10. Occupational disease of squamous cell carcinoma of the skin or/and actinic keratosis – Actinic keratosis and squamous cell carcinoma of the skin

See: https://www.dguv.de/bk-info/icd-10-kapitel/kapitel_12/bk5103/index.jsp

On January 1st, 2015, with the amendment of the Occupational Diseases Ordinance (BKV), the occupational disease (BK) No. 5103 BKV: "Squamous cell carcinoma or multiple actinic keratoses of the skin caused by natural UV radiation“ was included as a new occupational disease in the BKV list.

According to § 202 SGB VII, physicians are legally obligated to report an occupational disease if there is a reasonable suspicion that an occupational disease exists in the course of an insured occupational activity. This also applies to dentists and entrepreneurs. A report must be made even if the insured person objects. It can only be dispensed with if there is certainty that the illness has already been reported. A reasonable suspicion of an occupational disease can also (but does not have to) be reported by the insured person concerned, family, friends, etc.

The medical BK notification must be made if there is a reasonable suspicion that an occupational disease in the sense of the so-called „BK list“ (Annex 1 of the Occupational Diseases Ordinance (BKV)) exists. In the case of BK No. 5103 BKV, the suspicion is well-founded if the following have been diagnosed at work-related exposed body regions:

• a SCC or
• a Bowen carcinoma or
• their precursors, AK or Bowen's disease

The precancerous lesions must be multiple in the sense of BK-No. 5103 BKV, i.e. with a number of more than 5 within 12 months or a field cancerization in a confluent area larger than 4 cm².

In addition, there must have been relevant work-related UV exposure from outdoor work. A rough estimate is sufficient for this at the time of reporting. The guideline value is a ratio of private and work-related UV exposure. Since the private dose increases with each year of life, the work-related UV exposure duration required for BK recognition also increases. Long-term exposure for the purposes of this occupational disease is considered to be, for example, for an age of

• 50 years - 15 years of outdoor work
• 60 years - 18 years of outdoor work
• 70 years - 21 years of outdoor work
• 80 years - 24 years of outdoor work

Histological confirmation of the diagnosis is required for the presence of SCC, but not for multiple AK, in which case clinical diagnosis is sufficient. Nevertheless, it is recommended that histology be performed for at least one of the present AKs and that this be enclosed with the BK report.

The SCC and/or AK/field cancerization must be localized on occupationally exposed areas such as face, ears, capillitium, neck, hands, and forearms. However, depending on the particular outdoor activities and the inadequate or lack of protective measures in many cases, other localizations may also be considered as occupational, e.g. the back if work was regularly performed without a shirt.

The following occupations/activities are listed in the scientific rationale as being at significantly higher risk than the rest of the population for developing multiple AK or SCC due to occupational natural UV exposure: Agriculture, forestry, nurseries, fishing and maritime, construction and trades (e.g., roofers, carpenters, builders, masons, steelworkers, etc.), road workers, lifeguards, mountain guides, and the like. But it is not so much the occupation that matters, but the actual activity performed outdoors. Bicycle couriers, sports instructors, educators in day-care centers, waiters in beer gardens etc. are also potentially at risk.

The medical report in the event of a suspected occupational disease is submitted using form F6000 „Medical report in the event of a suspected occupational disease“ to the responsible statutory accident insurance institution (Employer's Liability Insurance Association, Accident Insurance Fund) or to a state authority as the body responsible for medical occupational safety and health (http://www.dguv.de/medien/formtexte/aerzte/f_6000/f6000.pdf). It must be submitted without delay, i.e. without culpable hesitation. The report is remunerated separately by the AIF agency (UV-GOÄ No. 141). The insured persons must be informed of the contents and of the AIF institution to which the BK notification is sent. The responsible AIF institution depends on the last hazardous activity of the insured person and is:

• in the case of companies in the commercial sector, an employers' liability insurance association (broken down by industry),
• in the case of public-sector companies, one of the regionally subdivided accident insurance funds, and
• for activities in agriculture and horticulture, the Social Insurance for Agriculture, Forestry and Horticulture (SVLFG).

Special regulations apply to civil servants (e.g. in the police service or the armed forces) and other persons who are not insured under the statutory accident insurance scheme, and the suspected BK must generally be reported to the employer by the person who has fallen ill. Further details are regulated in the respective civil service pension laws of the federal states/federal government.

