Original Research

Molluscum contagiosum (MC), which is caused by a DNA virus in the Poxviridae family, is a common viral skin infection that primarily affects children.^1-4 The reported incidence and prevalence of MC exhibit notable geographic variation. Worldwide, annual incidence rates per 1000 individuals range from 3.1 to 25, and prevalence ranges from 0.27% to 34.6%.^2-7

Molluscum contagiosum is diagnosed clinically and typically manifests as smooth, flesh-colored papules measuring 2 to 6 mm in diameter with central umbilication. It can manifest as a single lesion or multiple clustered lesions, or in a disseminated pattern. The primary mode of transmission is through contact with skin, lesions, or contaminated personal items, or via self-inoculation. The majority of cases are asymptomatic, but in some patients, MC may be associated with pruritus, tenderness, erythema, or irritation. When present, secondary bacterial infections can cause localized inflammation and pain.^1,3,4 The pathogenesis hinges on MC virus replication within keratinocytes, disrupting cellular differentiation and keratinization. The virus persists in the host by influencing the immune response through various mechanisms, including interference with signaling pathways, apoptosis inhibition, and antigen presentation disruption.^3,4

Molluscum contagiosum typically follows a self-limiting trajectory, resolving over several months to 2 years.^3,4 The resolution timeframe is intricately linked to variables such as the patient’s immune profile, lesion burden, and treatment approach. For symptomatic lesions, a variety of treatment options have been described, including physical ablation (eg, cryotherapy, curettage) and topical agents such as potassium hydroxide, cantharidin, imiquimod, and salicylic acid.^3,4,8,9

Atopic dermatitis (AD) is a common chronic relapsing inflammatory skin disorder. In the United States, its prevalence ranges from 15% to 30% in children and from 2% to 10% in adults, with ongoing evidence of a growing global incidence.^10-14 While AD can emerge at any age, typical onset is during early childhood. The clinical manifestation of AD includes a spectrum of eczematous features, often accompanied by persistent itching. The pathogenesis is multifactorial, involving a complex interplay of genetic, immunologic, and environmental factors. Key contributors to this multifaceted process encompass a compromised epidermal barrier, alterations in the skin microbiome, and an immune dysregulation promoting a type 2 immune response. Epidermal barrier dysfunction can be attributed to various factors, including diminished ceramide production, altered lipid composition, the release of inflammatory mediators, and mechanical damage from the persistent itch-scratch cycle.^10-13,15 These factors or their interplay may enhance the susceptibility of patients with AD to infections. 

Several studies conducted across various geographic regions examining the relationship between MC and AD have reported variable findings.^2,6,7,16-21 Published studies have reported a prevalence of AD in children with MC ranging from 13.2% to 43%.^2,6,7,16-21 Although some studies suggest a higher rate of atopy in patients with MC, not all research has confirmed this association.^16,21 Dohil et al² reported a greater number of MC lesions in children with AD than those without an atopic background. Silverberg²⁰ reported that in 10% (5/50) of children with MC, the onset of AD was triggered, and in 22% (11/50) MC was associated with flares of pre-existing AD.

In this study, we aimed to assess MC infection rates in children with AD, analyze the epidemiologic aspects and severity differences between atopic children with and without MC infection, and compare data from atopic and nonatopic children with MC.

Methods

In this retrospective cohort study, we analyzed the medical records of pediatric patients diagnosed with MC, AD, or both conditions at an outpatient dermatology practice in Netanya, HaSharon, Israel, from September 2013 to August 2022. Data were collected from the electronic medical records and included patient demographics, the clinical presentation of MC and/or AD at diagnosis, and the duration of both conditions. Only patients with complete data and at least 6 months of follow-up were included. Key epidemiologic characteristics assessed included patient sex, age at the initial visit, and age at the onset of MC and/or AD. Diagnoses of MC and AD were established through clinical examinations conducted by dermatologists. The clinical evaluation of AD encompassed the assessment of body surface area involvement (categorized as <5%, 5%-10%, or >10%). Atopic dermatitis severity was classified as mild, moderate, or severe using the validated Investigator Global Assessment Scale for Atopic Dermatitis.²² Clinical evaluation of MC included assessment of the number of lesions (categorized as ≤4, 5-9, or ≥10), presence of inflammatory lesions, and resolution times for individual lesions (categorized as <1 week, several weeks, or unknown), as well as the overall resolution time for all lesions (categorized as <6 months, 6-12 months, 13-18 months, or >18 months). The temporal relationship between the appearance of MC and AD also was assessed.

Statistical Analysis—Numbers and percentages were used for categorical variables. Continuous variables were represented by mean and standard deviation. Categorical variables were compared using the χ² test, and continuous variables between groups were compared using the Student t test. All statistical tests were 2-sided, with statistical significance defined as P≤.05. Statistical analysis was performed using SPSS software version 28 (IBM).

Results

Study Population—A total of 610 children were included in the study; 263 (43%) were female and 347 (57%) were male. The patients ranged in age from 4 months to 10 years, with a mean (SD) age of 4.87 (1.82) years. Five hundred fifty-six (91%) patients had AD, and 336 (55%) had MC. Within this cohort, 274 (45%) children had AD only, 54 (9%) had MC only, and 282 (46%) had both AD and MC. Regarding the temporal sequence, among the 282 children who had both AD and MC, AD preceded MC in 203 (72%) cases, both conditions were diagnosed concomitantly in 43 (15%) cases, and MC preceded AD in 36 (13%) cases. For cases in which the MC diagnosis followed the diagnosis of AD, the mean (SD) time between each diagnosis was 3.17 (1.5) years.

Comparison of Atopic and Nonatopic Children With MC—Although a higher proportion of males were diagnosed with MC (with or without concurrent AD), the differences in sex distribution between the 2 groups did not reach statistical significance. Among all children with MC, the majority (81.5% [274/336]) were aged 1 to 6 years at presentation. Patients with MC as their sole diagnosis had a similar mean age compared with those with concurrent AD. However, a detailed age subgroup analysis revealed a notable distinction: in the group with MC as the sole diagnosis, the majority (95% [51/54]) were younger than 7 years. In contrast, in the combined MC and AD group, MC manifested across a wider age range, with 21% (58/282) of patients being older than 7 years. In MC cases associated with AD, a notably higher lesion count and increased local inflammatory response were observed compared to those without AD. The time for complete resolution of all MC lesions was substantially prolonged in patients with comorbid AD. Specifically, 93% (50/54) of patients with MC without comorbid AD achieved full resolution within 1 year, whereas 52% (146/282) of patients with comorbid AD required more than 1 year for resolution (eTable 1). 

Comparison of Atopic Children With and Without MC—Sex, age distribution, and disease duration showed no differences between atopic patients with and without MC. Atopic patients with MC exhibited greater body surface area involvement and higher validated Investigator Global Assessment Scale for Atopic Dermatitis scores compared to atopic patients without MC (eTable 2).

Comment

This study examined the relationship between MC and AD in pediatric patients, revealing a notable correlation and yielding valuable epidemiologic and clinical insights. Consistent with previous research, our study demonstrated a high prevalence of AD in children with MC.^2,6,7,16-21 Previous studies indicated AD rates of 13% to 43% in pediatric patients with MC, whereas our study found a higher prevalence (84%), signifying a substantial majority of patients with MC in our cohort had AD. This discrepancy arises from factors such as demographic, genetic, and environmental differences, along with differences in access to medical care, referral practices, and diagnostic approaches across health care systems.¹⁴

Our temporal analysis of MC and AD diagnoses offers important insights. In the majority (72% [203/282]) of cases, the diagnosis of AD preceded MC, supporting previous research suggesting that the underlying pathophysiology of AD heightens susceptibility to MC.^15,17-20 Less frequently, MC was diagnosed before or concurrently with AD, indicating that MC may occasionally trigger or exacerbate milder or undiagnosed AD, as previously proposed.²⁰

A notable finding in our study was the expanded age range for MC onset in patients with AD, encompassing older age groups compared to patients with MC as their sole diagnosis, possibly due to persistent immune dysregulation. To the best of our knowledge, this specific observation has not been systematically reported or documented in prior cohort studies. Visible skin lesions of MC may have a psychological impact on patients, influencing self-consciousness and causing embarrassment and emotional distress. This may be more pronounced in older children, who are more aware of their appearance and social perceptions.^23-25 These considerations should play a role in the management of MC. 

Our study revealed that children with AD and MC displayed higher lesion counts, increased local inflammatory responses, and a more protracted resolution period compared to nonatopic children. In more than 50% of children with AD, MC took more than 1 year for resolution, whereas the majority of those without AD achieved resolution within 1 year. These findings may be attributed to AD-related immune dysregulation, influencing the natural course of MC. Consequently, it suggests that while nonatopic children with MC usually are managed through observation, atopic patients may benefit from an intervention-oriented approach. 

Comparing atopic patients with and without MC showed a heightened occurrence of severe and extensive AD among those with concurrent MC. Several factors could contribute to this observation. On one hand, there could be a direct association between the extent and severity of AD, leading to an elevated susceptibility to MC. Conversely, MC might exacerbate immunologic dysregulation and intensify skin inflammation in atopic individuals.²⁰ Additionally, itching related to both disorders may exacerbate inflammation and compromise the epidermal barrier, facilitating the spread of MC. This interplay suggests that each condition exacerbates the other in a self-reinforcing cycle. The importance of patient and caregiver education is underscored by recognizing these interactions. To manage both conditions effectively, health care providers should counsel patients and caregivers on maintaining proper skin care practices such as gentle cleansing with mild, fragrance-free products, regular moisturization, and avoidance of irritants, encourage them to avoid scratching, and recommend adopting an active treatment approach.

Our study had notable strengths. Firstly, a substantial sample size enhanced the statistical reliability of our findings. Additionally, valuable insights into the epidemiology and clinical aspects of AD and MC were obtained by utilizing real-world data from an outpatient dermatology practice. In our study, clinical evaluations covered body surface area involvement and disease severity for AD while also assessing lesion counts and the presence of inflammatory lesions for MC. This comprehensive approach facilitated a thorough analysis of both conditions. The extended data collection period not only allowed for observation of their clinical course and duration, but also enabled a detailed assessment of their interplay.

