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Aoki KC, Glick BP, Bartos S. Complex Management of Basal Cell Carcinoma in a Frail Patient. Cureus 2024; 16:e53518. [PMID: 38440025 PMCID: PMC10911882 DOI: 10.7759/cureus.53518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/31/2024] [Indexed: 03/06/2024] Open
Abstract
Basal cell carcinoma (BCC) is one of the most common cancers diagnosed in older patients and has low mortality. Surgical versus medical management is considered in patients with multiple comorbidities and limited life expectancy (LLE), where the risk-to-benefit ratio must be carefully assessed. Watchful waiting (WW) is a viable option for some patients with severe LLE when follow-up care can be provided vigilantly and frequently. Special consideration should be given to morbidity factors such as tumor growth, bleeding, pain, and social withdrawal that negatively affect the quality of life. We present the case of a 75-year-old male with a past medical history of multiple system atrophy, who presented with a BCC on the ear and face. We discuss the management of this patient and factors that may have led to the inappropriate use of WW.
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Affiliation(s)
- Kawaiola Cael Aoki
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Brad P Glick
- Dermatology, Larkin Community Hospital Palm Springs Campus, Margate, USA
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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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Hussain K, Bogucki P, Patel NP. Undertaking skin cancer surgery in patients lacking capacity: a growing challenge. Clin Exp Dermatol 2023; 48:259-261. [PMID: 36763730 DOI: 10.1093/ced/llac100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 11/08/2022] [Indexed: 01/22/2023]
Abstract
We highlight the growing challenge of undertaking skin cancer surgery in adult patients lacking capacity, given the nature of the ageing population, increasing prevalence of dementia and rise in skin cancer diagnoses. In such cases a decision must be made in the patient’s best interests, taking into account the patient’s own views, the existence of a lasting power of attorney, and the views of close family and friends. On occasion it may be reasonable not to aim to cure a skin cancer in a patient approaching the end of life.
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Affiliation(s)
- Khawar Hussain
- Department of Dermatology, Imperial College Healthcare NHS Trust, London, UK
| | - Pawel Bogucki
- Department of Dermatology, Imperial College Healthcare NHS Trust, London, UK
| | - Neil P Patel
- Department of Dermatology, Imperial College Healthcare NHS Trust, London, UK
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Van Coile L, Verhaeghe E, Ongenae K, Destrooper L, Mohamadi Z, Brochez L, Hoorens I. The therapeutic dilemma of basal cell carcinoma in older adults: A review of the current literature. J Geriatr Oncol 2023; 14:101475. [PMID: 36990928 DOI: 10.1016/j.jgo.2023.101475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 01/26/2023] [Accepted: 03/07/2023] [Indexed: 03/29/2023]
Abstract
Skin cancer is known to be a significant health care threat due to the massively increasing numbers of diagnoses. In 2019, 4 million basal cell carcinoma (BCC) cases were diagnosed globally, making BCC the most frequent of all cancers worldwide in fair skinned populations. Given the increasing life-expectancy for all countries worldwide (by 2050, the world's population of people aged 60 years and older will have doubled), the incidence of BCC is expected to keep increasing in the future. Management of BCCs is challenging, especially among older adults, as mortality due to BCCs is extremely rare, whereas locally destructive growth can cause significant morbidity in certain cases. Therapeutic management in this population is further hampered because of the presence of comorbidities, frailty, and the heterogeneity of these aspects in older patients, leading to treatment dilemmas. A literature review was conducted to identify relevant patient, tumour, and treatment related factors that should be considered in the decision making for BCC treatment in older adults. This narrative review synthesizes all aspects concerning BCC treatment in older adults and aims to make some specific suggestions considering BCC treatment in older adults that can be used in daily practice. We found that nodular BCC was found to be the most common subtype in older adults, most frequently located in the head and neck region. In non-facial BCCs, current literature has shown no significant impact on the quality of life (QoL) in older patients. Besides comorbidity scores, functional status should guide clinicians in treatment decisions. Taking all aspects into account when making treatment decisions is of great importance. When treating superficial BCCs on difficult-to-reach lesions in older adults, a clinician-administered treatment should be suggested because of possible impaired mobility in these patients. Based on current literature, we recommend assessing the comorbidities, the functional status, and frailty in older patients with BCC to evaluate life expectancy. In patients with low-risk BCCs and a limited life expectancy (LLE), an active surveillance or watchful waiting strategy can be suggested.