As a follow-up to the BK report, the dermatologist usually receives the form Skin Cancer Report from the UVT. In this report, a detailed history of the disease is requested (F 6120-5103 0416 Skin cancer report, http://www.dguv.de/medien/inhalt/versicherung/bk/hautkrankh/documents/f6120_5103.pdf, see appendix), so that the UVT can check whether there is or was a connection between the reported skin cancer and the occupational effects. The skin cancer report also asks about basal cell carcinomas (not relevant for BK 5103), as the report is also used for the skin cancer facts listed below (BK5102, BK1108, BK2402).

Work-related skin cancers can also be caused by work-related exposure to certain carcinogens. Currently, the BK numbers listed below may apply.

 

See: https://www.dguv.de/bk-info/icd-10-kapitel/kapitel_01/bk1108/index.jsp

After occupational exposure to arsenic or arsenic compounds, AK, SCC, as well as Bowen's disease, Bowen's carcinomas and basal cell carcinomas (predominantly superficial basal cell carcinomas) also occur on body parts covered by clothing. Pathognomonic manifestations include palmoplantar keratoses, but these may not always be present. SCC arise from precursors or on unchanged skin. Arsenic is absorbed into the body in the form of dust, vapor, or gas through the respiratory tract, gastrointestinal tract, and skin. A threshold for carcinogenic effects cannot be quantified at this time. Biological effects have been observed even at low concentrations [557]. Sources of occupational hazards are rarely found today, e.g., in semiconductor manufacturing. In addition, arsenic or arsenic compounds can be a component of alloys.

Latency periods between exposure and disease manifestation may take years to decades. For Bowen's disease and basal cell carcinoma, latency periods of an average of 17.8 years and for SCC of an average of 19.7 years after initial contact with arsenic have been published [558]. The BK-Nr. 1108 BKV plays almost no role in dermatological practice anymore, since contamination is extremely unlikely due to optimized occupational safety measures. Historical exposures, e.g. due to the application of arsenic in viticulture, are rarely of importance today, as the persons affected have often already died due to old age. 

See: https://www.dguv.de/bk-info/icd-10-kapitel/kapitel_02/bk2402/index.jsp

Ionizing radiation can cause malignant diseases of the skin, depending on the dose (see scientific justification for BK No. 2402 BKV), such as SCC and basal cell carcinoma, rarely fibrosarcoma and angiosarcoma. Workers in the medical field, in material testing, in the X-ray apparatus or X-ray tube industry may be exposed to X-rays directly or indirectly via scattered radiation. Radioactive substances and elements in appropriate doses can be a source of danger to persons who come into contact with these substances or the radiation they emit during extraction, processing, use, or transport (medical diagnostics or therapy, scientific examinations, materials testing, measurement procedures, industrial processing and application of radionuclides, activities in uranium mining and in nuclear facilities). The latency period between radiation exposure and the development of basal cell carcinoma is estimated to be at least 20 years [559][560]. The latency period for SCC is reported to be at least 20–30 years [561].

See: https://www.dguv.de/bk-info/icd-10-kapitel/kapitel_02/bk5102/index.jsp

This is one of the oldest occupational diseases in Germany, having been included in the BKV as early as 1925. According to current knowledge, substances in the sense of BK No. 5102 BKV can cause SCC and carcinomata in situ as well as basal cell carcinomas. Direct skin contact plays an essential role in this context. The latency period from initial exposure to the appearance of the corresponding skin tumors can be years to decades. This development is also possible after cessation of exposure.

Often, when the skin cancer appears, there are other signs of a so-called „tar or pitch skin disease“ (e.g. folliculitis, acne, brownish diffuse pigmentation (melanosis), hyperkeratosis), but the tumors can also appear without these bridging symptoms. On such altered skin, but also without these changes, single or multiple so-called tar or pitch warts (carcinomata in situ) can develop. Tar or pitch warts occur mainly on the face (including the nose, periorbital region, ears) and on the back of the hand, but also on the forearm, lower abdomen, and scrotum.

There is no more precise information on how long/how intense chronic PAH–exposure must be in each activity to induce tumors. For a cumulative exposure of ≥ 2 years during the working life, a report should be made at the first manifestation of an epithelial tumor or precancerous lesion (see above). A detailed exposure determination is made by the UVT in the determination procedure.

The latency period from exposure to tumor manifestation may take years to decades. In an evaluation of data from tar refinery workers (1946–2002), SCC was found after an average latency period of 29.1 years and for basal cell carcinoma of 36.0 years after the onset of exposure [562].

For BKs B-No. K5102, 2402 and 1108 BKV no minimum number/area of precancerous lesions is required. A BK report is made at the occurrence of the first precancerous lesion or one of the above-mentioned tumors.