Aggressive Surgery for Nonfatal Skin Cancers Might Not Be Best for All Elderly Patients

Surgery is often recommended for skin cancers, but older, sicker patients can endure complications as a result and may not live long enough to benefit from the treatment.        

A new study led by UC San Francisco focused on the vexing problem of how best to handle non-melanoma skin cancers – which are very common -- among frail, elderly patients. In the study sample, the researchers found that most non-melanoma skin cancers were typically treated surgically, regardless of the patient’s life expectancy or whether the tumor was likely to recur or harm the patient.

One in five patients in the study reported a complication from the skin cancer treatment, and approximately half the patients with limited life expectancy died of other causes within five years.

As a result, the authors say, doctors should take into consideration the benefits, risk and preference of a patient when determining appropriate treatment for nonfatal skin cancers.

The study was published online on April 29 in JAMA Internal Medicine. 

“It can be very challenging to decide whether and how to treat patients with non-melanoma skin cancer who have limited life expectancy, especially when the tumors are asymptomatic,” said Eleni Linos, MD, DrPH, an assistant professor of dermatology at UCSF and lead author of the study.

“One challenge is that it is hard to precisely predict an individual’s life expectancy,” Linos noted. “Another challenge is that elderly patients are very diverse. For example, some 90-year-olds are active, healthy and would like to choose the most aggressive treatments for skin cancer, while others are very frail and unable to care for themselves, and may prefer less invasive management for a skin cancer that doesn’t bother them.

“Bothersome or medically dangerous skin tumors should always be treated, regardless of age or life expectancy,” Linos said. “But treatment of asymptomatic tumors might not be the best option for all patients.”

Non-Melanoma Skin Cancer in Older Patients

Skin cancers are by far the most common type of cancer, according to the American Cancer Society. An estimated 2.2 million Americans – predominantly older patients -- are diagnosed annually with a non-melanoma skin cancer, including basal cell carcinoma and squamous cell carcinoma. This type of cancer can be slow-growing and typically does not affect survival or short-term quality of life.

“The current standard of care in the United States is to treat non-melanoma skin cancers,” the authors wrote in their study, “and no guidelines exist about whether physicians should consider patient age or functional status in choosing treatments.”

In comparing treatment options and clinical options, the researchers followed more than 1,300 patients in San Francisco for about a decade. About a quarter of the patients were classified as having limited life expectancy because they were at least 85 years old or they suffered from multiple serious health conditions.

Most of the non-melanoma skin cancers were treated surgically, a taxing process for some seniors who have difficulty tolerating extended procedures or adequately treating their wounds at home. The researchers found that medical complications included poor wound healing, numbness, itching and pain.

Tumor recurrence was very low – less than 4 percent after five years, the authors said. 

Nearly half the patients with limited life expectancy died within five years -- none of the deaths resulted from the skin cancers, the researchers reported. Most deaths were related to heart disease, cerebrovascular disease, lung cancer, pneumonia, chronic respiratory disease, prostate cancer and Alzheimer’s disease.

“The findings highlight a challenge not just for dermatologists, but for all physicians treating non-fatal conditions: to focus not exclusively on treating the disease, but on caring for the patient,” said senior author Mary-Margaret Chren, MD, a dermatology professor at the UCSF School of Medicine. “Our study illustrates a common dilemma for clinicians and patients; it focuses on a cancer whose natural history is generally benign in the short term, and where treatment itself may be discretionary, especially for sicker patients.”

The research was conducted by the Unit for Patient-Oriented Research in Skin Diseases in the Department of Dermatology at UCSF, and supported by the National Center for Research Resources (Award KL2RR024130); the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health (Grants R01 AR 054983 and K24 AR052667); and by Career Development Awards from the American Skin Association and Dermatology Foundation.