Our study also had several limitations. Primarily, its retrospective design relied on the accuracy and comprehensiveness of medical records, which may have introduced bias. The exclusion of some patients due to incomplete data further increased the potential for selection bias. Additionally, this study was conducted in a single outpatient dermatology practice in Israel, resulting in a study population composed predominantly of Jewish patients (94%), with a minority (6%) of Arab patients. Other ethnic groups, including Black, Asian, and Hispanic populations, were not represented. This reflects the country’s demographic composition rather than an intentional selection bias. However, the limited ethnic diversity reduces the generalizability of our findings. Differences in demographics, coding practices, health care utilization (eg, timeliness of seeking care, access to dermatology services), and treatment strategies also may impact the observed prevalence, clinical characteristics, and patient outcomes. Furthermore, while our study highlighted the potential advantages of a proactive treatment approach for atopic children with MC, it did not evaluate specific treatment protocols. Future research should aim to confirm the most efficacious therapeutic strategies for managing MC in atopic individuals and to include a more diverse population to better understand the applicability of findings across various ethnic groups.

Conclusion

Our study found a high prevalence of AD in children with MC and a strong bidirectional relationship between these conditions. Pediatric patients with AD display a broader age range for MC, greater lesion burden, increased local inflammatory responses, prolonged resolution times, and more extensive and severe AD.

Recognizing the interplay between MC and AD is crucial, highlighting the importance of health care providers educating patients and caregivers. Emphasizing skin hygiene, discouraging scratching, and implementing proactive treatment approaches can enhance the outcomes of both conditions. Further research into the underlying mechanisms of this association and effective therapeutic strategies for MC in atopic individuals is warranted.

Acknowledgments—The authors thank Zvi Segal, MD (Tel Hashomer, Israel) for his insightful contribution to the statistical analysis of the results. We would like to express our appreciation to the dedicated team of the dermatology practice in Netanya for the support throughout the performance of the study. Additionally, we thank all study participants and their parents for their participation and contribution to our research.

Molluscum contagiosum (MC), which is caused by a DNA virus in the Poxviridae family, is a common viral skin infection that primarily affects children.^1-4 The reported incidence and prevalence of MC exhibit notable geographic variation. Worldwide, annual incidence rates per 1000 individuals range from 3.1 to 25, and prevalence ranges from 0.27% to 34.6%.^2-7

Molluscum contagiosum is diagnosed clinically and typically manifests as smooth, flesh-colored papules measuring 2 to 6 mm in diameter with central umbilication. It can manifest as a single lesion or multiple clustered lesions, or in a disseminated pattern. The primary mode of transmission is through contact with skin, lesions, or contaminated personal items, or via self-inoculation. The majority of cases are asymptomatic, but in some patients, MC may be associated with pruritus, tenderness, erythema, or irritation. When present, secondary bacterial infections can cause localized inflammation and pain.^1,3,4 The pathogenesis hinges on MC virus replication within keratinocytes, disrupting cellular differentiation and keratinization. The virus persists in the host by influencing the immune response through various mechanisms, including interference with signaling pathways, apoptosis inhibition, and antigen presentation disruption.^3,4

Molluscum contagiosum typically follows a self-limiting trajectory, resolving over several months to 2 years.^3,4 The resolution timeframe is intricately linked to variables such as the patient’s immune profile, lesion burden, and treatment approach. For symptomatic lesions, a variety of treatment options have been described, including physical ablation (eg, cryotherapy, curettage) and topical agents such as potassium hydroxide, cantharidin, imiquimod, and salicylic acid.^3,4,8,9

Atopic dermatitis (AD) is a common chronic relapsing inflammatory skin disorder. In the United States, its prevalence ranges from 15% to 30% in children and from 2% to 10% in adults, with ongoing evidence of a growing global incidence.^10-14 While AD can emerge at any age, typical onset is during early childhood. The clinical manifestation of AD includes a spectrum of eczematous features, often accompanied by persistent itching. The pathogenesis is multifactorial, involving a complex interplay of genetic, immunologic, and environmental factors. Key contributors to this multifaceted process encompass a compromised epidermal barrier, alterations in the skin microbiome, and an immune dysregulation promoting a type 2 immune response. Epidermal barrier dysfunction can be attributed to various factors, including diminished ceramide production, altered lipid composition, the release of inflammatory mediators, and mechanical damage from the persistent itch-scratch cycle.^10-13,15 These factors or their interplay may enhance the susceptibility of patients with AD to infections. 

Several studies conducted across various geographic regions examining the relationship between MC and AD have reported variable findings.^2,6,7,16-21 Published studies have reported a prevalence of AD in children with MC ranging from 13.2% to 43%.^2,6,7,16-21 Although some studies suggest a higher rate of atopy in patients with MC, not all research has confirmed this association.^16,21 Dohil et al² reported a greater number of MC lesions in children with AD than those without an atopic background. Silverberg²⁰ reported that in 10% (5/50) of children with MC, the onset of AD was triggered, and in 22% (11/50) MC was associated with flares of pre-existing AD.

In this study, we aimed to assess MC infection rates in children with AD, analyze the epidemiologic aspects and severity differences between atopic children with and without MC infection, and compare data from atopic and nonatopic children with MC.

Methods

In this retrospective cohort study, we analyzed the medical records of pediatric patients diagnosed with MC, AD, or both conditions at an outpatient dermatology practice in Netanya, HaSharon, Israel, from September 2013 to August 2022. Data were collected from the electronic medical records and included patient demographics, the clinical presentation of MC and/or AD at diagnosis, and the duration of both conditions. Only patients with complete data and at least 6 months of follow-up were included. Key epidemiologic characteristics assessed included patient sex, age at the initial visit, and age at the onset of MC and/or AD. Diagnoses of MC and AD were established through clinical examinations conducted by dermatologists. The clinical evaluation of AD encompassed the assessment of body surface area involvement (categorized as <5%, 5%-10%, or >10%). Atopic dermatitis severity was classified as mild, moderate, or severe using the validated Investigator Global Assessment Scale for Atopic Dermatitis.²² Clinical evaluation of MC included assessment of the number of lesions (categorized as ≤4, 5-9, or ≥10), presence of inflammatory lesions, and resolution times for individual lesions (categorized as <1 week, several weeks, or unknown), as well as the overall resolution time for all lesions (categorized as <6 months, 6-12 months, 13-18 months, or >18 months). The temporal relationship between the appearance of MC and AD also was assessed.

Statistical Analysis—Numbers and percentages were used for categorical variables. Continuous variables were represented by mean and standard deviation. Categorical variables were compared using the χ² test, and continuous variables between groups were compared using the Student t test. All statistical tests were 2-sided, with statistical significance defined as P≤.05. Statistical analysis was performed using SPSS software version 28 (IBM).

Results

Study Population—A total of 610 children were included in the study; 263 (43%) were female and 347 (57%) were male. The patients ranged in age from 4 months to 10 years, with a mean (SD) age of 4.87 (1.82) years. Five hundred fifty-six (91%) patients had AD, and 336 (55%) had MC. Within this cohort, 274 (45%) children had AD only, 54 (9%) had MC only, and 282 (46%) had both AD and MC. Regarding the temporal sequence, among the 282 children who had both AD and MC, AD preceded MC in 203 (72%) cases, both conditions were diagnosed concomitantly in 43 (15%) cases, and MC preceded AD in 36 (13%) cases. For cases in which the MC diagnosis followed the diagnosis of AD, the mean (SD) time between each diagnosis was 3.17 (1.5) years.

Comparison of Atopic and Nonatopic Children With MC—Although a higher proportion of males were diagnosed with MC (with or without concurrent AD), the differences in sex distribution between the 2 groups did not reach statistical significance. Among all children with MC, the majority (81.5% [274/336]) were aged 1 to 6 years at presentation. Patients with MC as their sole diagnosis had a similar mean age compared with those with concurrent AD. However, a detailed age subgroup analysis revealed a notable distinction: in the group with MC as the sole diagnosis, the majority (95% [51/54]) were younger than 7 years. In contrast, in the combined MC and AD group, MC manifested across a wider age range, with 21% (58/282) of patients being older than 7 years. In MC cases associated with AD, a notably higher lesion count and increased local inflammatory response were observed compared to those without AD. The time for complete resolution of all MC lesions was substantially prolonged in patients with comorbid AD. Specifically, 93% (50/54) of patients with MC without comorbid AD achieved full resolution within 1 year, whereas 52% (146/282) of patients with comorbid AD required more than 1 year for resolution (eTable 1). 

Comparison of Atopic Children With and Without MC—Sex, age distribution, and disease duration showed no differences between atopic patients with and without MC. Atopic patients with MC exhibited greater body surface area involvement and higher validated Investigator Global Assessment Scale for Atopic Dermatitis scores compared to atopic patients without MC (eTable 2).

Comment

This study examined the relationship between MC and AD in pediatric patients, revealing a notable correlation and yielding valuable epidemiologic and clinical insights. Consistent with previous research, our study demonstrated a high prevalence of AD in children with MC.^2,6,7,16-21 Previous studies indicated AD rates of 13% to 43% in pediatric patients with MC, whereas our study found a higher prevalence (84%), signifying a substantial majority of patients with MC in our cohort had AD. This discrepancy arises from factors such as demographic, genetic, and environmental differences, along with differences in access to medical care, referral practices, and diagnostic approaches across health care systems.¹⁴

Our temporal analysis of MC and AD diagnoses offers important insights. In the majority (72% [203/282]) of cases, the diagnosis of AD preceded MC, supporting previous research suggesting that the underlying pathophysiology of AD heightens susceptibility to MC.^15,17-20 Less frequently, MC was diagnosed before or concurrently with AD, indicating that MC may occasionally trigger or exacerbate milder or undiagnosed AD, as previously proposed.²⁰

A notable finding in our study was the expanded age range for MC onset in patients with AD, encompassing older age groups compared to patients with MC as their sole diagnosis, possibly due to persistent immune dysregulation. To the best of our knowledge, this specific observation has not been systematically reported or documented in prior cohort studies. Visible skin lesions of MC may have a psychological impact on patients, influencing self-consciousness and causing embarrassment and emotional distress. This may be more pronounced in older children, who are more aware of their appearance and social perceptions.^23-25 These considerations should play a role in the management of MC. 

