Keratinocyte Carcinoma Research Articles

Chemopreventive Measurements and Oxidative Stress Effects of Terpenoid-rich Canarium odontophyllum Miq. Leaf Extract (TRCO) in Ultraviolet B-Induced In-Vitro Skin Carcinogenesis Model

The most common type of cancer found in the human outer and middle skin layers is keratinocyte carcinoma, often known as non-melanoma skin cancer. Although it can be aggressive, skin cancer is generally not fatal. This study aims to measure the chemopreventive and oxidative stress effects of terpenoid-rich Canarium odontophyllum Miq.’s leaf extract (TRCO) in the UVB-induced skin carcinogenesis model. The model involving human keratinocytes (HaCaT) was adapted with optimisations with pretreatment of 500 µg/ml TRCO (TRCO500) & 1000 µg/ml TRCO (TRCO1000). The HaCaT oncogenic transformation model's repetitive UVB exposure resulted in altered cell shape, according to our findings. Pretreatment of TRCO1000 significantly reduced tumour protein p53 (TP53) and marker of proliferation KI-67 (KI67) expression in UVB-induced HaCaT. Treatment with TRCO resulted in an overall reduction in oxidative stress. TRCO pretreatment showed reduced lipid peroxides, LPO and significantly reduced protein carbonyls. In conclusion, the promising results of this chemopreventive study using TRCO on this in-vitro skin carcinogenesis model suggested that it is worthwhile to conduct further isolations and assessments of terpenoids from C. odontophyllum Miq. leaf as a possible chemoprevention agent.

Quality of Life Before and after Radiotherapy for Early-Stage Keratinocyte Carcinoma: A Longitudinal Analysis

Cutaneous squamous and basal cell carcinoma (keratinocyte carcinoma, KC) are common malignancies treated with radiotherapy (RT) to preserve form and function. Treatment of KC can compromise quality of life (QOL), but little is known about patient-reported QOL before and after RT for early KC. The purpose of this study was to assess prospectively collected patient-reported QOL before and after RT for early KC and compare this to previously reported studies of other treatments. It was hypothesized that QOL deteriorates soon after RT, with subsequent improvement of a magnitude similar to previously published reports of other KC treatments. Patients undergoing RT for early-stage (T0-2, <4 cm) KC who completed a QOL assessment before and at least once after RT were the subjects of study. Characteristics of patients, tumors and treatment were recorded. Patient-reported QOL was measured by 2 validated indices: Skindex-16 (S16, including subscales of symptoms, emotions, functioning; lower score is better QOL) and Skin Cancer Index (SCI, including emotional, social and appearance subscales; higher score is better QOL). Paired t-tests compared scores before and at 4 time points after treatment (6 weeks, 3 months, 1 and 2+ years), with a ≥10-point difference considered clinically significant, and a p<0.0125 considered statistically significant due to Bonferroni correction. A total of 85 patients (median age 79 years) with early KC, most of which were basal cell carcinomas (87%) on the face (80%) and an average of 1.3 cm in diameter were treated with a median of 48 Gy in 12 fractions. Composite S16 scores and total SCI scores showed significant, clinically meaningful improvements 3 months (15.2→5.2) and 6 weeks (72.0→85.7) after RT. Non-significant declines in QOL happened 6 weeks after treatment on the S16 symptom subscale (11.3→16.6). Concurrently, S16 and SCI emotional subscales (25.9→14.4 and 67.2→79.3) significantly improved, and this trend persisted for 2+ years. Improvements in S16 functioning (8.7→2.8) and SCI social (80.2→89.6) and appearance (68.6→90.5) QOL occurred. S16 demonstrated that 1-2 years after treatment, composite QOL improved by 45%, 47%, 39% and 10% in patients treated with RT, Mohs surgery, excision and electrodessication and curettage, respectively. SCI demonstrated that 3-4 months after treatment, total QOL improved by 24% and 4-13% after RT and Mohs surgery, respectively. QOL related to symptoms deteriorates at 6 weeks after RT, with clinically and statistically significant improvement seen by 3 months after RT. QOL related to emotions, functioning, social and appearance domains all improve after RT. The changes in QOL are similar if not greater than those observed after other treatments of early KC, and may help guide patient expectations following RT.

