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Cheryl Guttman Krader is a contributor to Dermatology Times, Ophthalmology Times, and Urology Times.
As age is the strongest risk factor in NMSC, dermatologists can see an increase in this type of cancer in elderly patients, and treatment preferences vary.
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.
“If, in the clinician’s judgment, an elderly patient is unlikely to be able to sit for the lengthy procedure, standard excision can be an acceptable alternative,” Dr. Moye says.
ALTERNATIVES TO SURGERY
In some cases of high-risk or advanced NMSC, surgery may be declined or contraindicated for reasons that include comorbidity or the likelihood of causing significant disfigurement or functional impairment. Surgery itself may also not be enough if there is metastasis to lymph nodes or distant organs.
Systemic treatment options for advanced NMSC include oral Hedegehog pathway inhibitors, vismodegib (Erivedge, Genentech) and sonidegib (Odomzo, SUN Pharma) for advanced BCC and IV cemiplimab (Libtayo, Regeneron)/ Sanofi-Aventis), a programmed death -1 inhibitor, for advanced cutaneous SCC. The use of platinum-based chemotherapy as well as other chemotherapies have also been described in small clinical trials, case series or case reports as treatments for advanced NMSCs.
Radiotherapy can be considered for palliative vs. curative intent. The lack of data about efficacy, safety and quality-of-life impact in the very elderly (age ≥80 years) is an issue for all of these interventions, Dr. Chang says.
“There is not a good evidence base to guide decisions about the use of these treatments for NMSC in the very elderly. Although the clinical trials that led to approval of the newer medical options included participants age 65 and older, the number of such patients is fairly low,” she explains.
“Functional and health status affects the ability of patients to tolerate potential side effects of systemic treatments, and there is a real need for more data,” she says.
When considering the use of a systemic medication for treating NMSC in very elderly patients, Dr. Chang suggests using the Eastern Cooperative Oncology Group performance status scale or the Karnofsky score to assess functional status and ordering laboratory tests to evaluate major organ function.
Individual goals of care and the potential for treatment and follow-up adherence are also taken into account.
“Patients need to remember to take their medications, watch for side effects, and return for appointments. Therefore, it is important to assess the patient’s living situation because they may need a caregiver or family member to assist them in these areas. It is also helpful to provide written instructions using large font and simple verbiage that is easy to understand,” Dr. Chang says.
SHARED DECISION MAKING
Eleni Linos, M.D., Dr.PH., professor of dermatology, Stanford University School of Medicine, Stanford, Calif., advocates for shared decision making and incorporating principles of geriatrics to the care of older adults with skin cancer.
“We need to apply principles of geriatrics to the practice of dermatology when caring for older patients. This type of approach is something our colleagues in pediatric dermatology have been doing for decades when caring for younger patients. It is time to do the same for geriatric dermatology,” Dr. Linos says. “When caring for a on older patient with skin cancer, we cannot only focus on removing skin cancer cells. Instead, we need to think about the patient’s overall health, multimorbidity, polypharmacy, function, cognition, mobility, social support, life expectancy and, especially, the patient’s preferences.”
Doctors need to balance the benefits and harms of treatment for each patient, she adds.
“Older adults are a diverse group with varying medical needs, values, life expectancies and preferences, and the relative weight of benefits and harms will often be swayed by the patient’s preferences. Therefore, we cannot follow a onesize-fits-all recommendation for the treatment of NMSCs in this population. The relative weight of benefits and harms will often be swayed by the patient’s preferences.”
Dr. Moye and Dr. Linos have no relevant financial interests to disclose. Dr. Chang receives grants and research funding from Genentech and Regeneron.