Our study revealed that children with AD and MC displayed higher lesion counts, increased local inflammatory responses, and a more protracted resolution period compared to nonatopic children. In more than 50% of children with AD, MC took more than 1 year for resolution, whereas the majority of those without AD achieved resolution within 1 year. These findings may be attributed to AD-related immune dysregulation, influencing the natural course of MC. Consequently, it suggests that while nonatopic children with MC usually are managed through observation, atopic patients may benefit from an intervention-oriented approach. 

Comparing atopic patients with and without MC showed a heightened occurrence of severe and extensive AD among those with concurrent MC. Several factors could contribute to this observation. On one hand, there could be a direct association between the extent and severity of AD, leading to an elevated susceptibility to MC. Conversely, MC might exacerbate immunologic dysregulation and intensify skin inflammation in atopic individuals.²⁰ Additionally, itching related to both disorders may exacerbate inflammation and compromise the epidermal barrier, facilitating the spread of MC. This interplay suggests that each condition exacerbates the other in a self-reinforcing cycle. The importance of patient and caregiver education is underscored by recognizing these interactions. To manage both conditions effectively, health care providers should counsel patients and caregivers on maintaining proper skin care practices such as gentle cleansing with mild, fragrance-free products, regular moisturization, and avoidance of irritants, encourage them to avoid scratching, and recommend adopting an active treatment approach.

Our study had notable strengths. Firstly, a substantial sample size enhanced the statistical reliability of our findings. Additionally, valuable insights into the epidemiology and clinical aspects of AD and MC were obtained by utilizing real-world data from an outpatient dermatology practice. In our study, clinical evaluations covered body surface area involvement and disease severity for AD while also assessing lesion counts and the presence of inflammatory lesions for MC. This comprehensive approach facilitated a thorough analysis of both conditions. The extended data collection period not only allowed for observation of their clinical course and duration, but also enabled a detailed assessment of their interplay.

Our study also had several limitations. Primarily, its retrospective design relied on the accuracy and comprehensiveness of medical records, which may have introduced bias. The exclusion of some patients due to incomplete data further increased the potential for selection bias. Additionally, this study was conducted in a single outpatient dermatology practice in Israel, resulting in a study population composed predominantly of Jewish patients (94%), with a minority (6%) of Arab patients. Other ethnic groups, including Black, Asian, and Hispanic populations, were not represented. This reflects the country’s demographic composition rather than an intentional selection bias. However, the limited ethnic diversity reduces the generalizability of our findings. Differences in demographics, coding practices, health care utilization (eg, timeliness of seeking care, access to dermatology services), and treatment strategies also may impact the observed prevalence, clinical characteristics, and patient outcomes. Furthermore, while our study highlighted the potential advantages of a proactive treatment approach for atopic children with MC, it did not evaluate specific treatment protocols. Future research should aim to confirm the most efficacious therapeutic strategies for managing MC in atopic individuals and to include a more diverse population to better understand the applicability of findings across various ethnic groups.

Conclusion

Our study found a high prevalence of AD in children with MC and a strong bidirectional relationship between these conditions. Pediatric patients with AD display a broader age range for MC, greater lesion burden, increased local inflammatory responses, prolonged resolution times, and more extensive and severe AD.

Recognizing the interplay between MC and AD is crucial, highlighting the importance of health care providers educating patients and caregivers. Emphasizing skin hygiene, discouraging scratching, and implementing proactive treatment approaches can enhance the outcomes of both conditions. Further research into the underlying mechanisms of this association and effective therapeutic strategies for MC in atopic individuals is warranted.

Acknowledgments—The authors thank Zvi Segal, MD (Tel Hashomer, Israel) for his insightful contribution to the statistical analysis of the results. We would like to express our appreciation to the dedicated team of the dermatology practice in Netanya for the support throughout the performance of the study. Additionally, we thank all study participants and their parents for their participation and contribution to our research.

Molluscum contagiosum (MC), which is caused by a DNA virus in the Poxviridae family, is a common viral skin infection that primarily affects children.^1-4 The reported incidence and prevalence of MC exhibit notable geographic variation. Worldwide, annual incidence rates per 1000 individuals range from 3.1 to 25, and prevalence ranges from 0.27% to 34.6%.^2-7

Molluscum contagiosum is diagnosed clinically and typically manifests as smooth, flesh-colored papules measuring 2 to 6 mm in diameter with central umbilication. It can manifest as a single lesion or multiple clustered lesions, or in a disseminated pattern. The primary mode of transmission is through contact with skin, lesions, or contaminated personal items, or via self-inoculation. The majority of cases are asymptomatic, but in some patients, MC may be associated with pruritus, tenderness, erythema, or irritation. When present, secondary bacterial infections can cause localized inflammation and pain.^1,3,4 The pathogenesis hinges on MC virus replication within keratinocytes, disrupting cellular differentiation and keratinization. The virus persists in the host by influencing the immune response through various mechanisms, including interference with signaling pathways, apoptosis inhibition, and antigen presentation disruption.^3,4

Molluscum contagiosum typically follows a self-limiting trajectory, resolving over several months to 2 years.^3,4 The resolution timeframe is intricately linked to variables such as the patient’s immune profile, lesion burden, and treatment approach. For symptomatic lesions, a variety of treatment options have been described, including physical ablation (eg, cryotherapy, curettage) and topical agents such as potassium hydroxide, cantharidin, imiquimod, and salicylic acid.^3,4,8,9

Atopic dermatitis (AD) is a common chronic relapsing inflammatory skin disorder. In the United States, its prevalence ranges from 15% to 30% in children and from 2% to 10% in adults, with ongoing evidence of a growing global incidence.^10-14 While AD can emerge at any age, typical onset is during early childhood. The clinical manifestation of AD includes a spectrum of eczematous features, often accompanied by persistent itching. The pathogenesis is multifactorial, involving a complex interplay of genetic, immunologic, and environmental factors. Key contributors to this multifaceted process encompass a compromised epidermal barrier, alterations in the skin microbiome, and an immune dysregulation promoting a type 2 immune response. Epidermal barrier dysfunction can be attributed to various factors, including diminished ceramide production, altered lipid composition, the release of inflammatory mediators, and mechanical damage from the persistent itch-scratch cycle.^10-13,15 These factors or their interplay may enhance the susceptibility of patients with AD to infections. 

Several studies conducted across various geographic regions examining the relationship between MC and AD have reported variable findings.^2,6,7,16-21 Published studies have reported a prevalence of AD in children with MC ranging from 13.2% to 43%.^2,6,7,16-21 Although some studies suggest a higher rate of atopy in patients with MC, not all research has confirmed this association.^16,21 Dohil et al² reported a greater number of MC lesions in children with AD than those without an atopic background. Silverberg²⁰ reported that in 10% (5/50) of children with MC, the onset of AD was triggered, and in 22% (11/50) MC was associated with flares of pre-existing AD.

In this study, we aimed to assess MC infection rates in children with AD, analyze the epidemiologic aspects and severity differences between atopic children with and without MC infection, and compare data from atopic and nonatopic children with MC.

Methods

In this retrospective cohort study, we analyzed the medical records of pediatric patients diagnosed with MC, AD, or both conditions at an outpatient dermatology practice in Netanya, HaSharon, Israel, from September 2013 to August 2022. Data were collected from the electronic medical records and included patient demographics, the clinical presentation of MC and/or AD at diagnosis, and the duration of both conditions. Only patients with complete data and at least 6 months of follow-up were included. Key epidemiologic characteristics assessed included patient sex, age at the initial visit, and age at the onset of MC and/or AD. Diagnoses of MC and AD were established through clinical examinations conducted by dermatologists. The clinical evaluation of AD encompassed the assessment of body surface area involvement (categorized as <5%, 5%-10%, or >10%). Atopic dermatitis severity was classified as mild, moderate, or severe using the validated Investigator Global Assessment Scale for Atopic Dermatitis.²² Clinical evaluation of MC included assessment of the number of lesions (categorized as ≤4, 5-9, or ≥10), presence of inflammatory lesions, and resolution times for individual lesions (categorized as <1 week, several weeks, or unknown), as well as the overall resolution time for all lesions (categorized as <6 months, 6-12 months, 13-18 months, or >18 months). The temporal relationship between the appearance of MC and AD also was assessed.

Statistical Analysis—Numbers and percentages were used for categorical variables. Continuous variables were represented by mean and standard deviation. Categorical variables were compared using the χ² test, and continuous variables between groups were compared using the Student t test. All statistical tests were 2-sided, with statistical significance defined as P≤.05. Statistical analysis was performed using SPSS software version 28 (IBM).

Results

Study Population—A total of 610 children were included in the study; 263 (43%) were female and 347 (57%) were male. The patients ranged in age from 4 months to 10 years, with a mean (SD) age of 4.87 (1.82) years. Five hundred fifty-six (91%) patients had AD, and 336 (55%) had MC. Within this cohort, 274 (45%) children had AD only, 54 (9%) had MC only, and 282 (46%) had both AD and MC. Regarding the temporal sequence, among the 282 children who had both AD and MC, AD preceded MC in 203 (72%) cases, both conditions were diagnosed concomitantly in 43 (15%) cases, and MC preceded AD in 36 (13%) cases. For cases in which the MC diagnosis followed the diagnosis of AD, the mean (SD) time between each diagnosis was 3.17 (1.5) years.

Comparison of Atopic and Nonatopic Children With MC—Although a higher proportion of males were diagnosed with MC (with or without concurrent AD), the differences in sex distribution between the 2 groups did not reach statistical significance. Among all children with MC, the majority (81.5% [274/336]) were aged 1 to 6 years at presentation. Patients with MC as their sole diagnosis had a similar mean age compared with those with concurrent AD. However, a detailed age subgroup analysis revealed a notable distinction: in the group with MC as the sole diagnosis, the majority (95% [51/54]) were younger than 7 years. In contrast, in the combined MC and AD group, MC manifested across a wider age range, with 21% (58/282) of patients being older than 7 years. In MC cases associated with AD, a notably higher lesion count and increased local inflammatory response were observed compared to those without AD. The time for complete resolution of all MC lesions was substantially prolonged in patients with comorbid AD. Specifically, 93% (50/54) of patients with MC without comorbid AD achieved full resolution within 1 year, whereas 52% (146/282) of patients with comorbid AD required more than 1 year for resolution (eTable 1). 

