Lesley E. Rhodes

PROBLEM/CONDITION: High-risk behaviors (e.g., physical inactivity, cigarette smoking, and drinking and driving) and lack of preventive health care (e.g., screening for cancer) are associated with morbidity and mortality from chronic disease and injury. The Behavioral Risk Factor Surveillance System (BRFSS) collects state-specific information to determine the prevalence of such behaviors and preventive practices. By using the BRFSS, states can gain a better understanding of the factors that have a major affect on the health of their adult populations. The BRFSS is also used to monitor progress toward national health objectives. REPORTING PERIOD COVERED: 1996 and 1997. DESCRIPTION OF SYSTEM: The BRFSS is a state-based telephone survey of the civilian, noninstitutionalized, adult (i.e., persons aged 18 years) population. In both 1996 and 1997, 50 states, the District of Columbia, and the Commonwealth of Puerto Rico participated in the BRFSS. RESULTS: As in previous years, state- and sex-specific variations occurred in the prevalence of high-risk behaviors, awareness of certain medical conditions, use of preventive health services, and health-care coverage. For example, in 1997, the percentage of adults who reported being current cigarette smokers ranged from 13.8% to 30.7% among states (median: 23.2%), and the percentage of adults who reported driving after drinking too much alcohol ranged from 0.6% to 5.3% (median: 1.9%). Binge drinking varied substantially not only by state (range: 6.3%-23.3%; median: 14.5%) but also by sex (men: 22.3%; women: 6.7%). Similarly, the prevalence of overweight varied considerably by sex: 62.2% of men and 44.5% of women were overweight in 1997. INTERPRETATION: The 1996 and 1997 BRFSS data demonstrate that U.S. adults engage in behaviors that are detrimental to their health. The data also demonstrate that many adults are making efforts to prevent chronic disease and injury. The prevalence of certain behaviors and health practices differs between states and between men and women. The reasons for these differences by state and sex are subjects for further analysis, but only through continued surveillance can the areas that need further study be identified. PUBLIC HEALTH ACTIONS: Data from the BRFSS are useful in developing and guiding public health programs and policies. For many states, the BRFSS is the only source of state-level data on behaviors and practices related to chronic disease and injury; therefore, BRFSS data are vital for effective decision-making at the local level. States will continue to use these data to help prevent premature morbidity and mortality among their adult population and to assess progress toward national health objectives.

Multicentre randomized controlled studies now demonstrate high efficacy of topical photodynamic therapy (PDT) for actinic keratoses, Bowen's disease (BD) and superficial basal cell carcinoma (BCC), and efficacy in thin nodular BCC, while confirming the superiority of cosmetic outcome over standard therapies. Long-term follow-up studies are also now available, indicating that PDT has recurrence rates equivalent to other standard therapies in BD and superficial BCC, but with lower sustained efficacy than surgery in nodular BCC. In contrast, current evidence does not support the use of topical PDT for squamous cell carcinoma. PDT can reduce the number of new lesions developing in patients at high risk of skin cancer and may have a role as a preventive therapy. Case reports and small series attest to the potential of PDT in a wide range of inflammatory/infective dermatoses, although recent studies indicate insufficient evidence to support its use in psoriasis. There is an accumulating evidence base for the use of PDT in acne, while detailed study of an optimized protocol is still required. In addition to high-quality treatment site cosmesis, several studies observe improvements in aspects of photoageing. Management of treatment-related pain/discomfort is a challenge in a minority of patients, and the modality is otherwise well tolerated. Long-term studies provide reassurance over the safety of repeated use of PDT.

Topical photodynamic therapy (PDT) is effective in the treatment of certain non-melanoma skin cancers and is under evaluation in other dermatoses. Its development has been enhanced by a low rate of adverse events and good cosmesis. 5-Aminolaevulinic acid (ALA) is the main agent used, converted within cells into the photosensitizer protoporphyrin IX, with surface illumination then triggering the photodynamic reaction. Despite the relative simplicity of the technique, accurate dosimetry in PDT is complicated by multiple variables in drug formulation, delivery and duration of application, in addition to light-specific parameters. Several non-coherent and coherent light sources are effective in PDT. Optimal disease-specific irradiance, wavelength and total dose characteristics have yet to be established, and are compounded by difficulties comparing light sources. The carcinogenic risk of ALA-PDT appears to be low. Current evidence indicates topical PDT to be effective in actinic keratoses on the face and scalp, Bowen's disease and superficial basal cell carcinomas (BCCs). PDT may prove advantageous where size, site or number of lesions limits the efficacy and/or acceptability of conventional therapies. Topical ALA-PDT alone is a relatively poor option for both nodular BCCs and squamous cell carcinomas. Experience of the modality in other skin diseases remains limited; areas where there is potential benefit include viral warts, acne, psoriasis and cutaneous T-cell lymphoma. A recent British Photodermatology Group workshop considered published evidence on topical PDT in order to establish guidelines to promote the efficacy and safety of this increasingly practised treatment modality.

BACKGROUND: Photodynamic therapy (PDT) is increasingly used as a noninvasive treatment for nodular basal cell carcinoma (BCC), without a sound evidence base. OBJECTIVE: To compare topical PDT, with the use of the sensitizer methyl aminolevulinate, and standard excision surgery in nodular BCC. DESIGN: Prospective, randomized study. SETTING: University dermatology departments. PATIENTS: A total of 101 adults with previously untreated nodular BCC. INTERVENTIONS: Patients received methyl aminolevulinate PDT (n = 52) or surgery (n = 49). The PDT was given twice, 7 days apart, with methyl aminolevulinate cream (160 mg/g) and 75 J/cm(2) red light (570-670 nm). Thirteen patients with a noncomplete response to PDT at 3 months (24% lesions) were retreated. OUTCOME MEASURES: Primary end point was clinically assessed lesion clearance at 3 months after treatment. Secondary end points were sustained response rate at 12 months and cosmetic outcome at 3 and 12 months. Cosmesis and lesion recurrence were further assessed at 24 months. RESULTS: Data from 97 patients (105 lesions) were included in the 3-month per-protocol analysis. Complete response rates did not differ significantly between groups (51/52 [98%] lesions with surgery vs 48/53 [91%] lesions with methyl aminolevulinate PDT; difference [95% confidence interval], 4.8% (-3.4% to 13.0%]; P =.25). At 12 months, tumor-free rates were 50 (96%) of 52 lesions with surgery vs 44 (83%) of 53 with methyl aminolevulinate PDT (P =.15). More patients treated with methyl aminolevulinate PDT than surgery had an excellent or good cosmetic outcome at all time points (significant at 12 and 24 months on patient assessment, P<.05, and at 3, 12, and 24 months on investigator evaluation, P<.001). At 24 months, 5 lesions that had initially cleared with methyl aminolevulinate PDT had recurred, compared with 1 after surgery. CONCLUSIONS: Methyl aminolevulinate PDT is an effective treatment for nodular BCC, and while there is a trend for higher recurrence with this modality, it conveys the advantage over surgery of better cosmesis.