Health Disparities in Management of Keratinocyte Carcinoma: A Multicenter Observational Study

Background/Objectives: Keratinocyte carcinoma (KC) treatment is guided primarily by tumor characteristics, but sociodemographic factors may also influence care. We examined associations of age, sex, marital status, and educational level with treatment selection. Methods: Adults with actinic keratosis or KC were recruited in four Belgian and Dutch settings between 2020 and September 2023. Treatment was categorized as topical/non-invasive therapy, Mohs micrographic surgery (MMS), or standard surgical excision (reference). Multinomial regression adjusted for histologic group, tumor size, location, recruiting center, and an age-independent Charlson comorbidity component. The primary analysis included 681 participants, with additional sensitivity analyses. Results: The model converged normally. Age (global p = 0.023) and educational level (p = 0.002) were associated with treatment selection; sex and marital status were not. Each additional decade of age was associated with lower odds of MMS versus standard excision (adjusted odds ratio [aOR] 0.755, 95% confidence interval [CI] 0.595–0.959). Low versus high education was associated with lower odds of topical/non-invasive treatment versus standard excision (aOR 0.123, 95% CI 0.034–0.450), but not with MMS (aOR 0.533, 95% CI 0.232–1.222). Conclusions: Age and educational level were associated with KC treatment selection after clinical and center adjustment. These associations do not establish inequitable care because relevant patient-, clinician-, and pathway-level determinants were not captured.