Comparison of Atopic Children With and Without MC—Sex, age distribution, and disease duration showed no differences between atopic patients with and without MC. Atopic patients with MC exhibited greater body surface area involvement and higher validated Investigator Global Assessment Scale for Atopic Dermatitis scores compared to atopic patients without MC (eTable 2).

Comment

This study examined the relationship between MC and AD in pediatric patients, revealing a notable correlation and yielding valuable epidemiologic and clinical insights. Consistent with previous research, our study demonstrated a high prevalence of AD in children with MC.^2,6,7,16-21 Previous studies indicated AD rates of 13% to 43% in pediatric patients with MC, whereas our study found a higher prevalence (84%), signifying a substantial majority of patients with MC in our cohort had AD. This discrepancy arises from factors such as demographic, genetic, and environmental differences, along with differences in access to medical care, referral practices, and diagnostic approaches across health care systems.¹⁴

Our temporal analysis of MC and AD diagnoses offers important insights. In the majority (72% [203/282]) of cases, the diagnosis of AD preceded MC, supporting previous research suggesting that the underlying pathophysiology of AD heightens susceptibility to MC.^15,17-20 Less frequently, MC was diagnosed before or concurrently with AD, indicating that MC may occasionally trigger or exacerbate milder or undiagnosed AD, as previously proposed.²⁰

A notable finding in our study was the expanded age range for MC onset in patients with AD, encompassing older age groups compared to patients with MC as their sole diagnosis, possibly due to persistent immune dysregulation. To the best of our knowledge, this specific observation has not been systematically reported or documented in prior cohort studies. Visible skin lesions of MC may have a psychological impact on patients, influencing self-consciousness and causing embarrassment and emotional distress. This may be more pronounced in older children, who are more aware of their appearance and social perceptions.^23-25 These considerations should play a role in the management of MC. 

Our study revealed that children with AD and MC displayed higher lesion counts, increased local inflammatory responses, and a more protracted resolution period compared to nonatopic children. In more than 50% of children with AD, MC took more than 1 year for resolution, whereas the majority of those without AD achieved resolution within 1 year. These findings may be attributed to AD-related immune dysregulation, influencing the natural course of MC. Consequently, it suggests that while nonatopic children with MC usually are managed through observation, atopic patients may benefit from an intervention-oriented approach. 

Comparing atopic patients with and without MC showed a heightened occurrence of severe and extensive AD among those with concurrent MC. Several factors could contribute to this observation. On one hand, there could be a direct association between the extent and severity of AD, leading to an elevated susceptibility to MC. Conversely, MC might exacerbate immunologic dysregulation and intensify skin inflammation in atopic individuals.²⁰ Additionally, itching related to both disorders may exacerbate inflammation and compromise the epidermal barrier, facilitating the spread of MC. This interplay suggests that each condition exacerbates the other in a self-reinforcing cycle. The importance of patient and caregiver education is underscored by recognizing these interactions. To manage both conditions effectively, health care providers should counsel patients and caregivers on maintaining proper skin care practices such as gentle cleansing with mild, fragrance-free products, regular moisturization, and avoidance of irritants, encourage them to avoid scratching, and recommend adopting an active treatment approach.

Our study had notable strengths. Firstly, a substantial sample size enhanced the statistical reliability of our findings. Additionally, valuable insights into the epidemiology and clinical aspects of AD and MC were obtained by utilizing real-world data from an outpatient dermatology practice. In our study, clinical evaluations covered body surface area involvement and disease severity for AD while also assessing lesion counts and the presence of inflammatory lesions for MC. This comprehensive approach facilitated a thorough analysis of both conditions. The extended data collection period not only allowed for observation of their clinical course and duration, but also enabled a detailed assessment of their interplay.

Our study also had several limitations. Primarily, its retrospective design relied on the accuracy and comprehensiveness of medical records, which may have introduced bias. The exclusion of some patients due to incomplete data further increased the potential for selection bias. Additionally, this study was conducted in a single outpatient dermatology practice in Israel, resulting in a study population composed predominantly of Jewish patients (94%), with a minority (6%) of Arab patients. Other ethnic groups, including Black, Asian, and Hispanic populations, were not represented. This reflects the country’s demographic composition rather than an intentional selection bias. However, the limited ethnic diversity reduces the generalizability of our findings. Differences in demographics, coding practices, health care utilization (eg, timeliness of seeking care, access to dermatology services), and treatment strategies also may impact the observed prevalence, clinical characteristics, and patient outcomes. Furthermore, while our study highlighted the potential advantages of a proactive treatment approach for atopic children with MC, it did not evaluate specific treatment protocols. Future research should aim to confirm the most efficacious therapeutic strategies for managing MC in atopic individuals and to include a more diverse population to better understand the applicability of findings across various ethnic groups.

Conclusion

Our study found a high prevalence of AD in children with MC and a strong bidirectional relationship between these conditions. Pediatric patients with AD display a broader age range for MC, greater lesion burden, increased local inflammatory responses, prolonged resolution times, and more extensive and severe AD.

Recognizing the interplay between MC and AD is crucial, highlighting the importance of health care providers educating patients and caregivers. Emphasizing skin hygiene, discouraging scratching, and implementing proactive treatment approaches can enhance the outcomes of both conditions. Further research into the underlying mechanisms of this association and effective therapeutic strategies for MC in atopic individuals is warranted.

Acknowledgments—The authors thank Zvi Segal, MD (Tel Hashomer, Israel) for his insightful contribution to the statistical analysis of the results. We would like to express our appreciation to the dedicated team of the dermatology practice in Netanya for the support throughout the performance of the study. Additionally, we thank all study participants and their parents for their participation and contribution to our research.

To the Editor:

The popularity of the social media platform TikTok, which is known for its short-form videos, has surged in recent years. Viral videos demonstrating skin care routines reach millions of viewers,¹ showcasing specific products, detailing beauty regimens, and setting fads that many users eagerly follow. These trends often influence consumer behavior—in 2023, viral videos using the tag #TikTokMadeMeBuy lead to a 14% growth in the sale of skin care products.² However, they also encourage purchasing decisions that may escalate environmental waste through plastic packaging and single-use products. In this study, we analyzed videos on TikTok to assess the environmental impact of trending skin care routines. By examining the types of products promoted, their packaging, and the frequency with which they appear in viral content, we aimed to investigate how these trends, which may be imitated by users, impact the environment.

A search of TikTok videos using #skincareroutine was conducted on June 21, 2024. Sponsored content, non–English language videos, videos without demonstrated skin care routines, and videos showing makeup routines were excluded from our analysis. Data collected from each video included username, date posted, number of likes, total number of skin care products used, number of single-use skin care products used, average amount of product used, number of skin care applicators used, and number of single-use applicators used. Single-use items, defined as those intended for one-time use and subsequent disposal, were identified visually by packaging, manufacturer intent, and common consumer usage patterns. The amount of product used per application was graded on a scale of 1 to 3 (1=pea-sized amount or less; 2=single full pump/spray; 3=multiple pumps/sprays). Videos were categorized as personal (ie, skin care routine walk-throughs by the creator) or autonomous sensory meridian response (ASMR)(focused on product sounds and aesthetics).³ A Mann-Whitney U test was utilized to statistically compare the 2 groups. Statistical analysis was performed using Microsoft Excel (α=0.05). 

A total of 50 videos met the inclusion criteria and were included in the analysis. The average number of likes per video was 499,696.15, with skin care routines featuring an average of 6.4 unique products (Table). There was a weak positive correlation (r=0.1809) between the number of skin care products used and the number of likes. A total of 320 products were used across the videos, 23 of which were single-use (7.2%).On average, single-use skin care items were used 0.46 times per routine, comprising a mean 7.99% of total products per video. The average score for the amount of product used per application was 2.18. There was no difference in personal vs ASMR videos with regard to the total number of skin care products used or the average amount of product used per application (P>.05). Thirty-three (70.2%) of the 47 applicators used across all videos were single-use. An average of 0.94 applicators per routine were utilized, with a mean 68.83% being single-use applicators. Common single-use products were toner wipes and eye patches, and single-use applicators included cotton pads and plastic spatulas. 

Our findings indicated a prevalence of multiple products and large amount of product used in trending skin care routines, suggesting a shift toward multistep skin care. This implies a high rate of product consumption that may accelerate the carbon footprint associated with skin care products,³ which could contribute to climate change and environmental degradation. Consumers also may feel compelled to purchase and discard numerous partially used products in order to keep up with the latest trends, exacerbating the environmental impact. Furthermore, the utilization of single-use products and applicators contributes to increased plastic waste, pollution, and resource depletion. Single-use items often are difficult to recycle due to their mixed materials and small size,^4,5 and therefore they can accumulate in landfills and oceans. This impact can be mitigated by switching to reusable applicators, refillable packaging, and biodegradable materials. 

The substantial average number of likes per video indicates high engagement with skin care content among TikTok users. The continued popularity of complex multi­step skin care routines, despite a weak correlation between the number of skin care products used and the number of likes per video, likely stems from factors such as aesthetic appeal, ASMR effects, and creators’ established followings, which may drive user engagement to contribute to unsustainable consumption patterns. Factors such as presentation style, aesthetics, or creators’ pre-existing online following may have a major impact on how well a video performs on TikTok. The similarity between personal and ASMR videos, particularly in the number of products used and the amount applied, suggests that both formats employ common approaches to meet audience expectations and align with promotional trends, relying more on sensory and aesthetic strategies than substantive differences in skin care routines.

Our use of only one tag in our search as well as the subjective quantity scale limits the generalizability of these findings to broader TikTok skin care content.

Overall, our study underscores the role of brands and social media influencers in skin care education and promotion of sustainable practices. The extensive number of products used and generous application of each product in skin care routines demonstrated in TikTok videos may mislead viewers into believing that using more product improves outcomes, when often, less is more. We recommend that dermatologists counsel patients about informed skin care regimens that prioritize individual needs over social media fads.

