All pretty obvious actually
- Surgical treatment of nonmelanoma skin cancer in elderly patients with other underlying health conditions may do more harm than good, researchers found.Surgical treatment of nonmelanoma skin cancer in elderly patients with other underlying health conditions may do more harm than good.
- Note that 43% of patients with limited life expectancy and nonmelanoma skin cancer died within 5 years of the study baseline from complications unrelated to their skin cancer.
In a cohort of nonmelanoma skin cancer patients, those with limited life expectancy experienced more complications with therapy (20%) than those who did not have limited life expectancy (15%), according to Eleni Linos, MD, DrPH, of the University of California San Francisco, and colleagues.
In addition, 43% of patients with limited life expectancy and nonmelanoma skin cancer died within 5 years of the study baseline from complications unrelated to their skin cancer, such as heart disease, prostate cancer, and Alzheimer’s disease, they wrote online inJAMA Internal Medicine.
Patients were considered of limited life expectancy if they were 85-years-old or older or if they had a Charlson Comorbidity Index score of 3 or greater, the authors explained.
Nonmelanoma skin cancers “grow slowly, rarely metastasize or affect survival, and typically do not result in significant morbidity or diminished quality of life.” These tumors are often asymptomatic “and patients are often unaware of them,” the authors said, adding that treatment for nonmelanoma skin cancer is meant to prevent expansion and local recurrence of the tumor.
They also noted that nonmelanoma skin cancer is the fifth most costly cancer for Medicare.
The researchers compared treatment patterns and clinical outcomes in patients with nonmelanoma skin cancer who were of limited life expectancy with patients who were not of limited life expectancy at two California dermatology clinics (one private and one university-affiliated Veterans Administration program).
Treatment options included elliptical excision, chemosurgery (Mohs surgery), tumor destruction, and no treatment. Overall, 68.7% of tumors underwent surgery.
Data were collected through clinician notes and pathology records.
The patient population included 1,360 patients with 1,739 tumors, including 332 patients with 428 tumors who were of limited life expectancy. Median patient age was 69 years. Most participants were male (72.7%) and had a comorbidity index score of 1. Roughly one quarter of patients were bothered by their tumor frequently (22%).
Tumor recurrence was uncommon both in the overall study population and among patients with limited life expectancy at 5 years (3.7% for both). Among limited life expectancy patients with tumor recurrence, 9 of 14 died within a median time of 21 months after recurrence of non-nonmelanoma skin cancer causes.
Patients who were not of limited life expectancy had better 5-year mortality than those of limited life expectancy (11% versus 43.3%, P<0.001). Overall 10-year mortality was 49.9%, but was significantly higher among those with limited life expectancy (76.8% versus 32.7%, P<0.001).
No patients in the study died of nonmelanoma skin cancer-related causes. Leading causes of death in the study population included ischemic heart disease and myocardial infarction, cerebrovascular disease, lung cancer, pneumonia and chronic respiratory diseases, prostate cancer, and Alzheimer’s disease.
Most patients’ tumors were treated surgically, either with excision (34.5%) or chemosurgery (34.2%). Roughly a quarter (26.7%) of patients’ tumors were destroyed through cryotherapy, electrodessication and curettage, laser, or irradiation. Only 3.1% of patients received no treatment. Rates of treatment did not differ significantly between limited life expectancy and nonlimited life expectancy groups.
In a subsample of patients who responded to a questionnaire about treatment-related complications (671 patients, including 212 with limited life expectancy), 30% reported a complication after treatment. Of those reporting complications, 32% were of limited life expectancy.
Common complications included poor wound healing, numbness, itching, and pain.
Finally, treatment patterns did differ between the two study sites, with more surgery (chemosurgery plus excision) performed at the VA center compared with the private clinic (multivariable adjusted relative risk 0.87, 95% CI 0.77 to 1.00, P=0.04).
The authors noted that although symptomatic or medically nonmelanoma skin cancer tumors should be treated regardless of a patient’s life expectancy, asymptomatic tumors “may not be indicated,” and treatment should be considered for benefits, risks, and patient preference.
In an accompanying editorial, Neil Wenger, MD, MPH, of the University of California Los Angeles, seconded the emphasis for shared decision making, particularly in limited life expectancy patients who may not be at increased risk of mortality from disease and who may have quality of life affected by invasive treatment.
“The findings suggest that we are training a new generation of physicians who will inadequately regard the importance of open, honest, patient-oriented communication that strives to facilitate optimal clinical decisions,” he wrote.
The authors noted that the major study limitation was an observational design. The study was also limited by potential lack of generalizability because half of the cohort were veterans