Treatment of Nonmelanoma Skin Cancer at End of Life

Healthcare providers, particularly those treating a population of geriatric patients, may face the challenge of determining appropriate care of nonfatal conditions for patients with limited life expectancy (LLE). A study of Medicare beneficiaries found that >30% of patients underwent surgery in the last year of life, and nearly 20% underwent a procedure in the last year of life.

Nonmelanoma skin cancer (NMSC), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is the most common malignant neoplasm and is usually nonfatal. Noting that there have been few studies examining the treatment of NMSC in patients who may not survive long enough to benefit, researchers recently conducted a study designed to compare treatment patterns and clinical outcomes of patients with NMSC with and without LLE. Study results were reported in JAMA Internal Medicine [2013;173(11):1006-1012].

The prospective cohort study was conducted at 2 dermatology clinics: a university-based private practice and a Veterans Affairs Medical Center in San Francisco, California. The main outcomes and measures were treatment type.

The study population included 1536 consecutive patients diagnosed with NMSC. The patients were recruited from January 1999 through December 2000; median follow-up was 9 years. The final study cohort included 1360 patients with 1739 tumors.

Median patient age was 69.0 years and 72.7% were male. Most patients had a Charlson Comorbidity Index score of 1.0 and 22% were frequently bothered by their tumor(s). At baseline, 332 patients with 428 tumors were classified as having LLE, based on advanced age and multiple comorbidities. Patients with LLE were generally older and had more comorbidites compared with patients without LLE. Further, patients with LLE had lower incomes and educational status and their tumors were larger and more likely to be SCCs and located on the central face. They were also more likely to report being bothered by their tumor(s) compared with patients without LLE.

Regardless of life expectancy, most NMSCs (68.7%) were treated surgically: 34.2% underwent Mohs surgery and 34.5% underwent simple excision. An additional 26.7% were treated with destruction, which included cryotherapy, electrodessication, and curettage, laser, and irradiation. The remaining 3.1% received no treatment.

In the cohort with LLE, 70.1% underwent surgery (Mohs, 33.9%; simple excision, 36.2%), 25.2% were treated with destruction, and 3.3% received no treatment. There was no significant difference in treatment rates in regard to life expectancy. When stratified by BCC or SCC, the results remained similar.

Tumor recurrence data were available for 1269 patients with 1618 tumors. The 5-year recurrence rates were low in the entire cohort as well as in the LLE subgroup (3.7% vs 3.7%). Of 14 patients in the LLE group whose tumors recurred, 9 died soon after the recurrence of causes unrelated; medial survival after recurrence was 21 months.

The 5-year mortality of the total cohort was 22.6%; 43.3% of patients in the LLE group died within 5 years compared with an 11.0% mortality for those in the group without LLE (P<.001).

There was no difference in the probability of undergoing surgical treatment between the 2 cohorts. In addition, following adjustment for multiple patient, tumor, and care-setting characteristics, LLE was unrelated to choice of surgery for NMSC, a finding that remained true in univariate and multivariate models.

In conclusion, the researchers stated, “Most NMSCs are treated surgically, regardless of the patients’ life expectancy. Given the very low tumor recurrence rates and high mortality from causes unrelated to NMSC in patients with LLE, clinicians should consider whether these patients would prefer less invasive treatment strategies.”