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With recent changes in staging of cutaneous squamous cell carcinoma (SSC), we examine the underuse of the sentinel lymph node biopsy (SLNB) in the management of high-risk SCC. To date, the most important determinant of mortality in SCC is the presence of lymph node metastasis. 1 Recent data have led to an updated staging system for cutaneous SCC proposed by Brigham and Women's Hospital, which emphasizes the presence or absence of high-risk features. This new staging system stratified T staging of SCC tumors based on the number of high-risk features present (>2-cm diameter, poor differentiation, perineural invasion, extension beyond subcutaneous fat). T1 tumors have no high-risk features, whereas T2a tumors have 1, T2b have 2 to 3, and T3 have all 4 or bone invasion. In a validation study by Schmitt et al, 2 tumors with 2 or 3 high-risk features had an SLNB positivity rate of 29%, whereas tumors with all 4 risk features had lymph node metastasis rate of 50%. The reported positivity rate of SLNB in the setting of high-risk SCC in the literature is 12% to 44%. 3 The National Comprehensive Cancer Network guidelines recommend discussing and offering SLNB to patients with melanoma skin cancers of stages 1B and up. 4 The SLNB positivity rate for stage 1B tumors is 7% to 10%, which is lower than that of high-risk SCC tumors. 5Methods | We created a database of all high-risk patients with SCC treated at the University of Southern California, including the Keck Medical Center and Los Angeles County Hospital in Los Angeles, California, from 2006 to the present time. Patient and tumor characteristics were documented, including treatment modality and whether SLNB was performed. Keck Medicine of the University of Southern California determined that institutional review board approval or human subjects committee approval and informed consent were not required for this retrospective study. All data were deidentified.Results | With preliminary data results from our institution spanning from 2006 to present, less than 0.1% of all patients with high-risk SCC tumors underwent SLNB procedures. Alternatively, 14.0% underwent complete lymph node dissections. A little more than half (56.7%) of these complete lymph node dissections had microscopic tumor metastasis to local lymph nodes, whereas 43.3% of them were free of metastasis.Discussion | Overall, we found prophylactic lymph node dissection to be overused and SLNB is underused in high-risk SCC. Given the cost and morbidity associated with prophylactic lymph node dissection, patients may benefit from a less invasive SLNB procedure before considering dissection. Limitations to SLNB include false-negative rates, particularly high for tumors on the head and neck because of alternate draining routes and bifurcating anatomy. Some view this as a contraindication for performing SLNB, but the use of single-photon emission computed tomography and preoperative lymphoscintigraphy can substantially decrease this false-negative rate. 6 An uncertainty to be explored is the next step in the trea...

Approximately 2.4 million Americans are infected with hepatitis C virus (HCV), and persons born from 1945 through 1965 (i.e. baby boomers) account for nearly three‐fourths of all HCV infections. The purpose of this study was to implement HCV screening for baby boomers presenting to a community hospital emergency department (ED) and to facilitate linkage to care. We developed a process within our electronic medical record system to screen patients for HCV testing eligibility, link eligible patients to laboratory orders, notify patients of HCV test results (via patient navigator) and track follow‐up care. We tracked performance from February 2016 to December 2018. Sociodemographic compositions and linkage to care rates of all participants were evaluated. A total of 14,927 patients from the birth cohort of 1945–1965 were screened for HCV. Of those tested, 555 (3.7%) had a positive HCV antibody test and 147 were HCV RNA‐positive patients (1.0%) demonstrating that only 27% of HCV antibody‐positive individuals were chronically infected. Males, black race and USA‐born baby boomers had a higher prevalence of HCV antibody and viral load positivity (p < 0.05). Initially, only 17.6% of patients were ultimately linked to care, which improved to over 94% after the implementation of patient navigation support. There is a need for HCV screening protocol in the community. The cost of implementing an HCV screening programme must include information technology and a team of care coordinators to improve screening rates and facilitate linkage to continual care using the four pillars framework.

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