Recently a 93 year old highly educated patient asked me “Why should I have these basal cell skin cancers treated?” He then recounted that he had previously been diagnosed with several basal cell skin cancers on the face. He had not followed the doctor’s advice to undergo surgical treatment and 6 months later the skin cancers had disappeared. Had he been lucky or is surgical treatment of basal cell and squamous cell skin cancer not always necessary?
Over my 28 years in practice I have also seen the opposite scenario. In several cases I recommended curettage, a less aggressive type of surgery, for squamous cell skin cancers in very elderly patients (> 85 years old ). In several patients I observed the cancers grow back in less than 6 months, requiring a second surgery.
A recent study published in JAMA Internal Medicine questioned the current standard in the US, for surgical treatment of non-melanoma skin cancer in patients over 85. The researchers at the University of California, San Francisco Medical Center studied 1,400 patients over the age of 85 who were diagnosed with non-melanoma skin cancer (basal or squamous cell). About 25% of the patients were considered to have limited life expectancy due to their age as well as multiple other medical problems. The patients were followed for 9 years, on average, after surgical treatment by cutting and stitching, Moh’s surgery, destruction by scraping and cautery or no treatment. About 20% of the patients with limited life expectancy (based on their age and medical conditions) had a complication from their skin cancer treatment and 43% of that group died within 5 years. None of the patients died from the non- melanoma skin cancer.
The study provides scientific evidence for elderly patients and their physicians facing a treatment choice in dealing with a type of cancer whose natural history is benign. Based on the study, surgical treatment for certain types of skin cancer may be elective in some elderly patients. The key is to identify which basal and squamous cell cancers have the potential to be more aggressive. Certain locations (scalp, nose, ears, eyelids) and pathologic patterns are associated with faster growing skin cancers. Those basal and squamous cell cancers are the ones requiring surgery.
Clearly there are some non-melanoma skin cancers that may be appropriately treated with topical chemotherapy cream, radiation or, depending on the patient’s age and overall health, perhaps can be observed. This study provides evidence that doctors and their elderly patients need to have that conversation. It also is helpful for family members to know the options in guiding elderly parents in making treatment decisions about non-melanoma skin cancer. Caveat: these recommendations are not applicable for younger patients with the same diagnosis.