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EDITOR’S PICKS 16

Age at Diagnosis as a Contraindication for Intervention in Nonmelanoma Skin Cancer JAMA Surgery Take-home message • The authors assessed the utility of facial nonmelanoma skin cancer (NMSC) excision according to age. Standard excision was performed on 569 biopsy-proven NMSCs in 440 patients, 55.5% of whom had basal cell carcinoma (BCC) and 30.2% squa- mous cell carcinoma (SCC). No residual cancer was found on histology in 35.3% of samples (24.7% of BCCs, 48.3% of SCCs, and 42.1% of SCC in situ). Mortality increased with age, with rates at 3 years post excision as follows: <60 years, 3.6%; 60–69 years, 4.4%; 70–79 years, 7.6%; 80–89 years, 19.8%; and >90 years, 48.1%. Death occurred in 11.4% of patients, but no deaths were due to the spread of NMSC. • The survival rate at 3 years after NMSC excision in patients aged >90 years is approximately 52%, and no patient in this study died of NMSC. Further research is needed to confirm these findings in the general population and to investigate patient satisfaction and the cost-effectiveness of watchful waiting vs excision in this age group. InYoung Kim MD, PhD

COMMENT By Joseph F. Sobanko MD T he authors in this study examined the excisional specimens of 569 biopsy- proven keratinocytic carcinomas (KC) in 440 patients from a VA medical center in Indianapolis to determine the frequency with which a pathological diagnosis of “no residual carcinoma” was identified. Just over one-third of these biopsy-proven tumors failed to reveal residual cancer in the definitive excisional specimen. The authors suggest that age at diagnosis of KC should be a relative contraindication for intervention of facial skin cancer. Their reasoning is twofold: 1) there is a relatively high amount of “no residual cancer” in excisional specimens; and 2) there is an exceedingly low risk of death from KC in patients above the eighth decade of life. The authors should be commended for attempting to avoid unnecessary surgery in a vulnerable population often with concomitant health issues unrelated to their skin cancer. Unfortunately, it is very easy for the press and media to misconstrue this study’s sug- gestion and extrapolate that “skin cancer is not a big deal.” It must be emphasized that this is a relatively small single-institutional study that did not exhaustively evaluate the

easily treated when detected early; 2) few predictive models currently exist regard- ing which cancers will become aggressive and destructive; and 3) outpatient dermato- logic surgery is safe and comes with very few complications. With these principles in mind, patients and family members can make informed and shared decisions with confidence. " …until more robust data are published to support “no intervention of skin cancers in the elderly,” a dialogue must occur between practitioner and skin cancer patient and all treatment options should be discussed. "

excisional specimens. The false-negative rate of bread-loaf excisional skin spec- imens varies, but has been noted to be as high as 25% to 33%. En face examina- tion of many of the excisional specimens in this study would have revealed residual cancer, which could subsequently present as a symptomatic problem for any of the patients, even those above their eighth decade in age. Prudent use of procedures in patients who are near death is an irrefutable prin- ciple as is shared-decision making for choosing a course of medical care. All KCs do not require surgical management. Patients with severe illness and multiple comorbidities may be poor surgical candi- dates, even in the outpatient setting, and require alternative approaches to their KC. The current study offers interesting data that should help begin a debate as to how to best triage KC treatment in the elderly. However, until more robust data are published to support “no intervention of skin cancers in the elderly,” a dialogue must occur between practitioner and skin cancer patient and all treatment options should be discussed. Patients must be made aware that: 1) skin cancer is more

Dr. Sobanko is Assistant Professor and Director of Dermatologic Surgery Education at The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania.

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