In 2013, Dr. Vishal A. Patel was completing a fellowship in Mohs surgery and cutaneous oncology at Columbia University Irving Medical Center, New York City. During this period, a significant study was published, revealing that most nonmelanoma skin cancers (NMSCs) were treated surgically, irrespective of the patient’s life expectancy. The study’s authors argued that life expectancy should influence treatment decisions, sparking considerable debate among Mohs surgeons.
“The article received a lot of pushback from the Mohs surgery community,” Patel recalled. The value of surgery for older adults, particularly those with limited life expectancy, became a contentious topic. Patel shared these insights at the ElderDerm conference, hosted by the Department of Dermatology at The George Washington University, Washington, DC. The event, described as a pioneering meeting, focused on improving dermatologic care for older adults.
Despite over a decade having passed since the study’s publication, guidelines still largely endorse surgical therapy as the gold standard. Patel, an associate professor of dermatology and medicine/oncology at The George Washington University, noted that the questions raised by the study remain unresolved. This issue grows more urgent as the incidence of skin cancer, especially NMSC, increases among older adults, particularly those over 85 years old. “Our training and treatment guidelines often lead us to opt for the most definitive, yet aggressive, treatments,” said Patel, who also directs the cutaneous oncology program at the GW Cancer Center.
Patel emphasized the need for dermatologists to provide care that aligns with the best interests of older patients. “Surgery may be the gold standard for treating most NMSCs, but is it the best option for our older patients or those with limited life expectancy?” he questioned.
Adopting an Age-Friendly, Whole-Person Care Approach
Dr. Christina Prather, director and professor of geriatrics and palliative medicine at The George Washington University, highlighted the importance of understanding what truly matters to patients. This understanding is crucial for dermatologists as the older adult population becomes an increasingly significant subset of their patients. By 2040, the number of adults aged 85 and older in the United States is projected to nearly quadruple from 2000 levels.
“We currently have fewer than 6,000 practicing geriatricians in the country,” Prather noted. “The healthcare system needs more practitioners who know how to provide age-friendly care.” Dermatology, she added, is among the specialties that need to be “geriatricized.”
The Rising Incidence of NMSC in Older Adults
The incidence of skin cancer is increasing faster than any other type of cancer, Patel said. He referenced data from the Medical Expenditure Panel Survey (MEPS) showing that, on average, 6.1 million adults were treated for skin cancer annually from 2016 to 2018, with 5.2 million cases being NMSC. This represents an increase from an average of 5.8 million annually between 2012 and 2015.
For context, the average number of adults treated annually for non-skin cancers rose from 10.8 to 11.9 million during the same periods. “Skin cancer accounts for about one-third of all cancer cases,” Patel said.
NMSC not only has a higher incidence than melanoma but also shows a more pronounced aging trend. A long-term observational study from Japan revealed a significant increase in the median age of patients with NMSC compared to other cancers, with the median age rising to 80 years by 2021.
Addressing NMSC in Patients with Limited Life Expectancy
The 2013 study that caught Patel’s attention involved 1,536 consecutive patients diagnosed with NMSC at two dermatology clinics. The researchers found that NMSCs were treated aggressively with surgery, regardless of patients’ life expectancy. Patients aged 85 or older or with a Charleston Comorbidity Index ≥ 3 were considered to have a limited life expectancy. Approximately half of these patients died within five years, none from NMSC. Most patients with limited life expectancy were not significantly bothered by their tumors, and about one in five reported treatment complications within two years. The five-year tumor recurrence rate was 3.7%.
A more recent study examined 1,181 patients over 85 with NMSC referred for Mohs surgery. Nearly all were treated surgically, primarily due to high cure rates, functional status, and high-risk tumor types. Patel questioned whether such frequent use of Mohs surgery in elderly patients is always necessary.
Exploring Underutilized Management Options for NMSC
In his practice, Patel prioritizes thorough discussions about the disease and treatment options with his patients. He emphasizes the importance of risk assessment, both in staging and stratifying risk concerning outcomes like recurrence, metastasis, or death. “I think we underutilize risk assessment,” he said.
He also advocates for considering less invasive options, such as shave removal for low-risk squamous cell and basal cell carcinomas, noting that the National Comprehensive Cancer Network guidelines include this option for cases with clear margins. Similarly, disc excision during the initial biopsy might suffice for older patients with obvious or highly suspicious lesions.
Advances in Systemic and Intralesional Treatments
Systemic immunotherapy has become a treatment option for advanced basal cell carcinoma and advanced cutaneous squamous cell carcinoma. Patel mentioned ongoing research into intralesional programmed cell death protein 1 inhibitor treatment, which could offer another alternative for older adults, potentially reducing the need for surgery by targeting drug delivery directly to tumors.
A Personal Perspective on Treatment Decisions
Dr. Prather shared a personal story about her 97-year-old grandfather, who had a skin lesion removed despite cognitive impairment and being on oral anticoagulants. The procedure led to years of wound care and doctor visits, raising questions about its necessity.
“We must critically evaluate what is feasible and important for our older patients,” she said. “What is the most important thing I need to know about the patient?”
The Economic Impact of Skin Cancer Treatment
Patel also highlighted the economic burden of skin cancer treatment. The MEPS survey data showed a nearly 30% increase in the average annual cost of treating NMSC, from $5 billion in 2012-2015 to $6.5 billion in 2016-2018. The average annual costs of treating melanoma, by contrast, decreased slightly. “Skin cancer is a significant drain on our limited resources,” he said.
Rethinking Melanoma Overdiagnosis
Patel urged dermatologists to adopt a holistic approach to skin cancer treatment, considering each patient’s unique situation rather than adhering to a one-size-fits-all treatment model. He referenced a “Sounding Board” article published in The New England Journal of Medicine in 2021, which argued that there is an overdiagnosis of cutaneous melanoma due to increased screening and lower thresholds for biopsy and cancer diagnosis.
“There is a diagnostic disconnect and an issue of overdiagnosis,” Patel said. “We must ask ourselves if all lesions labeled as skin cancers require aggressive treatment and consider what it means for the patient in front of us.”
Conclusion
As the population ages and the incidence of skin cancer rises, particularly among older adults, it is crucial for dermatologists to reevaluate treatment approaches. Embracing age-friendly, whole-person care and considering less invasive options can help ensure that treatments align with the best interests and life expectancy of older patients. By doing so, the dermatology community can better serve this growing patient population and address the increasing burden of skin cancer on both patients and the healthcare system.
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