- Email: [email protected]
Management of skin cancer in the elderly
J O U RN A L OF GE RI A T RI C O NC O L O G Y 7 ( 2 01 6 ) 2 1 9 –22 0
Available online at www.sciencedirect.com
ScienceDirect
Letter to Editor
Management of skin cancer in the elderly
In their editorial discussing non-surgical approaches to skin cancer in the elderly, Lee and colleagues overlook two noteworthy domains, those of chemoprevention and conservative management of selected dermatological neoplasms.1 The use of systemic retinoids (e.g. acitretin, isotretinoin) in patients with multiple or recurrent keratinising tumours (including squamous cell carcinoma, keratoacanthoma, actinic keratoses) is long established in reducing the incidence of new lesions and can be particularly useful in patients who may have had high cumulative lifetime sun exposure or those on concomitant immunosuppressive agents (e.g. organ transplant recipients).2 The side-effects of retinoids include hypercholesterolaemia and liver dysfunction. More recently, nicotinamide (vitamin B3) has been proposed as a chemotherapeutic agent, with a randomised controlled trial suggesting 500 mg administered twice daily may reduce the incidence of non-melanoma skin cancer (NMSC) by 23%, with few significant side-effects of therapy.3 Whilst some skin tumours can rapidly enlarge and metastasize, others can have a more indolent evolution. Basal cell carcinoma (BCC), the commonest NMSC, is locally invasive but seldom metastasises nor impacts on life expectancy. In a retrospective study, the majority of patients with NMSC with limited life expectancy were shown to have been treated surgically, yet up to 20% subsequently had post-operative complications.4 A second lesion of note is lentigo maligna (LM), which has the propensity to develop into melanoma: for an individual aged 75 with LM, there is a 2.2% probability of progression to melanoma.5 Whilst surgery is the gold standard of treatment, excision with 5 mm margins (as advocated by guidelines) can leave troubling scars on cosmetically and functionally important sites on the face, head and neck, locations to which LM is anatomically predisposed. Where an individual's life expectancy is limited or there is a patient preference to avoid invasive procedures, a conservative (“watchful waiting”) approach could also be considered as a management strategy for asymptomatic lesions, in addition to the surgical and non-surgical options
http://dx.doi.org/10.1016/j.jgo.2016.03.007 1879-4068/© 2016 Elsevier Ltd. All rights reserved.
already discussed.6 Use of life expectancy estimation tools that take account of patients' comorbidities and functional status, such as the Eprognosis tool (www.eprognosis.ucsf. edu), may aid discussion with patients and inform decision making. Whilst we fully support surgical treatment being offered to all appropriate patients, irrespective of age, both chemoprevention and conservative management are suitable approaches for some patients, which should be recalled by attending physicians, particularly where surgery is being averted.
Disclosures and Conflict of Interest Statements None. Faisal R. Ali⁎,1 Emma E. Craythorne1 Dermatological Surgery & Laser Unit, St John's Institute of Dermatology, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK Corresponding author. Tel.: +44 20 7188 6407; fax: +44 20 7188 6259. E-mail address: [email protected].
9 January 2016 REFERENCES
1. Lee WW, Wysong A, Cotliar J, Jung JY. Management of elderly patients with skin cancer. J Geriatr Oncol 2016;7(1):7–9. 2. Chen K, Craig JC, Shumack S. Oral retinoids for the prevention of non-melanoma skin cancer in solid organ transplant recipients: a systematic review of randomized controlled trials. Br J Dermatol 2005;152:518–523. 1 Both authors participated in: conception and design, data collection, analysis and interpretation of data, manuscript writing, and approval of final article.
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J O U RN A L OF GE RI A TR I C O NC O LOG Y 7 ( 20 1 6 ) 2 1 9–2 2 0
3. Chen AC, Martin AJ, Choy B, Fernández-Peñas P, Dalziell RA, McKenzie CA, et al. A phase 3 randomized trial of nicotinamide for skin-cancer chemoprevention. N Engl J Med 2015;373:1618–1626. 4. Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Landefeld CS, Chren MM. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer. JAMA Intern Med 2013;173(11): 1006–1012.
5. Weinstock MA, Sober AJ. The risk of progression of lentigo maligna to lentigo maligna melanoma. Br J Dermatol 1987;116(3): 303–310. 6. Linos E, Schroeder SA, Chren MM. Potential overdiagnosis of basal cell carcinoma in patients with limited life expectancy. JAMA 2014;312(10):997–998.
