Geographic Analysis of Search Engine Utilization Trends Related to Nonmelanoma Skin Cancer and Mohs Micrographic Surgery, 2015 to 2020: Implications for Public Interest and Awareness in the United States.

The incidence of nonmelanoma skin cancer (NMSC) continues to rise in the United States, and is associated with significant morbidity and health expenditure. Prevention and early detection remain critical; as a result, major public health initiatives to increase public awareness have been directed by the American Academy of Dermatology, such as Skin Cancer Detection and Prevention Month. Public interest in Mohs micrographic surgery (MMS) is also increasing, because this treatment modality often demonstrates the greatest cure rate, lowest recurrence rate, and superior cosmetic outcomes in the treatment of NMSC. However, despite these positive developments, little is known regarding how public interest and awareness in skin cancer and MMS vary across different regions of the United States. As online resources have become an essential source of patient education, Google Trends permits insight and analysis into these informationseeking behaviors. The objective of this study is to use search engine analytics to approximate geographic variation in patient interest in skin cancer andMMS in the United States from 2015 to 2020. This study was exempt from review by the institutional review board; only publicly available data was used in our analyses. Google Trends was accessed on April 21, 2020 to evaluate the relative search volume indices (SVI) for queries relevant to non-melanoma skin cancer (i.e., “basal cell carcinoma,” “squamous cell carcinoma,” and “skin cancer”) and MMS (i.e., “Mohs surgery”) in the United States from May 17, 2015 to February 16, 2020. Google Trends reports relative SVI over time in a user-specified time interval and region. Values are normalized from 0 to 100. An SVI of 100 is associated with the location with the greatest interest as a fraction of total searches in that location, whereas an SVI of 0 indicates that a search item in a location was less than 1% as popular compared with the location with the maximum relative search interest. The primary outcome was the SVI in each U.S. state and the District of Columbia during the study interval. The output and data analysis were generated using STATA software, Version 16 (StataCorp, College Station, TX). AMoran’s I test was used to assess for spatial autocorrelation using ArcGIS (GIS software), Version 10.4 (Environmental Systems Research Institute Inc., Redlands, CA). Gradual increases in SVI are seen for both MMS (See Supplemental Digital Content 1, Figure S1, http://links.lww. com/DSS/A668) and skin cancer (See Supplemental Digital Content 2, Figure S2, http://links.lww.com/DSS/A669) queries, although the latter demonstratedamoremodest increaseduring the study interval. The search term “skin cancer” had a notable seasonal variability with SVI peaks seen during the summer months. A random geospatial distribution of SVI was seen for basal cell carcinoma (Moran’s I50.036374,p5 .525656) and skin cancer (Moran’s I 5 0.080501, p 5 .240998). The geospatial distribution of SVI of squamous cell carcinoma approached but did not achieve statistical significance (Moran’s I5 0.137160, p5 .070796) (See SupplementalDigital Content 3, Figure S3, http://links.lww.com/DSS/A670). In contrast, significant geospatial clustering of SVI was detected for MMS (Moran’s I 5 0.273847, p 5 .002336) (Figure 1). The greatest SVI for MMS were seen in Rhode Island, New Hampshire, Pennsylvania, Maine, and Arizona, whereas Alaska, Hawaii, Montana, North Dakota, South Dakota, Vermont, and Wyoming demonstrated the lowest (See Supplemental Digital Content 4, Table 1, http://links. lww.com/DSS/A671). Our findings corroborate prior studies demonstrating an overall growth in national public interest in MMS. However, despite this encouraging trend, significant geographical clustering is demonstrated, suggesting that this growth has been disproportionate, with particular deficiencies seen in more rural states. This variation is likely multifactorial, and may be in part explained by an uneven distribution of the MMS workforce, which shows a high saturation in metropolitan areas and deficits in rural areas; the lack of local access to MMS in some regions may limit patient awareness and interest in the procedure despite its effectiveness. However, this is not the sole factor, as there are some states—such as Rhode Island, Pennsylvania, and New Hampshire—in which interest in MMS outpaces relatively lower skin cancer-related SVI. As the incidence of NMSC continues to rise in the United States, our data suggests regions in which dedicated education campaigns, tailored to the specific needs of the local patient population, may augment its recognition. There is an opportunity to improve and promote online educational content related to MMS—which does not have geographic barriers—with accessible, graphical, and evidence-based content. For example, current MMSrelated online resources have been shown to be written at an excessively high reading level. In contrast, our analysis also shows that the growth in SVI for search queries related to NMSC (i.e., “basal cell carcinoma,” “squamous cell carcinoma,” and “skin cancer”) has been more geographically egalitarian. Previous studies have suggested that the overall increase in public interest may be related to the increasing incidence of NSMC in the United States. In turn, greater SVI for these search http://dx.doi. org/10.1097/DSS.0000000000002936