body clinical examination within the
three years prior to their melanoma diagnosis and this reduction in risk increased with increasing
The finding that patients exert a significant amount of pressure to excise apparently benign lesions
highlights the importance of educating patients about the early signs and symptoms of NMSC and
melanoma, and should be a routine part of the general practice consultation. Currently in the UK
core competencies for GPwSI in dermatology include effective communication of these topics
While this study was a large prospective study involving 154 primary care doctors some limitations
should be noted. The study only included excised or biopsied lesions found during a skin
examination and therefore may not reflect the site distribution of all lesions that present in general
practice. We relied on the participating doctors to record the body site where the skin lesion was to
be excised and it is possible there may be some misclassification. However body site was checked
against the histopathology results, and in the event of a discrepancy, the patient file was examined
to ensure the correct body site was recorded. While it is possible that there may be some error in the
interpretation of histopathology by the pathologist, this study was conducted in Queensland,
Australia, where the incidence of skin cancer is the highest in the world and pathologists have
extensive experience. Additionally, it is possible that participating doctors may have changed their
behaviour (Hawthorn effect in relation to deciding whether or not to excise a lesion during the
In conclusion, this study found more than half the lesions excised in general practice in Queensland,
Australia, were skin cancers which for the most part occurred on the more frequently sun exposed
body sites. This type of data provides GPs with an indication of the frequency and body site density
of common skin lesions, thus helping to inform possible diagnoses and management strategies.
These Australian data provide important benchmark information, against which other international
studies can be compared to provide additional insight into the possible aetiology of skin cancers and
pre-malignant lesions excised in general practice.
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Histological distribution of 9,650 excised or biopsied skin lesions according to sex and age group
Squamous cell carcinoma b
Basal cell carcinoma
Other benign pigmented c
a p-value reflects the difference in proportions and was adjusted for clustering of doctor and patient; b includes Bowen's disease and keratoacanthoma; c includes seborrhoeic keratosis, lentigo, lichenoid keratosis
Percent of excised or biopsied skin lesions by histology and body site for males and females
Melanoma / HMF
a Hutchinson's Melanotic Freckle; † P < 0.01; * 0.01 ≤ P < 0.05; P is the test of association between body sites and sex for each histology group and has been adjusted for clustering of doctor and patient.
Number and percent of excised or biopsied skin lesions by histology and body site for ages < 50 years and ≥ 50 years
Melanoma / HMF
a Hutchinson's Melanotic Freckle; † P < 0.01; * 0.01 ≤ P < 0.05. P is the test of association between body sites and age group for each histology group and has been adjusted for clustering by doctor and patient.
Factors associated with moderate to high levels of patient pressure to excise benign pigmented skin
lesions in primary practice
patient pressure to
Adjusted odds ratio*
< 30 years (n=459)
30-49 years (n=852)
50-69 years (n=934)
70+ years (n=399)
Head & neck (n=568)
Upper limbs (n=455)
Lower limbs (n=393)
Dysplastic naevus (n=562)
Melanocytic naevus (n=992)
Other benign pigmented (n=1,090)
Type of clinical skin examination
Whole body (n=1,285)
Part body (n=266)
Specific lesions (n=1,047)
* model adjusted for all factors within the table and for clustering by doctor and patient
NIH Public AccessAuthor ManuscriptBrain Res. Author manuscript; available in PMC 2013 August 01. NIH-PA Author Manuscript Published in final edited form as: Brain Res. 2013 June 13; 1514: 12–17. doi:10.1016/j.brainres.2013.04.011. Rationale and Design of the Kronos Early Estrogen Prevention Study (KEEPS) and the KEEPS Cognitive and Affective Sub
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