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Core principles can help patients make informed decisions with confidence
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The report by Linos and colleagues 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.
In this prospective cohort study, 1,536 patients with NMSC were recruited over a 1-year period, then followed for a decade after enrollment. Analyzed outcomes included treatment patterns, tumor recurrence, mortality and complications. Of the included 1,360 patients, 68.7% of tumors were treated with Mohs’ surgery or traditional surgical excision; 26.7% were treated with a destructive modality (eg, cryotherapy, electrodesiccation and curettage, laser, etc); and 3.1% received no treatment.
Joseph F. Sobanko
The authors are to be commended for a study that required a great deal of teamwork and effort, but it is important for patients and readers to be aware of certain issues that have the potential to be misinterpreted.
Definition of LLE
Linos and colleagues state that patients aged older than 85 years or with a LLE (Charlson Comorbidity Index [CCI] of 3 or higher) received a similar amount of surgical treatment for NMSC when compared with younger and healthier patients. Close inspection of the authors’ definition of LLE reveals that this conclusion demands further attention.
The CCI is a tool that attempts to predict the 10-year mortality of patients by adding a score that is assigned to various medical comorbidities; the higher the score, the worse the patient prognosis. Charlson herself updated the original CCI, stating that combining age and comorbidities into a single score better predicts patient prognosis for studies that involve more than 1 to 2 years of follow-up.
With this new CCI, the following patients would meet the authors’ criteria for LLE: a patient aged 61 years or older; a 51-year-old with a history of peptic ulcer disease; a 55-year-old with a history of a myocardial infarction; a 41-year-old with Hodgkin’s lymphoma; and a 45-year-old with moderate renal disease. In all five of these clinical scenarios, the 10-year survival for these patients is 77.5%.
Presuming that age was not factored into the authors’ CCI calculation, a patient would need more comorbidities to reach a CCI of 3 (eg, history of myocardial infarction plus history of peptic ulcer disease plus history of connective tissue disease). However, the authors analyze the LLE arm of data by combining all patients with a CCI of 3 or more together. It stands to reason that the health and surgical risk of a patient with a CCI of 3 varies markedly from a patient with a CCI of 6 (eg, a patient with AIDS). The 12-month mortality of a patient with a CCI of 3 is 19.3% compared with 37% in the patient with a CCI of 6. If the authors wish to demonstrate that discretion was not exercised when treating NMSC patients, they must reveal what treatments were selected, if any, when patients were stratified by CCI.
Early detection, early treatment
A second point to be highlighted in this article are the notions that NMSC are asymptomatic and grow slowly, and that treatment benefits may not occur within LLE patients’ remaining life span. Are patients and readers to believe that patients with a CCI of 3 don’t benefit from removal of their NMSC?
Predictive models estimate that more than three-quarters of these patients will be alive for at least a decade following NMSC diagnosis. Although it is true that NMSC may be asymptomatic, they frequently exhibit subclinical extension, resulting in larger and more challenging tumors to treat over time. As NMSC grow, they become more painful and invade surrounding structures, such as nerves, vessels and bone. Their subsequent eradication becomes significantly more involved than were it treated upon initial detection.
A guiding principle of NMSC management is similar to that of melanoma — early detection and treatment. Patient outcomes such as morbidity and mortality are improved with early detection and treatment of melanoma. Likewise, patient morbidity is reduced significantly with early detection and appropriate treatment of NMSC. Thus, standard of care for NMSC should remain early treatment, regardless of the chosen modality (surgical excision vs. curettage, etc). It is precisely this reason that the patients in the aforementioned clinical scenarios (CCI of 3) should be told they have “cancer” and not an “abnormal cluster of cells,” as suggested in a recent blog highlighting the investigation in question.
Treatment complications
A final item that must be addressed in this study is the conclusion that 1 in 5 patients with LLE — and 15% of patients overall — reported “complications” of 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, patients were asked to respond to the question, “In your opinion, were there any complications of your treatment during or after the treatment itself?” Then they were asked to grade the severity of the complication.
It is not surprising that the “complication” rate approaches 20% for those with LLE because the authors allow anticipated effects of cancer surgery, such as itching and discomfort, to be tallied. No cutaneous oncologic procedure (surgical or destructive) comes without varying amounts of these subjective items. Informed consent with surgical and destructive treatments for NMSC necessitates that patients be aware that, although these undesirable events may occur, they are frequently transient and minor.
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.
These data highlight that the complications in the study by Linos and colleagues are, in fact, not what most consider true complications. The authors would be advised to state what the objective complication rate is in all patients. Although it is very important to understand how patients “feel” postoperatively, it is imperative that this be separated from what is measurable and avoidable.
Dialogue needed
Prudent use of procedures in all patients, particularly the elderly and those with LLE, is an irrefutable principle. Certainly not all NMSC require surgical management. Patients with severe illness and multiple comorbidities may be poor surgical candidates, even in the outpatient setting, and require alternative approaches to their NMSC. 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:
With these principles in mind, patients can make informed decisions with confidence.
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For more information:
Joseph F. Sobanko, MD, is director of dermatologic surgery education and assistant professor of dermatology at the Hospital of the University of Pennsylvania’s Perelman Center for Advanced Medicine. He can be reached at Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, Division of Dermatologic Surgery and Cutaneous Oncology, 3400 Civic Center Blvd., Suite 1-330S, Philadelphia, PA 19104; email: joseph.sobanko@uphs.upenn.edu.