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Most nonmelanoma skin cancers treated surgically, regardless of life expectancy
Regardless of a patient’s life expectancy, most nonmelanoma skin cancers were treated surgically, according to recent study results.
“It can be very challenging to decide whether and how to treat patients with nonmelanoma skin cancer who have limited life expectancy, especially when the tumors are asymptomatic,” researcher Eleni Linos, MD, DrPH, assistant professor of dermatology at University of California, San Francisco, said in a press release.
Eleni Linos
“One challenge is that it is hard to precisely predict an individual’s life expectancy. Another challenge is that elderly patients are very diverse … some 90-year-olds are active, healthy and would like to choose the most aggressive treatments for skin cancer, while others are very frail … and may prefer less invasive management for a skin cancer that doesn’t bother them.”
In a prospective cohort study, Linos and colleagues evaluated 1,360 patients with nonmelanoma skin cancer (NMSC; 1,739 tumors) diagnosed and treated in 1999-2000 at a university-based private practice and a Veterans Affairs Medical Center in San Francisco. Patients aged 85 years or older at diagnosis or with multiple comorbidities (Charlson Comorbidity Index ≥3) defined limited life expectancy (LLE). No treatment, destruction, or elliptical excision or Mohs micrographic surgery (MMS) were treatment options and used as the main outcome and measure.
There were 68.7% of the NMSCs treated surgically (34.2%, MMS; 34.5%, elliptical excision). In univariate and multivariate models adjusted for tumor and patient characteristics, patient prognosis did not influence choice of surgery. Forty-three percent of patients with LLE died within 5 years, none related to NMSC. In all patients, tumor recurrence was rare (3.7% at 5 years; 95% CI, 2.6%-4.7%). Complications, including poor wound healing, numbness and itching, were reported by 20.2% of patients with LLE compared with 14.9% of other patients.
“Bothersome or medically dangerous skin tumors should always be treated, regardless of age or life expectancy,” Linos concluded. “But treatment of asymptomatic tumors might not be the best option for all patients.”
Disclosure: Researcher Mary-Margaret Chren, MD, is a consultant for Genentech.
Perspective
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The recently published study by Linos et al addresses the management of basal cell and squamous cell carcinomas at two dermatology clinics in Northern California. An emphasis is placed on determining if nonmelanoma skin cancer (NMSC) is managed differently in patients with limited life expectancy (LLE) compared with healthier and younger patients. The authors justify this approach because there is a current paucity of data investigating whether patient age or functional status influences NMSC treatment decisions and patient outcomes.
While the authors are to be commended for a study that required a great deal of teamwork and effort, it is important for patients and readers to be aware of certain issues that have the potential to be misinterpreted.
First, the investigators state that NMSCs are asymptomatic, grow slowly, and treatment benefits may not occur within LLE patients’ remaining life spans. Yet, patients with a Charlson Comorbidity Index of 3 are included in the LLE arm. Predictive models estimate that over three-fourths of these patients will be alive for at least a decade following NMSC diagnosis. While it is true that NMSCs may be asymptomatic, they frequently exhibit subclinical extension resulting in larger and more challenging tumors to treat over time. As NMSCs grow, they become more painful, invade surrounding structures such as nerves, vessels, and bone, and their subsequent eradication becomes significantly more involved than if it were treated upon initial detection. A guiding principle of NMSC management is similar to that of melanoma — early detection and treatment improves patient outcomes.
The second item that must be addressed is the conclusion that one in five patients with LLE (and 15% of patients overall) reported “complications” from therapy. Because death and other life-threatening complications occur so infrequently in skin cancer surgery, other definable complications must be utilized. Traditionally, these include infection, bleeding, necrosis and dehiscence. These four variables are objective, easily measured and often avoidable. Unfortunately, in the current study, anticipated effects of cancer surgery such as itching and discomfort were included. When the term “complication” was responsibly qualified and quantified in a multicenter prospective cohort study of 1,792 skin cancer resections, no major complications were identified, and minor complications occurred in less than 3% of cases. With regard to elderly patients, when a cohort of 214 patients aged older than 90 years was followed after their skin cancer resection, only one patient experienced a complication.
Prudent use of procedures in all patients, particularly the elderly and those with LLE, is an irrefutable principle. Certainly not all NMSCs require surgical management However, readers of this article should not be deterred from offering surgical treatment for NMSC in the elderly and those with medical comorbidities. A dialogue must occur between practitioner and patient and all treatment options should be discussed. Patients must be made aware that: 1. Skin cancer is more easily treated when detected early; 2. Few predictive models currently exist regarding which cancers will become rapidly aggressive and fatal; 3. Outpatient dermatologic surgery is safe and comes with very few complications. With these principles in mind, patients can make informed decisions with confidence.