To the Editor:

The popularity of the social media platform TikTok, which is known for its short-form videos, has surged in recent years. Viral videos demonstrating skin care routines reach millions of viewers,¹ showcasing specific products, detailing beauty regimens, and setting fads that many users eagerly follow. These trends often influence consumer behavior—in 2023, viral videos using the tag #TikTokMadeMeBuy lead to a 14% growth in the sale of skin care products.² However, they also encourage purchasing decisions that may escalate environmental waste through plastic packaging and single-use products. In this study, we analyzed videos on TikTok to assess the environmental impact of trending skin care routines. By examining the types of products promoted, their packaging, and the frequency with which they appear in viral content, we aimed to investigate how these trends, which may be imitated by users, impact the environment.

A search of TikTok videos using #skincareroutine was conducted on June 21, 2024. Sponsored content, non–English language videos, videos without demonstrated skin care routines, and videos showing makeup routines were excluded from our analysis. Data collected from each video included username, date posted, number of likes, total number of skin care products used, number of single-use skin care products used, average amount of product used, number of skin care applicators used, and number of single-use applicators used. Single-use items, defined as those intended for one-time use and subsequent disposal, were identified visually by packaging, manufacturer intent, and common consumer usage patterns. The amount of product used per application was graded on a scale of 1 to 3 (1=pea-sized amount or less; 2=single full pump/spray; 3=multiple pumps/sprays). Videos were categorized as personal (ie, skin care routine walk-throughs by the creator) or autonomous sensory meridian response (ASMR)(focused on product sounds and aesthetics).³ A Mann-Whitney U test was utilized to statistically compare the 2 groups. Statistical analysis was performed using Microsoft Excel (α=0.05). 

A total of 50 videos met the inclusion criteria and were included in the analysis. The average number of likes per video was 499,696.15, with skin care routines featuring an average of 6.4 unique products (Table). There was a weak positive correlation (r=0.1809) between the number of skin care products used and the number of likes. A total of 320 products were used across the videos, 23 of which were single-use (7.2%).On average, single-use skin care items were used 0.46 times per routine, comprising a mean 7.99% of total products per video. The average score for the amount of product used per application was 2.18. There was no difference in personal vs ASMR videos with regard to the total number of skin care products used or the average amount of product used per application (P>.05). Thirty-three (70.2%) of the 47 applicators used across all videos were single-use. An average of 0.94 applicators per routine were utilized, with a mean 68.83% being single-use applicators. Common single-use products were toner wipes and eye patches, and single-use applicators included cotton pads and plastic spatulas. 

Our findings indicated a prevalence of multiple products and large amount of product used in trending skin care routines, suggesting a shift toward multistep skin care. This implies a high rate of product consumption that may accelerate the carbon footprint associated with skin care products,³ which could contribute to climate change and environmental degradation. Consumers also may feel compelled to purchase and discard numerous partially used products in order to keep up with the latest trends, exacerbating the environmental impact. Furthermore, the utilization of single-use products and applicators contributes to increased plastic waste, pollution, and resource depletion. Single-use items often are difficult to recycle due to their mixed materials and small size,^4,5 and therefore they can accumulate in landfills and oceans. This impact can be mitigated by switching to reusable applicators, refillable packaging, and biodegradable materials. 

The substantial average number of likes per video indicates high engagement with skin care content among TikTok users. The continued popularity of complex multi­step skin care routines, despite a weak correlation between the number of skin care products used and the number of likes per video, likely stems from factors such as aesthetic appeal, ASMR effects, and creators’ established followings, which may drive user engagement to contribute to unsustainable consumption patterns. Factors such as presentation style, aesthetics, or creators’ pre-existing online following may have a major impact on how well a video performs on TikTok. The similarity between personal and ASMR videos, particularly in the number of products used and the amount applied, suggests that both formats employ common approaches to meet audience expectations and align with promotional trends, relying more on sensory and aesthetic strategies than substantive differences in skin care routines.

Our use of only one tag in our search as well as the subjective quantity scale limits the generalizability of these findings to broader TikTok skin care content.

Overall, our study underscores the role of brands and social media influencers in skin care education and promotion of sustainable practices. The extensive number of products used and generous application of each product in skin care routines demonstrated in TikTok videos may mislead viewers into believing that using more product improves outcomes, when often, less is more. We recommend that dermatologists counsel patients about informed skin care regimens that prioritize individual needs over social media fads.

To the Editor:

The popularity of the social media platform TikTok, which is known for its short-form videos, has surged in recent years. Viral videos demonstrating skin care routines reach millions of viewers,¹ showcasing specific products, detailing beauty regimens, and setting fads that many users eagerly follow. These trends often influence consumer behavior—in 2023, viral videos using the tag #TikTokMadeMeBuy lead to a 14% growth in the sale of skin care products.² However, they also encourage purchasing decisions that may escalate environmental waste through plastic packaging and single-use products. In this study, we analyzed videos on TikTok to assess the environmental impact of trending skin care routines. By examining the types of products promoted, their packaging, and the frequency with which they appear in viral content, we aimed to investigate how these trends, which may be imitated by users, impact the environment.

A search of TikTok videos using #skincareroutine was conducted on June 21, 2024. Sponsored content, non–English language videos, videos without demonstrated skin care routines, and videos showing makeup routines were excluded from our analysis. Data collected from each video included username, date posted, number of likes, total number of skin care products used, number of single-use skin care products used, average amount of product used, number of skin care applicators used, and number of single-use applicators used. Single-use items, defined as those intended for one-time use and subsequent disposal, were identified visually by packaging, manufacturer intent, and common consumer usage patterns. The amount of product used per application was graded on a scale of 1 to 3 (1=pea-sized amount or less; 2=single full pump/spray; 3=multiple pumps/sprays). Videos were categorized as personal (ie, skin care routine walk-throughs by the creator) or autonomous sensory meridian response (ASMR)(focused on product sounds and aesthetics).³ A Mann-Whitney U test was utilized to statistically compare the 2 groups. Statistical analysis was performed using Microsoft Excel (α=0.05). 

A total of 50 videos met the inclusion criteria and were included in the analysis. The average number of likes per video was 499,696.15, with skin care routines featuring an average of 6.4 unique products (Table). There was a weak positive correlation (r=0.1809) between the number of skin care products used and the number of likes. A total of 320 products were used across the videos, 23 of which were single-use (7.2%).On average, single-use skin care items were used 0.46 times per routine, comprising a mean 7.99% of total products per video. The average score for the amount of product used per application was 2.18. There was no difference in personal vs ASMR videos with regard to the total number of skin care products used or the average amount of product used per application (P>.05). Thirty-three (70.2%) of the 47 applicators used across all videos were single-use. An average of 0.94 applicators per routine were utilized, with a mean 68.83% being single-use applicators. Common single-use products were toner wipes and eye patches, and single-use applicators included cotton pads and plastic spatulas. 

Our findings indicated a prevalence of multiple products and large amount of product used in trending skin care routines, suggesting a shift toward multistep skin care. This implies a high rate of product consumption that may accelerate the carbon footprint associated with skin care products,³ which could contribute to climate change and environmental degradation. Consumers also may feel compelled to purchase and discard numerous partially used products in order to keep up with the latest trends, exacerbating the environmental impact. Furthermore, the utilization of single-use products and applicators contributes to increased plastic waste, pollution, and resource depletion. Single-use items often are difficult to recycle due to their mixed materials and small size,^4,5 and therefore they can accumulate in landfills and oceans. This impact can be mitigated by switching to reusable applicators, refillable packaging, and biodegradable materials. 

The substantial average number of likes per video indicates high engagement with skin care content among TikTok users. The continued popularity of complex multi­step skin care routines, despite a weak correlation between the number of skin care products used and the number of likes per video, likely stems from factors such as aesthetic appeal, ASMR effects, and creators’ established followings, which may drive user engagement to contribute to unsustainable consumption patterns. Factors such as presentation style, aesthetics, or creators’ pre-existing online following may have a major impact on how well a video performs on TikTok. The similarity between personal and ASMR videos, particularly in the number of products used and the amount applied, suggests that both formats employ common approaches to meet audience expectations and align with promotional trends, relying more on sensory and aesthetic strategies than substantive differences in skin care routines.

Our use of only one tag in our search as well as the subjective quantity scale limits the generalizability of these findings to broader TikTok skin care content.

Overall, our study underscores the role of brands and social media influencers in skin care education and promotion of sustainable practices. The extensive number of products used and generous application of each product in skin care routines demonstrated in TikTok videos may mislead viewers into believing that using more product improves outcomes, when often, less is more. We recommend that dermatologists counsel patients about informed skin care regimens that prioritize individual needs over social media fads.

Purpose

Skin adnexal tumors (SAT) include a group of benign and malignant appendageal tumors that arise from hair follicles, sebaceous glands, or sweat glands. They typically appear as small, painless bumps or nodules on the skin, and are more common in men compared to women. The 5-year overall SAT survival rate ranges from 74-90%. To better understand the differences in survival outcomes based on subtypes of SAT, the National Cancer Database (NCDB) was analyzed.

Methods

A retrospective cohort study of 11,627 patients with histologically confirmed SAT between 2004 and 2021 was conducted across 1,500 Commission on Cancer facilities located in the US and Puerto Rico. Demographic factors such as sex, age, and race were analyzed using Pearson Chi-squared tests, and survival outcomes were analyzed by Kaplan- Meier survival analysis. P value < 0.05 was considered statistically significant.

Results

Most patients with SAT were male (57.3%). The average age at diagnosis was 65.9 (SD=14.4, range 0-90). Of the patient sample, 87.2% were White, 7.6% Black, 2.5% Asian, and 2.7% other. Several subtypes disproportionately affected Black individuals, including apocrine adenocarcinoma (15.7%) and hidradenocarcinoma (13.6%). The estimated 5-year survival of SAT was 74.9% with an overall survival of 135.8 months (SE=1.1). Sebaceous carcinoma (which accounts for 41.8% of all cases) had the lowest average survival time of 119.6 months (SE=1.8), while digital papillary adenocarcinoma had the highest survival at around 183.5 months (SE=4.6).

