PracticeUpdate Dermatology Best of 2018

EDITOR’S PICKS 17

Abstract Facial nonmelanoma skin cancers (fNMSCs), consisting of basal cell carcinoma and squa- mous cell carcinoma, are the most common cancers diagnosed worldwide and increase with age. Standard treatment for fNMSCs requires biopsy for pathological confirma- tion, followed by excision. Excision can lead to a pathological diagnosis of no residual carcinoma (NRC) due to no identifiable car- cinoma within the excisional specimen. This situation can occur owing to wound healing in the specimen clearing the carcinoma or to the original biopsy shaving off the entire lesion. This study assesses the utility of excising fNMSCs according to age, with the hypoth- esis that the indolent nature of fNMSCs and the high NRC rate, coupled with increasing age-related all-cause mortality, should cause the surgeon to counsel patients differently. Such counseling may prevent surgery among elderly patients (>90 years) who may never see a benefit from fNMSC excision. Age at Diagnosis as a Relative Contraindica- tion for Intervention in Facial Nonmelanoma Skin Cancer. JAMA Surg 2017 Dec 20;[EPub Ahead of Print], R Chauhan, BN Munger, MW Chu,et al. www.practiceupdate.com/c/62802

By Daniel M. Siegel MD, MS, CPCD E very skin cancer patient who visits my office has a choice to treat or not to treat after understanding the cost, risks, and benefits of available treatment options. We still live in a (theoretically) free country and the primacy of patient autonomy requires this approach. It is not uncommon that older patients with nonmelanoma skin cancer want “something” done! Some choose 1) simultaneous biopsy and destruction via C&D or cryo- surgery; 2) prolonged use of off-label topical therapies; or 3) no treatment, with a promise to return if the lesion enlarges or changes. I have my patients capture the lesion on their cell phone or we print out an image for them if they have a flip phone or no cell phone. Why would an elderly patient choose a surgical treatment? Some patients simply want a destructive procedure to remove a lesion that leaves blood on their pillow. Some choose Mohs surgery and reconstruction, and if appropriate (per AUC) and reasonable (patient asks for it and understands risks and benefits). Regardless of which approach is taken, I sleep well knowing that the patient and I are doing what is right for him or her. I contrast this with the nightmare tales of individuals with dementia falling out of bed and getting total hip replacements done emergently, only to die a short time later. Dr. Tom Price, short-lived HHS secretary, orthopedic surgeon, and former congressman, gutted a program that provided a bundled payment for joint replacement care that may or may not have been indicated. This program seemed to have us going in the right direction. Maybe it is time for a “bundled survival” program where if the patient does not survive for 180 to 365 days (statistics experts, pick a number) the doctor, corporate entity, or university must rebate the payment to the payer. This might encourage better behavior or it might encour- age someone to put a horse head on my bed!

Dr. Siegel is Clinical Professor of Dermatology, SUNY Downstate Medical Centre in Brooklyn, New York.

VOL. 2 • NO. 4 • 2018