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Han J, O'Neal S, Gravely A, Linos E, Goldfarb N. United States Academic Dermatologists' Attitudes Towards Active Surveillance for Basal Cell Carcinoma. Br J Dermatol 2022; 187:613-615. [PMID: 35612397 DOI: 10.1111/bjd.21675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 05/16/2022] [Accepted: 05/21/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Joohee Han
- Department of Dermatology, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Department of Dermatology, University of Minnesota, Minneapolis, MN, USA
| | - Sydney O'Neal
- Department of Dermatology, University of Minnesota, Minneapolis, MN, USA
| | - Amy Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Eleni Linos
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Noah Goldfarb
- Department of Dermatology, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Department of Dermatology, University of Minnesota, Minneapolis, MN, USA
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van Winden MEC, Hetterschijt CRM, Bronkhorst EM, van de Kerkhof PCM, de Jong EMGJ, Lubeek SFK. Evaluation of Watchful Waiting and Tumor Behavior in Patients With Basal Cell Carcinoma: An Observational Cohort Study of 280 Basal Cell Carcinomas in 89 Patients. JAMA Dermatol 2021; 157:1174-1181. [PMID: 34495284 DOI: 10.1001/jamadermatol.2021.3020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance Few studies have examined watchful waiting (WW) in patients with basal cell carcinoma (BCC), although this approach might be suitable in patients who might not live long enough to benefit from treatment. Objective To evaluate reasons for WW and to document the natural course of BCC in patients who chose WW and reasons to initiate later treatment. Design, Setting, and Participants An observational cohort study was performed at a single institution between January 2018 and November 2020 studying patients with 1 or more untreated BCC for 3 months or longer. Exposures Watchful waiting was chosen by patients and proxies regardless of this study. Main Outcome and Measures The reasons for WW and treatment were extracted from patient files and were categorized for analyses. Linear mixed models were used to estimate tumor growth and identify covariates associated with tumor growth. Results Watchful waiting was chosen for 280 BCCs in 89 patients (47 men [53%] and 42 women [47%]), with a median (interquartile range [IQR]) follow-up of 9 (4-15) months. The median (IQR) age of the included patients was 83 (73-88) years. Patient-related factors or preferences (ie, prioritizations of comorbidities, severe frailty, or limited life expectancy) were reasons to initiate WW in 74 (83%) patients, followed by tumor-related factors (n = 49; 55%). Treatment-related and circumstantial reasons were important for 35% and 46% of the patients, respectively. The minority of tumors increased in size (47%). Tumor growth was associated with BCC subtype (odds ratio, 3.35; 95% CI, 1.47-7.96; P = .005), but not with initial tumor size and location. The estimated tumor diameter increase was 4.46 mm (80% prediction interval, 1.42 to 7.46 mm) in 1 year for BCCs containing at least an infiltrative/micronodular component and 1.06 mm (80% prediction interval, -1.79 to 4.28 mm) for the remaining BCCs (only nodular/superficial component/clinical diagnosis). Most common reasons to initiate treatment were tumor burden or potential tumor burden, resolved reason(s) for WW, and reevaluation of patient-related factors. Conclusions and Relevance In this cohort study of patients with BCC, WW was an appropriate approach in several patients, especially those with asymptomatic nodular or superficial BCCs and a limited life expectancy. Patients should be followed up regularly to determine whether a WW approach is still suitable and whether patients still prefer WW and to reconsider consequences of treatment and refraining from treatment.