Conclusions

This study supports a higher frequency of SAT among men. While White patients were more likely to get SAT overall, including the most common sebaceous carcinoma, Black race were associated with higher frequency of rarer subtypes. The average age of diagnosis of SAT mimics other non-melanoma skin cancers, but has a lower overall survival rate. Future studies should consider other risk factors that may be impacting the differences in survival outcomes to guide treatment and address health disparities among the various subtypes.

Purpose

Skin adnexal tumors (SAT) include a group of benign and malignant appendageal tumors that arise from hair follicles, sebaceous glands, or sweat glands. They typically appear as small, painless bumps or nodules on the skin, and are more common in men compared to women. The 5-year overall SAT survival rate ranges from 74-90%. To better understand the differences in survival outcomes based on subtypes of SAT, the National Cancer Database (NCDB) was analyzed.

Methods

A retrospective cohort study of 11,627 patients with histologically confirmed SAT between 2004 and 2021 was conducted across 1,500 Commission on Cancer facilities located in the US and Puerto Rico. Demographic factors such as sex, age, and race were analyzed using Pearson Chi-squared tests, and survival outcomes were analyzed by Kaplan- Meier survival analysis. P value < 0.05 was considered statistically significant.

Results

Most patients with SAT were male (57.3%). The average age at diagnosis was 65.9 (SD=14.4, range 0-90). Of the patient sample, 87.2% were White, 7.6% Black, 2.5% Asian, and 2.7% other. Several subtypes disproportionately affected Black individuals, including apocrine adenocarcinoma (15.7%) and hidradenocarcinoma (13.6%). The estimated 5-year survival of SAT was 74.9% with an overall survival of 135.8 months (SE=1.1). Sebaceous carcinoma (which accounts for 41.8% of all cases) had the lowest average survival time of 119.6 months (SE=1.8), while digital papillary adenocarcinoma had the highest survival at around 183.5 months (SE=4.6).

Conclusions

This study supports a higher frequency of SAT among men. While White patients were more likely to get SAT overall, including the most common sebaceous carcinoma, Black race were associated with higher frequency of rarer subtypes. The average age of diagnosis of SAT mimics other non-melanoma skin cancers, but has a lower overall survival rate. Future studies should consider other risk factors that may be impacting the differences in survival outcomes to guide treatment and address health disparities among the various subtypes.

Purpose

Skin adnexal tumors (SAT) include a group of benign and malignant appendageal tumors that arise from hair follicles, sebaceous glands, or sweat glands. They typically appear as small, painless bumps or nodules on the skin, and are more common in men compared to women. The 5-year overall SAT survival rate ranges from 74-90%. To better understand the differences in survival outcomes based on subtypes of SAT, the National Cancer Database (NCDB) was analyzed.

Methods

A retrospective cohort study of 11,627 patients with histologically confirmed SAT between 2004 and 2021 was conducted across 1,500 Commission on Cancer facilities located in the US and Puerto Rico. Demographic factors such as sex, age, and race were analyzed using Pearson Chi-squared tests, and survival outcomes were analyzed by Kaplan- Meier survival analysis. P value < 0.05 was considered statistically significant.

Results

Most patients with SAT were male (57.3%). The average age at diagnosis was 65.9 (SD=14.4, range 0-90). Of the patient sample, 87.2% were White, 7.6% Black, 2.5% Asian, and 2.7% other. Several subtypes disproportionately affected Black individuals, including apocrine adenocarcinoma (15.7%) and hidradenocarcinoma (13.6%). The estimated 5-year survival of SAT was 74.9% with an overall survival of 135.8 months (SE=1.1). Sebaceous carcinoma (which accounts for 41.8% of all cases) had the lowest average survival time of 119.6 months (SE=1.8), while digital papillary adenocarcinoma had the highest survival at around 183.5 months (SE=4.6).

Conclusions

This study supports a higher frequency of SAT among men. While White patients were more likely to get SAT overall, including the most common sebaceous carcinoma, Black race were associated with higher frequency of rarer subtypes. The average age of diagnosis of SAT mimics other non-melanoma skin cancers, but has a lower overall survival rate. Future studies should consider other risk factors that may be impacting the differences in survival outcomes to guide treatment and address health disparities among the various subtypes.

Background

Studies show that early referral to Specialty Palliative Care (SPC) can improve patient- reported outcomes among Veterans with cancer; quality metrics include referral within 8 weeks of an advanced cancer diagnosis. In this study, we explored timeliness of specialty referrals and compared various factors.

Methods

We identified our cohort using Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). Eligibility criteria included active or history of cancer—using a peer-reviewed, in-house list of ICD-9 and ICD-10 codes—between 2013-2023. We stratified our cohort of Veterans using factors including cancer stage, rurality, and care assessment needs (CAN) scores. We performed survival analyses to look at time to SPC from initial diagnosis and peak CAN score. Predictors of utilization were evaluated using multinomial regression and Cox proportional hazards models through R.

Results

Using CDW’s oncology domain, we identified 475,775 Veterans. 28% received SPC. Most received it near the end of their life as evidenced by the mortality rates (79.5%) in the early period following SPC consultation. Median time to SPC was 515 days. There was a significant difference in utilization rates between urban and rural Veterans (Wilcoxon W-statistic = 2.31E+10, p < 0.001). Peak CAN scores ranged from 0 to 0.81, median peak of 0.057 and interquartile range of 0.1. Multinomial regression model indicated statistically significant associations of advanced cancer (Stages 3 and 4) with timing of SPC. Stage 4 cancer showed the strongest association with receipt of palliative care within 60 days of initial diagnosis (OR 4.8, 95% CI: 4.69-4.93, p < 0.001), suggesting higher stage disease increases the likelihood of palliative care referral and accelerates the timing of these referrals.

Conclusions

We found Veterans received SPC from a broad range of peak CAN scores (0 to 0.81), suggesting that absolute CAN scores may not be clinically actionable indicators but perhaps indicative of changes in condition warranting referral. Stage IV cancer at diagnosis was associated with early SPC. The significant differences in utilization rates between urban and rural patients highlight potential access barriers that should be addressed.

Background

Studies show that early referral to Specialty Palliative Care (SPC) can improve patient- reported outcomes among Veterans with cancer; quality metrics include referral within 8 weeks of an advanced cancer diagnosis. In this study, we explored timeliness of specialty referrals and compared various factors.

Methods

We identified our cohort using Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). Eligibility criteria included active or history of cancer—using a peer-reviewed, in-house list of ICD-9 and ICD-10 codes—between 2013-2023. We stratified our cohort of Veterans using factors including cancer stage, rurality, and care assessment needs (CAN) scores. We performed survival analyses to look at time to SPC from initial diagnosis and peak CAN score. Predictors of utilization were evaluated using multinomial regression and Cox proportional hazards models through R.

Results

Using CDW’s oncology domain, we identified 475,775 Veterans. 28% received SPC. Most received it near the end of their life as evidenced by the mortality rates (79.5%) in the early period following SPC consultation. Median time to SPC was 515 days. There was a significant difference in utilization rates between urban and rural Veterans (Wilcoxon W-statistic = 2.31E+10, p < 0.001). Peak CAN scores ranged from 0 to 0.81, median peak of 0.057 and interquartile range of 0.1. Multinomial regression model indicated statistically significant associations of advanced cancer (Stages 3 and 4) with timing of SPC. Stage 4 cancer showed the strongest association with receipt of palliative care within 60 days of initial diagnosis (OR 4.8, 95% CI: 4.69-4.93, p < 0.001), suggesting higher stage disease increases the likelihood of palliative care referral and accelerates the timing of these referrals.

Conclusions

We found Veterans received SPC from a broad range of peak CAN scores (0 to 0.81), suggesting that absolute CAN scores may not be clinically actionable indicators but perhaps indicative of changes in condition warranting referral. Stage IV cancer at diagnosis was associated with early SPC. The significant differences in utilization rates between urban and rural patients highlight potential access barriers that should be addressed.

Background

Studies show that early referral to Specialty Palliative Care (SPC) can improve patient- reported outcomes among Veterans with cancer; quality metrics include referral within 8 weeks of an advanced cancer diagnosis. In this study, we explored timeliness of specialty referrals and compared various factors.

Methods

We identified our cohort using Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). Eligibility criteria included active or history of cancer—using a peer-reviewed, in-house list of ICD-9 and ICD-10 codes—between 2013-2023. We stratified our cohort of Veterans using factors including cancer stage, rurality, and care assessment needs (CAN) scores. We performed survival analyses to look at time to SPC from initial diagnosis and peak CAN score. Predictors of utilization were evaluated using multinomial regression and Cox proportional hazards models through R.

Results

Using CDW’s oncology domain, we identified 475,775 Veterans. 28% received SPC. Most received it near the end of their life as evidenced by the mortality rates (79.5%) in the early period following SPC consultation. Median time to SPC was 515 days. There was a significant difference in utilization rates between urban and rural Veterans (Wilcoxon W-statistic = 2.31E+10, p < 0.001). Peak CAN scores ranged from 0 to 0.81, median peak of 0.057 and interquartile range of 0.1. Multinomial regression model indicated statistically significant associations of advanced cancer (Stages 3 and 4) with timing of SPC. Stage 4 cancer showed the strongest association with receipt of palliative care within 60 days of initial diagnosis (OR 4.8, 95% CI: 4.69-4.93, p < 0.001), suggesting higher stage disease increases the likelihood of palliative care referral and accelerates the timing of these referrals.

Conclusions

We found Veterans received SPC from a broad range of peak CAN scores (0 to 0.81), suggesting that absolute CAN scores may not be clinically actionable indicators but perhaps indicative of changes in condition warranting referral. Stage IV cancer at diagnosis was associated with early SPC. The significant differences in utilization rates between urban and rural patients highlight potential access barriers that should be addressed.

Background

To close the food insecurity gap by providing food assistance and increasing opportunities for screening in Veterans receiving cancer treatment at a VA outpatient cancer clinic. Food Insecurity is associated with chronic disease such as cancer given insufficient access to nutritious foods leading to nutritional deficiencies and worsening health outcomes. The rates of food insecurity among Veterans revealed 28% of female veterans and 16% overall in male Veterans were faced with limited or uncertain access to adequate food.