Survival of patients with basal cell carcinoma, squamous cell carcinoma, and squamous cell carcinoma in situ: A whole population study

Keratinocyte carcinoma (KC) is the commonest type of malignancy in humans; however, the impact of KC on survival is poorly understood. This study characterizes the impact of basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and squamous cell carcinoma in situ (SCCis) on the survival of Icelanders. This whole population study evaluated relative survival of KC in Iceland by using a cancer registry containing records of all BCC, SCCis, and SCC cases recorded in Iceland between 1981 and 2015. Between 1981 and 2015, 8767 Icelanders were diagnosed with their first localized KC. A total of 6473 individuals with BCC, 1194 with SCCis, and 1100 with invasive SCC, respectively. BCC was not associated with decreased survival except for men diagnosed with BCC between 1981 and 1995 for whom decreased 10-year relative survival was observed (85.3, 95% CI [77.9-92.7]). SCC and SCCis were both associated with a decrease in relative survival for certain population subgroups such as individuals <50years of age at time of diagnosis. Our whole population cohort survival study examining the Icelandic Cancer Registry supports prior studies demonstrating that BCC is not associated with a reduction in relative survival and that SCC and SCCis are associated with comparatively poor relative survival in certain population subgroups.

Anticipated Versus Unanticipated Incomplete Mohs Micrographic Surgery for Keratinocyte Carcinomas: Impact on Treatment Delays and Final Margin Status.

Mohs micrographic surgery may be discontinued with positive margins as an anticipated strategy for multidisciplinary care or as an unanticipated occurrence. Management of primary tumors has not been compared after anticipated versus unanticipated incomplete Mohs micrographic surgery (iMMS). To compare rates and timing of adjuvant surgery after iMMS and final margin status when iMMS is anticipated versus unanticipated. Secondary outcomes were preoperative and intraoperative clinicopathologic factors associated with iMMS. Cases of iMMS of keratinocyte carcinomas at a tertiary academic center between 2005 and 2022 were classified as anticipated (preoperative assembly of multidisciplinary teams) or unanticipated (ad hoc management of positive margins). Rate, timing, and final margin status of adjuvant surgery was compared between anticipated and unanticipated iMMS cohorts using χ2/Fisher exact test for categorical variables and t-test for continuous variables. Of 127 iMMS cases, 51.2% (65/127) were anticipated. Anticipated iMMS cases were more likely to undergo additional resection (98.5% vs 72.6%, p < .001), with fewer delays (3.9 vs 13.2 days, p < .001) and higher rates of final margin clearance (84.6% vs 59.7%, p < .001). When iMMS is anticipated as part of multidisciplinary care, patients are more likely to undergo additional resection, with fewer delays to next surgery and higher final margin clearance rates.

Nicotinamide for skin cancer chemoprevention in transplant recipients: acritically appraised topic.

This paper critically appraises a phase III trial examining the impact of oral nicotinamide on reducing keratinocyte carcinoma (KC) incidence in solid organ transplant recipients. Despite a well-conducted study finding no significant difference in KC rates between nicotinamide and placebo groups, we suggest that the conclusion could be premature due to the study’s underpowered sample size and lack of analysis on more invasive cancers.

40842 Histopathologic classification of actinic keratosis severity associated with burden of keratinocyte carcinoma

40842 Histopathologic classification of actinic keratosis severity associated with burden of keratinocyte carcinoma

42838 A Study of Factors Affecting Time to Definitive Surgery for Keratinocyte Carcinoma

42838 A Study of Factors Affecting Time to Definitive Surgery for Keratinocyte Carcinoma

42857 A Study of Factors Affecting Sun-Protective Behavior Change after Surgical Treatment of Keratinocyte Carcinoma

42857 A Study of Factors Affecting Sun-Protective Behavior Change after Surgical Treatment of Keratinocyte Carcinoma

Oral phytochemicals as photoprotectants in UVR exposed hairless mice: A study of hesperidin methyl chalcone, phloroglucinol, and syringic acid.

