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Van Coile L, Brochez L, Verhaeghe E, Boone B, Meertens A, Ongenae K, Hoorens I. A critical re-evaluation of Mohs micrographic surgery for a facial basal cell carcinoma in older adults: Should we waive this treatment in certain patients? J Eur Acad Dermatol Venereol 2023; 37:1792-1798. [PMID: 37147863 DOI: 10.1111/jdv.19158] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/27/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Skin cancer incidences are increasing. Treatment for basal cell carcinomas (BCCs) can be questioned in certain patients. Treatment options are various, but Mohs micrographic surgery (MMS) has the highest cure rate. It is, however, time-consuming and results in high logistical burden and treatment costs for both patients and society. OBJECTIVES This study critically re-evaluates MMS for facial BCCs in older adults. The main objective is to examine all clinical, tumour and patient characteristics in relation to safety and survival to detect a subgroup in which MMS was not the best choice. The overall aim is to identify characteristics that support clinical decision-making in daily practice. METHODS Patients that received MMS between November 1998 and December 2012 were included. Only patients >75 years with a facial BCC were withheld for analysis. This is a retrospective cohort study, since evaluating the outcome of MMS in accordance with life expectancy is the main objective. Patient charts were evaluated towards comorbidities, complications and survival. RESULTS This cohort comprises 207 patients. Median survival was 7.85 years. The age-adjusted Charlson comorbidity index (aCCI) was divided into low/medium scores (aCCI < 6) and high scores (aCCI ≥ 6). Median survival was 11.58 years in the low aCCI group and 3.60 years in the high aCCI group (p < 0.001). There was a very strong association between high aCCI and survival (HR, 6.25; 95% CI, 3.83-10.21). Other characteristics were not associated with survival. CONCLUSIONS Clinicians should assess the aCCI in older patients presenting with a facial BCC before deciding if MMS is an eligible treatment option. High aCCI has shown to be an indicator for low median survival, even in MMS patients with usually high functional status. MMS should be waived as treatment in older patients with high aCCI scores in favour of other, less intensive and less expensive treatment options.
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Affiliation(s)
- Laura Van Coile
- Department of Dermatology, University Hospital Ghent, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - Lieve Brochez
- Department of Dermatology, University Hospital Ghent, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - Evelien Verhaeghe
- Department of Dermatology, University Hospital Ghent, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - Barbara Boone
- Department of Dermatology, University Hospital Ghent, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - Annick Meertens
- Department of Dermatology, University Hospital Ghent, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - Katia Ongenae
- Department of Dermatology, University Hospital Ghent, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - Isabelle Hoorens
- Department of Dermatology, University Hospital Ghent, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
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Maisel-Campbell A, Lin KA, Ibrahim SA, Kang BY, Anvery N, Dirr MA, Christensen RE, Aylward JL, Bari O, Bhatti H, Bolotin D, Cherpelis BS, Cohen JL, Condon S, Farhang S, Firoz B, Garrett AB, Geronemus RG, Golda NJ, Humphreys TR, Hurst EA, Jacobson OH, Jiang SB, Karia PS, Kimyai-Asadi A, Kouba DJ, Lahti JG, Council ML, Le M, MacFarlane DF, Maher IA, Miller SJ, Moioli EK, Morrow M, Neckman J, Pearson T, Peterson SR, Poblete-Lopez C, Prather CL, Ranario JS, Rubin AG, Schmults CD, Swanson AM, Urban C, Xu YG, Alam M, Yoo S, Poon E, Harikumar V, Weil A, Iyengar S, Schaeffer MR. Nonmelanoma Skin Cancer in Patients Older Than Age 85 Years Presenting for Mohs Surgery: A Prospective, Multicenter Cohort Study. JAMA Dermatol 2022; 158:770-778. [PMID: 35612849 DOI: 10.1001/jamadermatol.2022.1733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs. Objective To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals. Design, Setting, and Participants This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019. Exposures Mohs surgery for nonmelanoma skin cancer. Main Outcomes and Measures Reason for treatment selection. Results Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%]). Conclusions and Relevance This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.
