Frail, elderly patients may not benefit from surgery for nonfatal skin cancers

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 focused on the vexing problem of how best to handle skin cancers among frail, elderly patients. In the study sample, the researchers found that most nonmelanoma 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 5 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 April 29 in JAMA Internal Medicine (2013; doi:10.1001/jamainternmed.2013.639).

"It can be very challenging to decide whether and how to treat patients with nonmelanoma skin cancer who have limited life expectancy, especially when the tumors are asymptomatic," said lead author Eleni Linos, MD, DrPH, an assistant professor of dermatology at University of California San Francisco.

"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 patients aged 90 yearsare 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."

"The current standard of care in the United States is to treat nonmelanoma 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 aged 85 years or they suffered from multiple serious health conditions.

Most of the nonmelanoma skin cancers were treated surgically, a taxing process for 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% after 5 years, the authors said. Nearly half the patients with limited life expectancy died within 5 years, and none of the deaths resulted from the skin cancers, the researchers reported.

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