Ultraviolet radiation is the primary risk factor for keratinocyte carcinoma. Because of increasing incidence rates, new methods of photoprotection must be explored. Oral supplementation with photoprotective compounds presents a promising alternative. Phytochemical compounds like hesperidin methyl chalcone, phloroglucinol, and syringic acid are particularly of interest because of their antioxidant properties. Our primary outcome was to evaluate the effects of oral phytochemicals on photocarcinogenesis with time until tumour onset as the primary endpoint. A total of 125 hairless C3.Cg-Hrhr/TifBom Tac mice were randomised to receive tap water supplemented with either 100mg/kg hesperidin methyl chalcone, phloroglucinol, or syringic acid, 600mg/kg nicotinamide as a positive control, or no supplementation. The mice were irradiated with 3.5 standard erythema doses thrice weekly to induce photocarcinogenesis. Supplementation with the phytochemicals phloroglucinol and syringic acid and nicotinamide delayed tumour onset from a median of 140days to 151 (p=0.036), 157days (p=0.02), and 178 (p=2.7·10-5), respectively. Phloroglucinol and nicotinamide supplementation reduced tumour number. Nicotinamide increased UV-induced pigmentation and reduced oedema formation, while phloroglucinol supplementation reduced epidermal thickness. These results indicate that oral supplementation with phloroglucinol and syringic acid protects against photocarcinogenesis in hairless mice, but not to the same extent as nicotinamide.

Long-term cost-effectiveness of a melanoma prevention program using genomic risk information compared with standard prevention advice in Australia

PurposeEvidence indicates that a melanoma prevention program using personalized genomic risk provision and genetic counseling can affect prevention behaviors, including reducing sunburns in adults with no melanoma history. This analysis evaluated its longer-term cost-effectiveness from an Australian health system perspective. MethodsThe primary outcome was incremental cost effectiveness ratio (ICER) of genomic risk provision (intervention) compared with standard prevention advice. A decision-analytic Markov model was developed using randomized trial data to simulate lifetime cost-effectiveness. All costs were presented in 2018/19 Australian dollars (AUD). The intervention effect on reduced sunburns was stratified by sex and traditional risk, which was calculated through a validated prediction model. Deterministic and probabilistic sensitivity analyses were undertaken for robustness checks. ResultsThe per participant cost of intervention was AUD$189. Genomic risk provision targeting high-traditional risk individuals produced an ICER of AUD$35,254 (per quality-adjusted life year gained); sensitivity analyses indicated the intervention would be cost-effective in more than 50% of scenarios. When the intervention was extended to low-traditional risk groups, the ICER was AUD$43,746 with a 45% probability of being cost-effective. ConclusionGenomic risk provision targeted to high-traditional melanoma risk individuals is likely a cost-effective strategy for reducing sunburns and will likely prevent future melanomas and keratinocyte carcinomas.

Gene-Environment Analyses in a UK Biobank Skin Cancer Cohort Identifies Important SNPs in DNA Repair Genes That May Help Prognosticate Disease Risk.

Despite well-established relationships between sun exposure and skin cancer pathogenesis/progression, specific gene-environment interactions in at-risk individuals remain poorly-understood. We leveraged a UK Biobank cohort of basal cell carcinoma (BCC, n = 17,221), cutaneous squamous cell carcinoma (cSCC, n = 2,331), melanoma in situ (M-is, n = 1,158), invasive melanoma (M-inv, n = 3,798), and healthy controls (n = 448,164) to quantify the synergistic involvement of genetic and environmental factors influencing disease risk. We surveyed 8,798 SNPs from 190 DNA repair genes, and 11 demographic/behavioral risk factors. Clinical analysis identified darker skin (RR = 0.01-0.65) and hair (RR = 0.27-0.63) colors as protective factors. Eleven SNPs were significantly associated with BCC, three of which were also associated with M-inv. Gene-environment analysis yielded 201 SNP-environment interactions across 90 genes (FDR-adjusted q<0.05). SNPs from the FANCA gene showed interactions with at least one clinical factor in all cancer groups, of which three (rs9926296, rs3743860, rs2376883) showed interaction with nearly every factor in BCC and M-inv. We identified novel risk factors for keratinocyte carcinomas and melanoma, highlighted the prognostic value of several FANCA alleles among individuals with a history of sunlamp use and childhood sunburns, and demonstrated the importance of combining genetic and clinical data in disease risk stratification. This study revealed genome-wide associations with important implications for understanding skin cancer risk in the context of the rapidly-evolving field of precision medicine. Major individual factors (including sex, hair and skin color, and sun protection use) were significant mediators for all skin cancers, interacting with >200 SNPs across four skin cancer types.