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Affiliation(s)
- Amanda Maisel-Campbell
- Department of Dermatology, Feinberg School of Medicine, Chicago, Illinois.,Department of Dermatology, Columbia University Medical Center, New York, New York
| | - Katherine A Lin
- Department of Dermatology, Feinberg School of Medicine, Chicago, Illinois
| | - Sarah A Ibrahim
- Department of Dermatology, Feinberg School of Medicine, Chicago, Illinois
| | - Bianca Y Kang
- Department of Dermatology, Feinberg School of Medicine, Chicago, Illinois
| | - Noor Anvery
- Department of Dermatology, Feinberg School of Medicine, Chicago, Illinois
| | - McKenzie A Dirr
- Department of Dermatology, Feinberg School of Medicine, Chicago, Illinois
| | | | - Juliet L Aylward
- Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison
| | - Omar Bari
- Mohs and Dermatologic Surgery Center, University of California, San Diego.,Division of Dermatology, University of California, Los Angeles
| | - Hamza Bhatti
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Somerset, New Jersey.,The Skin Institute of South Florida, Coral Springs
| | - Diana Bolotin
- Section of Dermatology, University of Chicago, Chicago, Illinois
| | - Basil S Cherpelis
- Department of Dermatology and Cutaneous Surgery, University of South Florida College of Medicine, Tampa
| | - Joel L Cohen
- AboutSkin Dermatology, Denver, Colorado.,Department of Dermatology, University of California Irvine
| | - Sean Condon
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio.,The Center For Dermatology Care, Thousand Oaks, California
| | - Sheila Farhang
- Department of Dermatology and Cutaneous Surgery, University of South Florida College of Medicine, Tampa.,Avant Dermatology and Aesthetics, Tucson, Arizona
| | - Bahar Firoz
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Somerset, New Jersey
| | | | - Roy G Geronemus
- Ronald O. Perelman Department of Dermatology, New York University Langone Medical Center, New York, New York.,Laser and Skin Surgery Center of New York, New York, New York
| | - Nicholas J Golda
- Department of Dermatology, University of Missouri School of Medicine, Columbia
| | - Tatyana R Humphreys
- Main Line Center for Skin Surgery, Bala Cynwyd, Pennsylvania.,Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Eva A Hurst
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri.,Distinctive Dermatology, Fairview Heights, Illinois
| | - Oren H Jacobson
- Revere Health Central Utah Mohs, Provo.,St George's University School of Medicine, Grenada, West Indies
| | - S Brian Jiang
- Mohs and Dermatologic Surgery Center, University of California, San Diego
| | - Pritesh S Karia
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - David J Kouba
- Wayne State University School of Medicine, Detroit, Michigan.,Toledo Clinic Facial Plastics and Dermatology, Toledo, Ohio
| | - James G Lahti
- Dermatology Partners of North Shore, Northbrook, Illinois
| | - Martha Laurin Council
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Marilyn Le
- Main Line Center for Skin Surgery, Bala Cynwyd, Pennsylvania
| | | | - Ian A Maher
- Department of Dermatology, St Louis University, St Louis, Missouri.,Department of Dermatology, University of Minnesota, Minneapolis
| | | | - Eduardo K Moioli
- Section of Dermatology, University of Chicago, Chicago, Illinois
| | - Meghan Morrow
- Department of Dermatology, Feinberg School of Medicine, Chicago, Illinois
| | - Julia Neckman
- Laser and Skin Surgery Center of New York, New York, New York.,Metroderm, Atlanta, Georgia
| | - Timothy Pearson
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio.,Anne Arundel Dermatology, Berlin, Maryland
| | - Samuel R Peterson
- Revere Health Central Utah Mohs, Provo.,ERderm, Newport Beach, California
| | | | | | - Jennifer S Ranario
- Department of Dermatology, MD Anderson Cancer Center, Houston, Texas.,US Dermatology Partners, Austin, Texas
| | - Ashley G Rubin
- Mohs and Dermatologic Surgery Center, University of California, San Diego.,Bernardo Dermatology Medical Group, Poway, California
| | - Chrysalyne D Schmults
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew M Swanson
- Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison
| | - Christopher Urban
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri.,Carolina Mountain Dermatology, Arden, North Carolina
| | - Y Gloria Xu
- Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison
| | - Murad Alam
- Department of Dermatology, Feinberg School of Medicine, Chicago, Illinois
| | | | - Simon Yoo
- Department of Dermatology, Feinberg School of Medicine, Chicago, Illinois
| | - Emily Poon
- Department of Dermatology, Feinberg School of Medicine, Chicago, Illinois
| | - Vishnu Harikumar
- Department of Dermatology, Feinberg School of Medicine, Chicago, Illinois
| | - Alexandra Weil
- Department of Dermatology, Feinberg School of Medicine, Chicago, Illinois
| | - Sanjana Iyengar
- Department of Dermatology, Feinberg School of Medicine, Chicago, Illinois.,Department of Dermatology, West Virginia University, Morgantown
| | - Matthew R Schaeffer
- Department of Dermatology, Feinberg School of Medicine, Chicago, Illinois.,Department of Surgery, Wright State University, Boonshoft School of Medicine, Dayton, Ohio
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