Assessment of Functionality in Elderly Patients When Determining Appropriate Treatment for Nonmelanoma Skin Cancers

Geriatric dermatologic surgery part I: Frailty assessment and palliative treatments in the geriatric dermatology population

Longer life expectancy and increasing keratinocyte carcinoma incidence contribute to an increase in geriatric patients presenting for dermatologic surgery. Unique considerations accompany geriatric patients including goals of care, physiologic changes in medication metabolism, cognitive decline, and frailty. Limited geriatric training in dermatology residency has created a knowledge gap and dermatologic surgeons should be familiar with challenges facing older patients to provide interventions more congruent with goals and avoid overtreatment. Frailty assessments including the Geriatric 8 and Karnofsky Performance Scale are efficient tools to identify patients who are at risk for poor outcomes and complications. When frail patients are identified, goals of care discussions can be aided using structured palliative care frameworks including the 4Ms (what matters, medications, mentation, and mobility), REMAP (reframing, expecting emotion, mapping patient goals, aligning patient goals, and proposing a plan), and Serious Illness Conversation Guide. Most geriatric patients will tolerate standard of care treatments including invasive modalities like Mohs surgery and excision. However, for frail patients, nonstandard treatments including topicals, energy-based devices, and intralesional chemotherapy may be appropriate options to limit patient morbidity while offering reasonable disease control.

Recommendations of the International Society of Geriatric Oncology on skin cancer management in older patients

INTRODUCTION

Non-melanoma skin cancer (NMSC) is becoming ever more prevalent among older adults. However, older adults with NMSC are often underrepresented in clinical trials and guidelines on effective management is still unclear. The International Society of Geriatric Oncology (SIOG) created a multi-disciplinary task force to explore the potential in developing practical guidelines for the treatment of older patients with basal cell carcinoma (BCC) and skin (cutaneous) squamous cell carcinoma (cSCC).

MATERIALS AND METHODS

A systematic literature search to identify relevant and up-to-date literature on treatment of NMSC in older adults was conducted on various databases including MEDLINE, Embase, CINAHL, Cochrane, and PubMed. The resulting papers were discussed by an expert panel, leading to a consensus recommendation.

RESULTS

A total of 154 articles were identified for the expert panel to utilise in generating consensus recommendations. A major focus on geriatric assessment and management options including surgery, radiotherapy, systemic therapy, clinical monitoring, and medical/medicophysical therapy were reviewed for recommendations.

DISCUSSION

Patient age should not be the sole deciding factor in the management of patients with NMSC. Assessment from a multidisciplinary team (MDT) is crucial, and the decision-making process should consider the patient's lifestyle, needs, and expectations. A comprehensive geriatric assessment should also be considered. Patients should feel empowered to advocate for themselves and have their views considered a part of the MDT discussion.

Nonmelanoma Skin Cancer in Patients Older Than Age 85 Years Presenting for Mohs Surgery: A Prospective, Multicenter Cohort Study

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.

Functional status and survival in patients ≥85 years of age who have keratinocyte carcinoma: A retrospective cohort study

BACKGROUND

Functional status assessment may help estimate which patients ≥85 years of age will benefit from surgical treatment for keratinocyte carcinoma (KC), but predictive value for short-term survival in this population has not been determined.

OBJECTIVE

We sought to assess the predictive value of functional status for short-term survival in patients ≥85 years of age who have KC.

METHODS

This was a retrospective cohort review of 238 patients ≥85 years of age who presented for the management of KC between 2010 and 2015. Functional status was assessed with the Karnofsky Performance Scale (KPS) and Katz Activities of Daily Living (ADL) index. Overall survival was determined.

RESULTS

Lower functional status scores of KPS ≤40 and Katz ADL ≤4 were associated with 37% and 53% survival at 2 years, respectively.

LIMITATIONS

Retrospective design and single-center study.

CONCLUSION

In this study, KPS and Katz ADL predicted short-term survival. Patients with low functional status scores had significantly decreased survival at 2 years, with double the death rate of patients with high functional status. Functional status should be considered during shared decision-making for elderly individuals who are seeking treatment for KC.