LB1772 Melanoma risk in skin of color patients with a history of keratinocyte carcinoma

LB1772 Melanoma risk in skin of color patients with a history of keratinocyte carcinoma

Treating the invisible: Subclinical actinic keratosis detected by imiquimod

AbstractBackgroundSkin in UV‐exposed areas may develop UV‐induced actinic damage in DNA sequences leading to proliferation of keratinocyte carcinoma, a type of non‐melanoma skin cancer. Actinic keratosis (AK) represents early‐stage in situ squamous cell carcinoma. It develops from the basal cell layer and may be present in subclinical stages, being reported as field cancerization, even before being clinically visible. Thus, we hypothesise that from the age of 50 + UV‐exposed skin features subclinical forms of AKs without visible skin lesions.ObjectivesThis study aims at clarifying the existence of the clinically invisible, early stages of AKs on chronically UV‐exposed skin without showing clinically evident features of AK.Methods46 volunteers (26 females and 20 males) aged 50+ with signs of moderate to severe UV‐damage (photodamage) applied imiquimod 3.75% creme on their entire face every night for a 2‐week period. All participants kept a diary noting onset, severity of inflammatory reactions, and unexpected side effects.ResultsMore than 90% of participants without clinical evidence of AK showed inflammatory reactions on topical treatment with imiquimod on their face demonstrating an interaction between UV‐damaged mutated keratinocytes and the topically applied immunomodifier, thus proofing the presence of subclinical AKs.ConclusionsThe action of imiquimod is not restricted to visible AK lesions, but often includes their vicinity, suggesting that neoplastic processes are frequent at a cellular level, not confined to clinically evident lesions, supporting the concept of field cancerization. Thus, subclinical AKs do exist in an early, macroscopically invisible state and may be targeted by imiquimod or 5‐FU. At this stage, AKs are being treated before diagnosis by usual clinical means, and well before potential progression to invasive squamous cell carcinoma (SCC). Eventually, imiquimod 3.75% cream could be recommended in UV‐exposed skin to prevent the presumptive development of AK and later on, early SCC.

Implementation of artificial intelligence for the detection of cutaneous melanoma within a primary care setting: prevalence and types of skin cancer in outdoor enthusiasts.

There is enthusiasm for implementing artificial intelligence (AI) to assist clinicians detect skin cancer. Performance metrics of AI from dermoscopic images have been promising, with studies documenting sensitivity and specificity values equal to or superior to specialists for the detection of malignant melanomas (MM). Early detection rates would particularly benefit Australia, which has the worlds highest incidence of MM per capita. The detection of skin cancer may be delayed due to late screening or the inherent difficulty in diagnosing early skin cancers which often have a paucity of clinical features and may blend into sun damaged skin. Individuals who participate in outdoor sports and recreation experience high levels of intermittent ultraviolet radiation (UVR), which is associated with the development of skin cancer, including MM. This research aimed to assess the prevalence of skin cancer in individuals who regularly participate in activities outdoors and to report the performance parameters of a commercially available AI-powered software to assess the predictive risk of MM development. Cross-sectional study design incorporating a survey, total body skin cancer screening and AI-embedded software capable of predictive scoring of queried MM. A total of 423 participants consisting of surfers (n = 108), swimmers (n = 60) and walkers/runners (n = 255) participated. Point prevalence for MM was highest for surfers (6.48%), followed by walkers/runners (4.3%) and swimmers (3.33%) respectively. When compared to the general Australian population, surfers had the highest odds ratio (OR) for MM (OR 119.8), followed by walkers/runners (OR 79.74), and swimmers (OR 61.61) rounded out the populations. Surfers and swimmers reported comparatively lower lifetime hours of sun exposure (5,594 and 5,686, respectively) but more significant amounts of activity within peak ultraviolet index compared with walkers/runners (9,554 h). A total of 48 suspicious pigmented lesions made up of histopathology-confirmed MM (n = 15) and benign lesions (n = 33) were identified. The performance of the AI from this clinical population was found to have a sensitivity of 53.33%, specificity of 54.44% and accuracy of 54.17%. Rates of both keratinocyte carcinomas and MM were notably higher in aquatic and land-based enthusiasts compared to the general Australian population. These findings further highlight the clinical importance of sun-safe protection measures and regular skin screening in individuals who spend significant time outdoors. The use of AI in the early identification of MM is promising. However, the lower-than-expected performance metrics of the AI software used in this study indicated reservations should be held before recommending this particular version of this AI software as a reliable adjunct for clinicians in skin imaging diagnostics in patients with potentially sun damaged skin.

