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Should old, sick patients get skin cancer surgery?

By Genevra Pittman

Reuters

4:04 PM EDT, April 29, 2013

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NEW YORK (Reuters Health) - More than two-thirds of people with non-melanoma skin cancer underwent surgery to treat the condition, according to a new study - including patients who were at least 85 years old or had multiple other chronic diseases.

Researchers found 43 percent of those patients with limited life expectancies died within five years of their diagnosis - but none from skin cancer. Many of them reported poor wound healing after skin surgery or other treatment-related complications including pain, numbness and itching.

The study team said its findings suggest many older patients may not live long enough to benefit from treatment for non-melanoma skin cancers, but can still be harmed by it.

"For so many conditions we just use a standard treatment without thinking about the long-term (clinical) cost," said Dr. Ashish Jha, a health policy researcher from the Harvard School of Public Health in Boston.

"What I think doctors often underestimate is how often patients don't want aggressive care."

Skin cancer is the most common type of cancer. About 2.2 million Americans are diagnosed with non-melanoma skin cancers - which include basal and squamous cell cancers - each year. But according to the American Cancer Society, only 2,000 people die annually from those cancers - less than 0.1 percent of the number diagnosed.

"Non-melanoma skin cancer in some ways is a classic example of a cancer that rarely kills people and it is something that can be treated in a variety of ways and (treatment) really should be customized," Jha, who wasn't involved in the new research, told Reuters Health.

Researchers led by Dr. Eleni Linos from the University of California, San Francisco, followed 1,360 people who were diagnosed with non-melanoma skin cancer at one of two dermatology clinics in 1999 and 2000.

Those patients were 69 years old, on average. About one-quarter of them had a limited life expectancy because they were at least 85 or had more than one chronic health condition, including heart, lung or kidney disease, diabetes and dementia.

Most of those older, sicker patients said they weren't frequently bothered by their skin cancers. Some may not have even noticed them, Linos said.

Age and underlying health did not influence what type of treatment patients received, she and her colleagues reported Monday in JAMA Internal Medicine. About 69 percent of all skin cancers were treated surgically - half with simple excisions and half with lengthier, more intensive procedures.

That was the case even for people who died within two years of getting skin cancer - from a heart attack or stroke, for example.

"We found that regardless of how old people were, how sick or frail they were, what their life expectancy was, they were getting similar treatment," Linos told Reuters Health. "We saw that as evidence that at the moment, we're not tailoring our treatment to specific patients."

She and her colleagues said that for some old and sick patients, just getting to the doctor and sitting in the waiting room may be trying - not to mention undergoing a three-hour surgery.

AGE DETERMINES TREATMENT?

Jha said he doesn't think age should be the determining factor behind who does or doesn't undergo surgery for non-melanoma skin cancer. Rather, patients should be given the relevant information about their diagnosis and underlying health and decide for themselves how aggressively their illness is treated.

"There are 80-, 85-year-olds who are extremely healthy (and) vigorous and my take is we should treat them as aggressively as they would like to be treated," he said, "whereas there are people in their 50s or 60s with advanced diseases who may have a much shorter lifespan."

Linos agreed.

"We would never want to restrict access to care based on age," she said.

"Our goal really is to involve patients in this decision and to be able to say, ‘Here are the risks, here are the benefits, what do you want?'"

SOURCE: http://bit.ly/MbBLbb JAMA Internal Medicine, online April 29, 2013.