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Treatment regimens differed for elderly, younger patients
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Age-related variations were observed throughout treatment for patients with melanoma and might contribute to poorer prognoses for the elderly, according to results of a retrospective study.
Researchers in France evaluated 1,621 patients (mean age, 48 years; 52% women) with stage I or II melanoma diagnosed as primary cutaneous melanoma in 2004 or 2008. Data was obtained from physician questionnaires, as well as a survey of cancer registries and pathology laboratories.
Patients were categorized by age into two groups. The older group included 487 patients aged at least 70 years (mean age, 78 years; 49.6% women), and the younger group included 1,134 patients younger than 70 years (mean age, 50 years; 53% women).
The older patients experienced more melanomas of the head and neck (29.4% vs. 8.7%; P<.001) than younger patients, as well as greater frequency of nodular, lentigo maligna or acral lentiginous melanomas (37.9% vs. 15.4%; P<.001).
Older patients’ tumors were thick and more frequently ulcerated (stage T3 or T4) in 36.7% of cases compared with 20.1% of younger patients.
Older patients were diagnosed with melanoma in general practice settings more often than at regular skin cancer screenings (18.7% vs. 3.5%). After diagnoses, older patients experienced longer time to definitive excision, with 16.8% having insufficient excision margins compared with 5% in younger patients (P<.001).
Among patients with melanoma thicker than 1 mm, sentinel lymph node biopsy was performed in 23.3% of older patients vs. 41.1% of younger patients (P<.001). Adjuvant therapy was recommended more commonly to younger patients than to older patients (58.8% vs. 18.9%; P<.001).
“Age-related variations are observed at every step of melanoma management,” the researchers concluded. “It may therefore be hypothesized that age-related variations in the management of melanoma in the present study might contribute to a poorer overall prognosis in the elderly.”
In an accompanying editorial, John G. Albertini, MD, of the Skin Surgery Center and department of plastic and reconstructive surgery at Wake Forest Baptist Health, and Nicholas B. Countryman, MD, MBA, of the Laser and Skin Surgery Center of Indiana and the department of dermatology at Indiana University, called the findings important.
The results should increase awareness that age bias can influence treatment decisions, Albertini and Countryman wrote.
Yet questions remain, they said.
“We do not know the dialogue exchanged between physician and patient that may have colored these decisions,” Albertini and Countryman wrote. “Perhaps recovery from an illness, use of anticoagulation therapy, lack of desire for sentinel lymph node prognostic information, or the need to care for a disabled spouse strongly influenced the timing, prioritization, and/or aggressiveness of primary or adjuvant treatment. ... The true challenge in bridging these specific melanoma management practice gaps in the elderly mirrors a much greater challenge in modern medicine: How do we reconcile outcomes research that defines population-based best practices with our duty to provide humanistic, artful care of individual patients in the context of their age, comorbidities, and socioeconomic situation?”
Reference:
Ciocan D. JAMA Dermatol. 2013;doi:10.1001/jamadermatol.2013.706.
Perspective
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Elizabeth A. Quigley, MD
Melanoma incidence and mortality rates are greater in the elderly (Wolf J. Cutis. 2013;91:81-86). Higher Breslow thickness, head and neck location, and increased frequency of nodular melanoma contribute to poorer prognosis (Macdonald JB. J Cancer. 2011;2:538-543). Ciocan and colleagues also identified variations in diagnosis, timing and type of treatment, and follow-up care in elderly compared with younger patients. Similar age-related disparities have been described previously in delayed diagnosis (Reyes-Ortiz CA. J Am Geriatr Soc. 2006;54:1758-1764), sentinel lymph node biopsy performance (Martinez SR. J Surg Oncol. 2012;106:807-810) and completion lymphadenectomy (Shah DR. J Surg Res. 2013;doi:10.1016/j.jss.2013.05.090). These variations may contribute to higher mortality, but the effects are unknown. Comorbidity has also been found to affect melanoma prognosis (Grann AF. Br J Cancer. 2013;109:265-271), but the interaction of the comorbidity, tumor characteristics and treatment differences on survival is unknown. Additionally, it is unclear if treatment variations result from patient preference, age bias, comorbidity or other reasons. Further research on the impact of these management variations on mortality is needed. Diagnosing melanoma earlier in elderly patients may improve survival; further research is needed to find and overcome barriers to early diagnosis. As the global population ages and melanoma incidence and mortality increase, understanding melanoma behavior and the impact of treatment in elderly patients is vital. Age-stratified, comorbidity melanoma mortality models may be needed to guide treatment decisions.
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