Use of multiple correspondence analysis to explore associations between caregivers and sun protective habits during summer vacations.

Childhood exposure to ultraviolet radiation (UVR) plays an important role in the development of keratinocyte carcinomas and melanomas. Therefore, sun protective measures ought to be implemented during early childhood. Young children are largely dependent upon adult care providers in order to achieve proper sun protection. To develop effective photoprotection in children, it is necessary to understand caregivers' attitudes and knowledge about UVR exposure. This study aimed to explore the variables associated with sun protective behaviour in parents and grandparents during summer vacations. A multinational, cross-sectional study was conducted using a web-based online survey with a representative sample of parents and grandparents of children aged ≤ 12 years, who cared for their children/grandchildren for at least 2 weeks during the summer of 2021, in five countries (France, Germany, Spain, Italy and the USA). Multiple correspondence analysis (MCA) was used to explore in an unbiased way the possible relationships among all the variables and to identify specific profiles. A total of 6190 adult participants responded to the questionnaire: 5104 parents (average age 42.0 years, 54.3% women) and 1086 grandparents (average age 64.2 years, 55.5% women). MCA allowed discrimination of two groups of respondents based on their answers: a profile with 'unprotected sun exposure habits' vs. those with 'protective sun exposure habits'. Parents fell in closer proximity to the 'unprotected sun exposure habits', and 'sunburn reported in youngest child'. Grandparents adopted more cautious behaviours than parents. Nevertheless, grandparents fell in proximity to 'having exposed the grandchild to the sun between 11 h and 17.00 h', 'not using an umbrella' and 'not using sunglasses'. Although grandparents appear to adopt more cautious behaviours than parents, many gaps in proper sun protection behaviour were observed in both groups of caregivers.

Impact of UV Modifying Factors on the Incidence of Keratinocyte Carcinomas in Solid Organ Transplant Recipients: A Systematic Review.

Solid organ transplant recipients (SOTR) are at an increased risk for developing keratinocyte carcinomas (KC). Four ultraviolet (UV) modifying factors have been identified that impact the incidence of KC: Fitzpatrick Skin Type (FST), race, sun exposure, and sun-protective factors. We conducted a systematic review to summarize the association between UV modifying factors and the incidence of KC in SOTR. We systematically searched PubMed, Scopus, and Web of Science databases, and after screening for inclusion and exclusion criteria, we included 13 studies with 6,910 solid organ transplant recipients in our analysis. Our review found that lower FST (I-II), white and Latinx populations, lack of regulated sunscreen application, and occupational and residential sun exposure are individual risk factors among solid organ transplant recipients for KC incidence. Although previous studies showed an in-creased SCC:BCC ratio, some studies found a contradictory increased BCC:SCC ratio. Limitations include few research studies that analyze these UV modifying factors and a lack of incorporating both varying immunosuppressant factors and transplantation follow-up times. These findings support the need for dermatological advice in increased risk patient demographic populations, lower FST and white and Latinx populations, and subsequently moderating sun exposure and protective factors.

Mohs micrographic surgery for keratinocyte carcinomas: clinicopathological predictors of the number of stages

Background The number of Mohs stages needed to remove a keratinocyte carcinoma affects resource use, expenses, and repair complexity. This study aimed to identify clinicopathological predictors associated with increased or decreased stages and areas for further research. Methods A retrospective review was conducted from a single private practice with two Mohs surgeons of 2788 consecutive Mohs cases between January 2017 and December 2021, analyzing the average number of stages taken versus national norms (P = 0.21) and subgroups using unpaired t tests (*<0.05). Results Several tumor features were significantly associated with fewer stages: squamous cell carcinomas, Mohs appropriate use criteria score of 7 or 8, preoperative size <0.25 cm2, tumors on the lips and extremities (including hands/fingers), and smoking. Clinicopathological features significantly associated with more stages included Mohs appropriate use criteria score of 9, recurrent skin cancers, basal cell carcinomas, tumor size of 2.25–3.99 cm2, cancers on ears, solid organ transplant patients, treatment delays >180 days, and patients ≥90 years old. Conclusions Significant predictors exist for both increased and decreased numbers of Mohs micrographic surgery stages required to eradicate a tumor, which may help Mohs surgeons facilitate, plan, and allocate resources more effectively. Areas for further research in Mohs micrographic surgery are identified.