Methods

A pivotal distress screening occurs at time of education consult or cycle 1 day 1 of antineoplastic therapy. A positive screening for any practical concern generates a discussion about food insecurity. A positive distress screen triggers an oncology social work referral to complete a systematic screening assessing circumstances and offering resources for needs (ACORN).

Results

Root cause analysis uncovered 24% of Veterans with cancer screened positive for food insecurity in the 9E oncology outpatient clinic. Post-implementation of robust screenings and conversation initiatives identified 36 unique Veterans who received 251 meals from July to December 2024.

Sustainability/Scalability

Prospective screening of Veterans at the time of a cancer diagnosis and ongoing screening during cancer treatment is the first step toward uncovering food insecurity and addressing this social determinate of health. A standard operating procedure following VA guidance and distress management guidelines should be updated as required. Oversight of the cancer leadership team annually evaluates the distress process, and the findings are reported to the cancer committee.

Conclusions

Uncovering food insecurity in Veterans at time of diagnosis and during cancer treatment is critical to optimize treatment outcomes. A systematic and robust screening standard operating procedure is key to implement. Veterans are a unique population with a spectrum of socioeconomic needs. Case management conferences or weekly huddles to discuss the Veteran’s needs will ensure food insecurity is addressed. Collection and analysis of screening data will highlight a program’s food insecurity need and supports community partnerships to available food resources and the opportunity to create a cancer outpatient clinic food hub for Veterans receiving cancer treatment.

Background

To close the food insecurity gap by providing food assistance and increasing opportunities for screening in Veterans receiving cancer treatment at a VA outpatient cancer clinic. Food Insecurity is associated with chronic disease such as cancer given insufficient access to nutritious foods leading to nutritional deficiencies and worsening health outcomes. The rates of food insecurity among Veterans revealed 28% of female veterans and 16% overall in male Veterans were faced with limited or uncertain access to adequate food.

Methods

A pivotal distress screening occurs at time of education consult or cycle 1 day 1 of antineoplastic therapy. A positive screening for any practical concern generates a discussion about food insecurity. A positive distress screen triggers an oncology social work referral to complete a systematic screening assessing circumstances and offering resources for needs (ACORN).

Results

Root cause analysis uncovered 24% of Veterans with cancer screened positive for food insecurity in the 9E oncology outpatient clinic. Post-implementation of robust screenings and conversation initiatives identified 36 unique Veterans who received 251 meals from July to December 2024.

Sustainability/Scalability

Prospective screening of Veterans at the time of a cancer diagnosis and ongoing screening during cancer treatment is the first step toward uncovering food insecurity and addressing this social determinate of health. A standard operating procedure following VA guidance and distress management guidelines should be updated as required. Oversight of the cancer leadership team annually evaluates the distress process, and the findings are reported to the cancer committee.

Conclusions

Uncovering food insecurity in Veterans at time of diagnosis and during cancer treatment is critical to optimize treatment outcomes. A systematic and robust screening standard operating procedure is key to implement. Veterans are a unique population with a spectrum of socioeconomic needs. Case management conferences or weekly huddles to discuss the Veteran’s needs will ensure food insecurity is addressed. Collection and analysis of screening data will highlight a program’s food insecurity need and supports community partnerships to available food resources and the opportunity to create a cancer outpatient clinic food hub for Veterans receiving cancer treatment.

Background

To close the food insecurity gap by providing food assistance and increasing opportunities for screening in Veterans receiving cancer treatment at a VA outpatient cancer clinic. Food Insecurity is associated with chronic disease such as cancer given insufficient access to nutritious foods leading to nutritional deficiencies and worsening health outcomes. The rates of food insecurity among Veterans revealed 28% of female veterans and 16% overall in male Veterans were faced with limited or uncertain access to adequate food.

Methods

A pivotal distress screening occurs at time of education consult or cycle 1 day 1 of antineoplastic therapy. A positive screening for any practical concern generates a discussion about food insecurity. A positive distress screen triggers an oncology social work referral to complete a systematic screening assessing circumstances and offering resources for needs (ACORN).

Results

Root cause analysis uncovered 24% of Veterans with cancer screened positive for food insecurity in the 9E oncology outpatient clinic. Post-implementation of robust screenings and conversation initiatives identified 36 unique Veterans who received 251 meals from July to December 2024.

Sustainability/Scalability

Prospective screening of Veterans at the time of a cancer diagnosis and ongoing screening during cancer treatment is the first step toward uncovering food insecurity and addressing this social determinate of health. A standard operating procedure following VA guidance and distress management guidelines should be updated as required. Oversight of the cancer leadership team annually evaluates the distress process, and the findings are reported to the cancer committee.

Conclusions

Uncovering food insecurity in Veterans at time of diagnosis and during cancer treatment is critical to optimize treatment outcomes. A systematic and robust screening standard operating procedure is key to implement. Veterans are a unique population with a spectrum of socioeconomic needs. Case management conferences or weekly huddles to discuss the Veteran’s needs will ensure food insecurity is addressed. Collection and analysis of screening data will highlight a program’s food insecurity need and supports community partnerships to available food resources and the opportunity to create a cancer outpatient clinic food hub for Veterans receiving cancer treatment.

Background

Prostate cancer is the most common non-cutaneous malignancy at the Veterans Health Administration (VHA) and every year approximately 15,000 Veterans are diagnosed and treated. Many advanced prostate cancer cases harbor genetic mutations that significantly impact prognosis, treatment decisions, and familial screening. In February 2021, the Prostate Cancer Molecular Testing Pathway (PCMTP) flow map was developed to increase appropriate genetic testing.

Methods

VHA initiated the Oncology Clinical Pathways (OCP) program to standardize cancer care for Veterans. The PCMTP was developed by a multidisciplinary team that created interactive templates within the Computerized Patient Record System (CPRS), to facilitate identification of eligible Veterans for germline and comprehensive genomic profiling (CGP). Clinical decision-making for these tests is documented as Health Factors (HF), in CPRS, allowing for assessment of pathway adherence and overall uptake.

Results

The PCMTP has achieved success, as there is over 90% compliance to molecular testing among participating Veterans which exceeds the pathway benchmark of 80%. PCMTP has been utilized at 88 VA sites, by over 700 distinct VA providers, with over 7,000 Veterans participating. This implementation has yielded over 19,200 Health Factors within CPRS.

Conclusions

The PCMTP has markedly improved the documentation and application of germline and CGP testing among Veterans diagnosed with prostate cancer. By facilitating genomic testing in appropriate patients, the PCMTP aims to enhance patient outcomes and optimize the quality of care. Prior to PCMTP establishment, assessing the prevalence of germline and CGP testing in eligible Veterans posed significant challenges. Future work will concentrate on increasing PCMTP utilization, evaluating downstream outcomes from genomic testing, including the identification of pathogenic variants, utilization of genetic counseling services, referrals to clinical trials, and the genomic impact on treatment strategies.

Background

Prostate cancer is the most common non-cutaneous malignancy at the Veterans Health Administration (VHA) and every year approximately 15,000 Veterans are diagnosed and treated. Many advanced prostate cancer cases harbor genetic mutations that significantly impact prognosis, treatment decisions, and familial screening. In February 2021, the Prostate Cancer Molecular Testing Pathway (PCMTP) flow map was developed to increase appropriate genetic testing.

Methods

VHA initiated the Oncology Clinical Pathways (OCP) program to standardize cancer care for Veterans. The PCMTP was developed by a multidisciplinary team that created interactive templates within the Computerized Patient Record System (CPRS), to facilitate identification of eligible Veterans for germline and comprehensive genomic profiling (CGP). Clinical decision-making for these tests is documented as Health Factors (HF), in CPRS, allowing for assessment of pathway adherence and overall uptake.

Results

The PCMTP has achieved success, as there is over 90% compliance to molecular testing among participating Veterans which exceeds the pathway benchmark of 80%. PCMTP has been utilized at 88 VA sites, by over 700 distinct VA providers, with over 7,000 Veterans participating. This implementation has yielded over 19,200 Health Factors within CPRS.

Conclusions

The PCMTP has markedly improved the documentation and application of germline and CGP testing among Veterans diagnosed with prostate cancer. By facilitating genomic testing in appropriate patients, the PCMTP aims to enhance patient outcomes and optimize the quality of care. Prior to PCMTP establishment, assessing the prevalence of germline and CGP testing in eligible Veterans posed significant challenges. Future work will concentrate on increasing PCMTP utilization, evaluating downstream outcomes from genomic testing, including the identification of pathogenic variants, utilization of genetic counseling services, referrals to clinical trials, and the genomic impact on treatment strategies.

Background

Prostate cancer is the most common non-cutaneous malignancy at the Veterans Health Administration (VHA) and every year approximately 15,000 Veterans are diagnosed and treated. Many advanced prostate cancer cases harbor genetic mutations that significantly impact prognosis, treatment decisions, and familial screening. In February 2021, the Prostate Cancer Molecular Testing Pathway (PCMTP) flow map was developed to increase appropriate genetic testing.

Methods

VHA initiated the Oncology Clinical Pathways (OCP) program to standardize cancer care for Veterans. The PCMTP was developed by a multidisciplinary team that created interactive templates within the Computerized Patient Record System (CPRS), to facilitate identification of eligible Veterans for germline and comprehensive genomic profiling (CGP). Clinical decision-making for these tests is documented as Health Factors (HF), in CPRS, allowing for assessment of pathway adherence and overall uptake.

Results

The PCMTP has achieved success, as there is over 90% compliance to molecular testing among participating Veterans which exceeds the pathway benchmark of 80%. PCMTP has been utilized at 88 VA sites, by over 700 distinct VA providers, with over 7,000 Veterans participating. This implementation has yielded over 19,200 Health Factors within CPRS.

Conclusions

The PCMTP has markedly improved the documentation and application of germline and CGP testing among Veterans diagnosed with prostate cancer. By facilitating genomic testing in appropriate patients, the PCMTP aims to enhance patient outcomes and optimize the quality of care. Prior to PCMTP establishment, assessing the prevalence of germline and CGP testing in eligible Veterans posed significant challenges. Future work will concentrate on increasing PCMTP utilization, evaluating downstream outcomes from genomic testing, including the identification of pathogenic variants, utilization of genetic counseling services, referrals to clinical trials, and the genomic impact on treatment strategies.