Available online at www.sciencedirect.com
ScienceDirect
Letter to Editor
Management of skin cancer in the elderly
In their editorial discussing non-surgical approaches to skin cancer in the elderly, Lee and colleagues overlook two noteworthy domains, those of chemoprevention and conservative management of selected dermatological neoplasms.1 The use of systemic retinoids (e.g. acitretin, isotretinoin) in patients with multiple or recurrent keratinising tumours (including squamous cell carcinoma, keratoacanthoma, actinic keratoses) is long established in reducing the incidence of new lesions and can be particularly useful in patients who may have had high cumulative lifetime sun exposure or those on concomitant immunosuppressive agents (e.g. organ transplant recipients).2 The side-effects of retinoids include hypercholesterolaemia and liver dysfunction. More recently, nicotinamide (vitamin B3) has been proposed as a chemotherapeutic agent, with a randomised controlled trial suggesting 500 mg administered twice daily may reduce the incidence of non-melanoma skin cancer (NMSC) by 23%, with few significant side-effects of therapy.3 Whilst some skin tumours can rapidly enlarge and metastasize, others can have a more indolent evolution. Basal cell carcinoma (BCC), the commonest NMSC, is locally invasive but seldom metastasises nor impacts on life expectancy. In a retrospective study, the majority of patients with NMSC with limited life expectancy were shown to have been treated surgically, yet up to 20% subsequently had post-operative complications.4 A second lesion of note is lentigo maligna (LM), which has the propensity to develop into melanoma: for an individual aged 75 with LM, there is a 2.2% probability of progression to melanoma.5 Whilst surgery is the gold standard of treatment, excision with 5 mm margins (as advocated by guidelines) can leave troubling scars on cosmetically and functionally important sites on the face, head and neck, locations to which LM is anatomically predisposed. Where an individual's life expectancy is limited or there is a patient preference to avoid invasive procedures, a conservative (“watchful waiting”) approach could also be considered as a management strategy for asymptomatic lesions, in addition to the surgical and non-surgical options
http://dx.doi.org/10.1016/j.jgo.2016.03.007 1879-4068/© 2016 Elsevier Ltd. All rights reserved.
already discussed.6 Use of life expectancy estimation tools that take account of patients' comorbidities and functional status, such as the Eprognosis tool (www.eprognosis.ucsf. edu), may aid discussion with patients and inform decision making. Whilst we fully support surgical treatment being offered to all appropriate patients, irrespective of age, both chemoprevention and conservative management are suitable approaches for some patients, which should be recalled by attending physicians, particularly where surgery is being averted.
Disclosures and Conflict of Interest Statements None. Faisal R. Ali⁎,1 Emma E. Craythorne1 Dermatological Surgery & Laser Unit, St John's Institute of Dermatology, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK Corresponding author. Tel.: +44 20 7188 6407; fax: +44 20 7188 6259. E-mail address: [email protected].
9 January 2016 REFERENCES
1. Lee WW, Wysong A, Cotliar J, Jung JY. Management of elderly patients with skin cancer. J Geriatr Oncol 2016;7(1):7–9. 2. Chen K, Craig JC, Shumack S. Oral retinoids for the prevention of non-melanoma skin cancer in solid organ transplant recipients: a systematic review of randomized controlled trials. Br J Dermatol 2005;152:518–523. 1 Both authors participated in: conception and design, data collection, analysis and interpretation of data, manuscript writing, and approval of final article.
220
J O U RN A L OF GE RI A TR I C O NC O LOG Y 7 ( 20 1 6 ) 2 1 9–2 2 0
3. Chen AC, Martin AJ, Choy B, Fernández-Peñas P, Dalziell RA, McKenzie CA, et al. A phase 3 randomized trial of nicotinamide for skin-cancer chemoprevention. N Engl J Med 2015;373:1618–1626. 4. Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Landefeld CS, Chren MM. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer. JAMA Intern Med 2013;173(11): 1006–1012.
5. Weinstock MA, Sober AJ. The risk of progression of lentigo maligna to lentigo maligna melanoma. Br J Dermatol 1987;116(3): 303–310. 6. Linos E, Schroeder SA, Chren MM. Potential overdiagnosis of basal cell carcinoma in patients with limited life expectancy. JAMA 2014;312(10):997–998.