Merkel cell polyomavirus and its etiological relationship with skin tumors

Viruses have been frequently identified in several human neoplasms, but the etiological role of these viruses in some tumors is still a matter of controversy. Polyomaviruses stand out among the main viruses with oncogenic capacity, specifically the Merkel cell polyomavirus (MCPyV). Recent revisions in the taxonomy of polyomaviruses have divided the Polyomaviridae family into six genera, including 117 species, with a total of 14 currently known human-infecting species. Although the oncogenicity of polyomaviruses has been widely reported in the literature since 1950, the first description of a polyomavirus as an etiological agent of a neoplasm in humans was made only in 2008 with the description of MCPyV, present in approximately 80% of cases of Merkel cell carcinoma (MCC), with the integration of its genome to that of the tumor cells and tumor-specific mutations, and it is considered the etiological agent of this neoplasm since then. MCPyV has also been detected in keratinocyte carcinomas, such as basal cell carcinoma and squamous cell carcinoma of the skin in individuals with and without immunosuppression. Data on the occurrence of oncogenic viruses potentially involved in oncogenesis, which cause persistence and tissue injury, related to the Merkel cell polyomavirus are still scarce, and the hypothesis that the Merkel cell polyomavirus may play a relevant role in the genesis of other cutaneous carcinomas in addition to MCC remains debatable. Therefore, the present study proposes to explore the current knowledge about the presence of MCPyV in keratinocyte carcinomas.

Coffee, Citrus, and Alcohol: A Review of What We Drink and How it May Affect our Risk for Skin Cancer.

Climate change and environmental health are closely linked with agriculture and food supply. The environment influences accessibility, quality, and variety of foods and drinks that are available for consumption, which in turn influences population health. A growing area of research is the role of dietary intake of nutrients and how they may influence risk for skin cancer. In recent years, our group has studied dietary nutrients, particularly those found in commonly consumed beverages, such as those containing caffeine, citrus products, and alcohol, in large prospective cohorts to evaluate how their intake may influence risk for skin cancer. Our data suggest that intake of citrus juices, when consumed around once per day or more, or around 5 to 6 times per week, may be associated with increased risk for both keratinocyte carcinomas (KC) and malignant melanoma (MM). With regards to alcohol consumption, we have found that intake of white wine may be associated with increased risk for both KC and MM, while beer and red wine have not shown such associations. Lastly, our work suggests caffeinated beverages, including coffee, tea, and cola, may be associated with decreased risk for basal cell carcinoma (BCC) and MM. While the associations between food intake and skin cancer development are complex, and remain to be further analyzed in future studies, we hope that our summary may help guide individuals to small changes they may make towards potentially reducing their risk for certain skin cancers.

Keratinocyte carcinomas, area-level socioeconomic status and geographic remoteness in Tasmania: cross-sectional associations and temporal trends

ObjectiveThis article aims to examine cross-sectional associations and assess temporal trends in keratinocyte carcinoma (KC) incidence by area-level socioeconomic status (SES) and geographic remoteness in Tasmania, Australia. MethodsKCs—basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (SCC)—registered by the Tasmanian Cancer Registry were assigned to area-level SES and remoteness area. Incidence rate ratios (2014–2018) were estimated using Poisson regression. Average annual percentage changes (2001–2018) were estimated using the Joinpoint Regression Program. ResultsBCC incidence increased with increasing area-level advantage (p value for trend <0.001), but no trend was found for SCC. SCC incidence was higher in rural than urban areas (p value <0.001), and BCC incidence was slightly lower in rural than urban areas for males (p value = 0.026), but not for females (p value = 0.381). BCC and SCC incidence increased between 2001 and the mid-2010s, when it peaked across most areas. ConclusionsAssociations were found between BCC and higher area-level SES, and between SCC and geographic remoteness. The findings suggest differences in sun exposure behaviours, skin cancer awareness and access to services, or ascertainment bias. Implications for public healthEfforts to control and deliver KC services in Tasmania should consider targeting populations with specific area-level characteristics.