Background

Department of Veterans Affairs (VA) faces a landscape of increasingly complex practice, especially in Hematology/Oncology (H/O), and a nationwide shortage of healthcare providers, while serving more Veterans than ever before. To understand current and future staffing needs, the VA National Oncology Program performed an assessment of H/O staffing, including attending physicians, residents/ fellows, licensed independent practitioners (LIPs) (nurse practitioners/physician assistants), and nurses for fiscal years (FY) 19–24.

Methods

Using VA Corporate Data Warehouse, we identified H/O visits in VA from 10/01/2018 through 09/30/2024 using stop codes. No-show (< 0.00001%) and National TeleOncology appointments (1%) were removed. We retrieved all notes associated with resulting visits and used area-ofspecialization and provider-type data to identify all attending physicians, trainees, LIPs, and nurses who authored or cosigned these notes. We identified H/O staff as 1. those associated with H/O clinic locations, 2. physicians who consistently cosigned H/O notes authored by fellows and LIPs associated with H/O locations, 3. fellows and LIPs authoring notes that were then cosigned by H/O physicians, and 4. nurses authoring notes associated with H/O visits.

Analysis

For each FY, we obtained total numbers of visits, unique patients, and care-providing staff by type. For validation, collaborating providers at several sites reviewed visit information, and a colleague also performed an independent, parallel data extraction. We adjusted FY totals to account for the growing patient population by dividing unique staff count by number of unique patients and multiplying by 200,000 (the approximate number of unique patients in FY19).

Results

From FY19 through FY24, VA Hematology/ Oncology saw a 14.6% rise in unique patients (from 232,084 to 265,926) and a 15.4% rise in visits (from 923,175 to 1,065,186). The absolute number of attendings rose by 4 (0.6%); of LIPs, by 138 (14.4%); and of nurses, by 142 (4.9%); trainees fell by 102 (4.3%). Adjusted to 200,000 patients, the number of attendings fell by 76 (12.3%); LIPs, by 1 (0.1%); trainees, by 335 (16.5%); and nurses, by 211 (8.4%).

Conclusions

Adjusted to number of Veterans, there are 10.4% fewer staff in Hematology/Oncology in FY24 compared to FY19.

Background

Department of Veterans Affairs (VA) faces a landscape of increasingly complex practice, especially in Hematology/Oncology (H/O), and a nationwide shortage of healthcare providers, while serving more Veterans than ever before. To understand current and future staffing needs, the VA National Oncology Program performed an assessment of H/O staffing, including attending physicians, residents/ fellows, licensed independent practitioners (LIPs) (nurse practitioners/physician assistants), and nurses for fiscal years (FY) 19–24.

Methods

Using VA Corporate Data Warehouse, we identified H/O visits in VA from 10/01/2018 through 09/30/2024 using stop codes. No-show (< 0.00001%) and National TeleOncology appointments (1%) were removed. We retrieved all notes associated with resulting visits and used area-ofspecialization and provider-type data to identify all attending physicians, trainees, LIPs, and nurses who authored or cosigned these notes. We identified H/O staff as 1. those associated with H/O clinic locations, 2. physicians who consistently cosigned H/O notes authored by fellows and LIPs associated with H/O locations, 3. fellows and LIPs authoring notes that were then cosigned by H/O physicians, and 4. nurses authoring notes associated with H/O visits.

Analysis

For each FY, we obtained total numbers of visits, unique patients, and care-providing staff by type. For validation, collaborating providers at several sites reviewed visit information, and a colleague also performed an independent, parallel data extraction. We adjusted FY totals to account for the growing patient population by dividing unique staff count by number of unique patients and multiplying by 200,000 (the approximate number of unique patients in FY19).

Results

From FY19 through FY24, VA Hematology/ Oncology saw a 14.6% rise in unique patients (from 232,084 to 265,926) and a 15.4% rise in visits (from 923,175 to 1,065,186). The absolute number of attendings rose by 4 (0.6%); of LIPs, by 138 (14.4%); and of nurses, by 142 (4.9%); trainees fell by 102 (4.3%). Adjusted to 200,000 patients, the number of attendings fell by 76 (12.3%); LIPs, by 1 (0.1%); trainees, by 335 (16.5%); and nurses, by 211 (8.4%).

Conclusions

Adjusted to number of Veterans, there are 10.4% fewer staff in Hematology/Oncology in FY24 compared to FY19.

Background

Department of Veterans Affairs (VA) faces a landscape of increasingly complex practice, especially in Hematology/Oncology (H/O), and a nationwide shortage of healthcare providers, while serving more Veterans than ever before. To understand current and future staffing needs, the VA National Oncology Program performed an assessment of H/O staffing, including attending physicians, residents/ fellows, licensed independent practitioners (LIPs) (nurse practitioners/physician assistants), and nurses for fiscal years (FY) 19–24.

Methods

Using VA Corporate Data Warehouse, we identified H/O visits in VA from 10/01/2018 through 09/30/2024 using stop codes. No-show (< 0.00001%) and National TeleOncology appointments (1%) were removed. We retrieved all notes associated with resulting visits and used area-ofspecialization and provider-type data to identify all attending physicians, trainees, LIPs, and nurses who authored or cosigned these notes. We identified H/O staff as 1. those associated with H/O clinic locations, 2. physicians who consistently cosigned H/O notes authored by fellows and LIPs associated with H/O locations, 3. fellows and LIPs authoring notes that were then cosigned by H/O physicians, and 4. nurses authoring notes associated with H/O visits.

Analysis

For each FY, we obtained total numbers of visits, unique patients, and care-providing staff by type. For validation, collaborating providers at several sites reviewed visit information, and a colleague also performed an independent, parallel data extraction. We adjusted FY totals to account for the growing patient population by dividing unique staff count by number of unique patients and multiplying by 200,000 (the approximate number of unique patients in FY19).

Results

From FY19 through FY24, VA Hematology/ Oncology saw a 14.6% rise in unique patients (from 232,084 to 265,926) and a 15.4% rise in visits (from 923,175 to 1,065,186). The absolute number of attendings rose by 4 (0.6%); of LIPs, by 138 (14.4%); and of nurses, by 142 (4.9%); trainees fell by 102 (4.3%). Adjusted to 200,000 patients, the number of attendings fell by 76 (12.3%); LIPs, by 1 (0.1%); trainees, by 335 (16.5%); and nurses, by 211 (8.4%).

Conclusions

Adjusted to number of Veterans, there are 10.4% fewer staff in Hematology/Oncology in FY24 compared to FY19.

Background

Prostate cancer is the most common non-cutaneous malignancy diagnosis within the Department of Veterans Affairs (VA). The Prostate Cancer Clinical Pathways (PCCP) were developed to enable providers to treat all Veterans with prostate cancer at subject matter expert level.

Methods

The PCCP was launched in February 2021; however, provider documentation of PCCP is variable across the VA healthcare system and within the PCCP, specific flow maps have differential use. To increase urology specific flow map use, a collaboration between the National Surgery Office and National Oncology Program was established to develop a Urology Prostate Cancer Note (UPCN). The UPCN was designed by urologists with assistance from a medical oncologist and a clinical applications coordinator.

Results

The UPCN functions as a working clinical note for urologists and has the PCCPs embedded into reminder dialog templates, which when completed generate health factors. The health factors that are generated from the UPCN are data mined to record PCCP use and to perform data analytics. Since the UPCN national deployment on 9/6/24, documentation of high risk prostate cancer pathway utilization has increased 75% from 226 unique Veterans prior to launch to 395 unique Veterans after launch.

Conclusions

This collaborative effort did improve pathway utilization and documentation however other tools will need to be developed to improve provider PCCP documentation.

Background

Prostate cancer is the most common non-cutaneous malignancy diagnosis within the Department of Veterans Affairs (VA). The Prostate Cancer Clinical Pathways (PCCP) were developed to enable providers to treat all Veterans with prostate cancer at subject matter expert level.

Methods

The PCCP was launched in February 2021; however, provider documentation of PCCP is variable across the VA healthcare system and within the PCCP, specific flow maps have differential use. To increase urology specific flow map use, a collaboration between the National Surgery Office and National Oncology Program was established to develop a Urology Prostate Cancer Note (UPCN). The UPCN was designed by urologists with assistance from a medical oncologist and a clinical applications coordinator.

Results

The UPCN functions as a working clinical note for urologists and has the PCCPs embedded into reminder dialog templates, which when completed generate health factors. The health factors that are generated from the UPCN are data mined to record PCCP use and to perform data analytics. Since the UPCN national deployment on 9/6/24, documentation of high risk prostate cancer pathway utilization has increased 75% from 226 unique Veterans prior to launch to 395 unique Veterans after launch.

Conclusions

This collaborative effort did improve pathway utilization and documentation however other tools will need to be developed to improve provider PCCP documentation.

Background

Prostate cancer is the most common non-cutaneous malignancy diagnosis within the Department of Veterans Affairs (VA). The Prostate Cancer Clinical Pathways (PCCP) were developed to enable providers to treat all Veterans with prostate cancer at subject matter expert level.

Methods

The PCCP was launched in February 2021; however, provider documentation of PCCP is variable across the VA healthcare system and within the PCCP, specific flow maps have differential use. To increase urology specific flow map use, a collaboration between the National Surgery Office and National Oncology Program was established to develop a Urology Prostate Cancer Note (UPCN). The UPCN was designed by urologists with assistance from a medical oncologist and a clinical applications coordinator.

Results

The UPCN functions as a working clinical note for urologists and has the PCCPs embedded into reminder dialog templates, which when completed generate health factors. The health factors that are generated from the UPCN are data mined to record PCCP use and to perform data analytics. Since the UPCN national deployment on 9/6/24, documentation of high risk prostate cancer pathway utilization has increased 75% from 226 unique Veterans prior to launch to 395 unique Veterans after launch.

Conclusions

This collaborative effort did improve pathway utilization and documentation however other tools will need to be developed to improve provider PCCP documentation.