Management of non-melanoma skin cancer (NMSC) in the very elderly patient mandates an individualized approach that takes into account multiple factors relating to tumor and patient characteristics along with the risks and benefits of biopsy and treatment options. Providers should utilize techniques of shared decision making with very elderly patients and their caregivers to help them make informed decisions regarding their treatment options.
“According to statistics from the World Health Organization, there are about 125 million people in the world who are aged 80 years or older and the number will reach 434 million by the year 2050,” says Anne Lynn S. Chang, M.D., associate professor of dermatology, Stanford University School of Medicine, Stanford, Calif. “As the incidence rate of NMSCs is increasing, and because age is the strongest risk factor, dermatologists can expect to see a dramatic increase in very elderly patients with NMSCs.”
In the very elderly, NMSCs are often detected as an incidental finding during a visit when a patient is being seen for another reason, according to Molly Moye, M.D., a fellowship-trained Mohs surgeon in private practice, Forefront Dermatology, Louisville, Ky. She posed the question of whether basal cell carcinomas (BCCs) are being over diagnosed and overtreated in this advanced age population.
An argument that favors biopsy of all suspicious lesions is that it is the only way to avoid missing the diagnosis of a more serious tumor, such as an amelanotic melanoma or Merkel cell carcinoma. To limit that risk, patients and their families can be educated to watch for worrisome changes and about the importance of returning for regular follow-up, Dr. Moye says.
“There is reason to intervene if a lesion is symptomatic, such that it is bleeding, itching or painful, or if it is reported to be growing rapidly,” she says. “In the case of a lesion that is likely to be an indolent BCC and not bothersome to the patient, however, I consider the patient’s overall health status, life expectancy and the likely consequences of treatment versus no treatment, and I have a conversation with the patient and his or her family to achieve shared decision making,” she says.
Dr. Moye recommends performing a biopsy whenever there is suspicion of squamous cell carcinoma (SCC). The pathology report will then guide the treatment decision. The choice of surgical options depends on tumor size, pathologic features, anatomic location and patient characteristics. Mohs surgery is generally indicated for any tumor that is larger than 2 cm, moderately or poorly differentiated, or when there is presence of acantholysis or perineural or perivascular invasion.
“Some of my toughest Mohs surgery cases involve patients who present with recurrence of an aggressive NMSC that was initially treated with electrodessication and curettage or some other less definitive technique. These tumors can grow back very quickly, and, consequently, the area of involvement may be much larger than it was at the time of initial treatment. In this situation, surgery results in much greater morbidity than if the tumor was treated appropriately with surgery at the outset.”
Simple surgical excision, however, may be preferred in some elderly patients given certain circumstances.
Dr. Moye and Dr. Linos have no relevant financial interests to disclose. Dr. Chang receives grants and research funding from Genentech and Regeneron.