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Affiliation(s)
- Marieke E C van Winden
- Radboud Institute for Health Sciences, Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Charlotte R M Hetterschijt
- Radboud Institute for Health Sciences, Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ewald M Bronkhorst
- Department of Biostatistics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Peter C M van de Kerkhof
- Radboud Institute for Health Sciences, Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Elke M G J de Jong
- Radboud Institute for Health Sciences, Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Satish F K Lubeek
- Radboud Institute for Health Sciences, Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
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van Winden MEC, Bronkhorst EM, Visch MB, Krekels GAM, van der Geer S, Damen GWJA, Amir A, Aben KKH, Gerritsen MJJP, van de Kerkhof PCM, de Jong EMGJ, Lubeek SFK. Predictors of surgical treatment burden, outcomes, and overall survival in older adults with basal cell carcinoma: Results from the prospective, multicenter BATOA cohort. J Am Acad Dermatol 2021; 86:1010-1019. [PMID: 34082036 DOI: 10.1016/j.jaad.2021.05.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/24/2021] [Accepted: 05/06/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Incorporating patient-related factors associated with treatment outcomes could improve personalized care in older patients with basal cell carcinoma (BCC). OBJECTIVE To evaluate and identify predictors of treatment burden, treatment outcomes, and overall survival in patients aged ≥70 years, surgically treated for BCC in the head and neck area. METHODS The data from the prospective, multicenter Basal Cell Carcinoma Treatment in Older Adults (BATOA) cohort study were extracted to evaluate the experienced treatment burden (visual analog scale, 0-10 cm; lower scores indicating higher treatment burden), treatment outcomes, and mortality. RESULTS A total of 539 patients were included (median age, 78 years). The patients experienced a low overall treatment burden (median, 8.6) and good cosmetic results. The predictors of higher treatment burden were instrumental activities of daily living (iADL) dependency, female sex, complications, larger tumor diameter, and polypharmacy. Thirty-five patients (6.5%) died (none of the deaths were due to BCC) within the follow-up period; the predictors of mortality were increasing comorbidity index and iADL dependency. No difference in these outcomes was seen between Mohs micrographic surgery and conventional excision after correction for covariates. Age was not significantly associated with any outcome. LIMITATIONS A selection bias may exist owing to the observational design. CONCLUSION BCC management decisions based on chronological age alone should be avoided, whereas more attention is recommended for patient-related factors. Based on these data, early BCC intervention is beneficial for robust and fit patients or those experiencing symptoms.
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Affiliation(s)
- Marieke E C van Winden
- Department of Dermatology, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.
| | - Ewald M Bronkhorst
- Department of Biostatistics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - M Birgitte Visch
- Department of Dermatology, Rijnstate Hospital, Arnhem, the Netherlands
| | | | | | | | - Avital Amir
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Katja K H Aben
- Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | | | | | - Elke M G J de Jong
- Department of Dermatology, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Satish F K Lubeek
- Department of Dermatology, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Reconstruction of a dorsal thoracic wall defect with a dorsal intercostal artery perforator flap after removal of a bulky cutaneous squamous cell carcinoma: a case report. J Med Case Rep 2019; 13:294. [PMID: 31526388 PMCID: PMC6747734 DOI: 10.1186/s13256-019-2226-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 08/09/2019] [Indexed: 11/10/2022] Open
Abstract
Introduction Surgical reconstruction of large soft tissue defects of the upper back is challenging. Although the usefulness of free perforator flaps has been demonstrated, local options remain limited. The dorsal intercostal artery perforator flap was recently described but its use is still uncommon. Case report An 88-year-old Causasian woman presented with a large, ulcerated, left prescapular cutaneous squamous cell carcinoma (T3N0M0). Complete excision was performed, and the resulting defect was reconstructed with a dorsal intercostal artery perforator flap based on two perforators. Postoperative recovery was uncomplicated and adjuvant radiotherapy commenced 10 weeks later. Conclusion Compared to conventional muscle flaps, the dorsal intercostal artery perforator flap offers greater protection of muscle function, is less invasive, and lowers donor site morbidity. Based on these advantages, this flap should be considered a useful local option for reconstructing large cutaneous defects of the upper back.
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