Problems in the current TNM staging of nonmelanoma skin cancer of the head and neck

Nonmelanoma skin cancer (NMSC) is the most common malignancy encountered in the white population, andmore than amillion new cases are expected annually in the United States alone. Overall, 75% arise in the head and neck region, approximately 80% are basal cell carcinoma (BCC) and 20% are squamous cell carcinoma (SCC) cases. Nearly half of the patients are over the age of 65 and 25% have multiple lesions. The incidence of SCC increases more rapidly with age and cumulative sun exposure than does that of BCC, is far more common in the older age group, and is more common in men than in women. The incidence of NMSC is increasing and age at initial presentation is decreasing. Other than sun exposure, host factors, medical syndromes, and environmental exposure were reported to be associated with increased incidence of NMSC. Countries with fair-skinned populations and excess sun exposure, such as Australia and Israel (ranking 1 and 2, respectively, in the incidence of skin cancer) are particularly prone to this type of neoplasia, reaching what was described as epidemic proportions. Skin cancer is usually noted early even if not necessarily recognized as such, and often a prolonged period of time elapses before a definite diagnosis is reached. The median delay between occurrence of initial symptoms and presentation is reported to be 3 years. Many of the patients with skin lesions tend to try different remedies, some of which may favorably affect or alter the appearance of the lesions to an extent, and this may lead to further delay. Although the majority of NMSCs occur in sunexposed skin and thus appear in readily observed areas, a significant number of patients present with advanced invasive disease, not infrequently accompanied by regional metastases. This may be due to a multitude of reasons: lack of awareness of the significance of local recurrence by either physician or patient, late detection of recurrent or residual disease, lack of adequate follow-up, failure to associate a neck or parotid mass with a skin lesion, an abundance of other skin lesions, the availability of fluorouracil cream treatment, and, of course, denial. Also, proximity to structures such as the eye or ear may generate reluctance to Correspondence to: Y. P. Talmi