One size does not fit all
Dermatologists discuss considerations and complexities in caring for older adults with skin cancer.
By Allison Evans, Assistant Managing Editor, February 1, 2024
In the same way that children cannot be treated as little adults, older adults (65+ years old) cannot be treated the same as younger adults. With psychosocial and medical factors that differ from younger adults, older adults often require different considerations and approaches, particularly when developing a plan to manage skin cancer.
“There is no perfect treatment for skin cancer in older adults,” said Daniel Butler, MD, FAAD, director of the University of Arizona Inflammatory and Aging Skin Research Program. “I often get asked what’s the correct treatment for a basal cell in a patient over 90 years old — and it’s contingent on many different factors.”
The National Ambulatory Medical Care Survey showed that dermatology had the largest increase in visits between 1980 to 2000 of all specialties for patients older than 65 years — and this patient population accounts for more than a third of all dermatology encounters. With a rapidly growing aging population, dermatology is positioned to be a leading presence in the care of older adults.
Short on time?
Key takeaways from this article:
With psychosocial and medical factors that differ from younger adults, older adults often require different considerations and approaches, particularly when developing a plan to manage and treat skin cancer.
When treating skin cancers in older adults, dermatologists must consider physical, lifestyle, and medical factors, like tumor characteristics.
Dermatologists want to provide collaborative, high-quality, patient-centered care. Doing more does not necessarily equate to doing better.
In 2017, the John A. Hartford Foundation and the Institute for Healthcare Improvement developed a practical geriatric care model called the “4Ms” that acknowledges the heterogeneity and complexity of aging: What Matters, Medication, Mentation, and Mobility.
Life expectancy is not the same as chronological age. There can be tremendous heterogeneity with aging, which is much different from childhood when we go through development milestones at certain ages.
The concept of “lag time to benefit” should be considered when treating older adults. This concept includes whether the intervention will help the patient and by how much.
“Older adults definitely have different skin characteristics and predispositions to skin conditions that are distinct from other age groups,” said Anne Lynn S. Chang, MD, FAAD, professor of Dermatology at Stanford University School of Medicine. “There’s more variability in this age group, so we shouldn’t assume that one size fits all. We have to take the time to find out where a particular patient is regarding treatment goals and diagnoses.”
When treating skin cancers in older adults, dermatologists have to consider patient factors, which are both physical and lifestyle factors, as well as medical factors, like tumor characteristics, said Dr. Butler. “We know a basal cell on the face is a higher-risk lesion than a basal cell on the back. Those tumor characteristics mixed with patient preferences and qualities should help guide physicians in counseling patients.”
Dermatologists want to provide collaborative, high-quality, patient-centered care. “Doing more does not necessarily equate to doing better,” said Justin Endo, MD, MHPE, FAAD, co-founder of the AAD’s Geriatric Dermatology Expert Resource Group. “By the same token, it is important to guard against ageism, where we might make certain assumptions about what older patients want or should have. That is why it is incumbent on us to clarify patient goals and to document these discussions.”
Context is key
Basal cell carcinoma is the most commonly diagnosed type of skin cancer. BCCs are especially prevalent in the elderly population, given their association with cumulative sun exposure and other risk factors. “We’re so well trained to spot basal cells that we often feel like that’s the end of our job, and I like to teach that it’s just the beginning,” Dr. Butler said. “Arguably, a harder skill set is to guide someone using medical expertise and empathy through the decision-making process.”
“If you biopsy a basal cell, which is considered a lower-risk lesion, and then there’s no conversation with the patient about what they want or their goals or any of these other factors and you go straight to the most significant treatment, then that’s probably overstepping,” said Dr. Butler. “But I’ve had many conversations with patients that even for a lower-risk lesion, they still want the basal cell surgically removed. When the risks and benefits of the procedure were explained to them, they still chose it. I think that’s the right treatment for that person.”
“Context is key,” noted Dr. Endo. Physicians must consider both the malignancy and the patient’s care goals. “A rapidly growing tumor that is causing discomfort or reduced function in a patient needs treatment. A ‘younger’ old patient who is active and healthy should be offered treatment options.”
Dr. Endo describes a grey zone situation: “A patient has multiple, severe comorbidities (e.g., severe dementia, pancreatic cancer) or is near the end of their life expectancy. You clinically suspect an indolent tumor like basal cell carcinomas in low-risk anatomic sites and they are not causing symptoms or reduced function. How much benefit or potential harm might there be in performing multiple biopsies? Are multiple procedures or prolonged courses of topical treatments always in the best interests of patients? The key is to get curious about the patient’s context.”
Older adults speak out on life expectancy–based cancer screening
Most U.S. screening guidelines for different types of cancers recommend ages for when to both start and stop regular screenings. Increasingly, however, screening guidelines are encouraging physicians to consider other factors in addition to age, including estimated life expectancy and general health. In January 2023, the University of Michigan National Poll on Healthy Aging asked a national sample of adults aged 50 to 80 about their views on how cancer screening decisions should be made.
The majority disagreed with the idea that life expectancy should guide whether a person is screened for cancer. Moreover, 70% of respondents reported thinking it was acceptable for older adults to continue being screened for cancer even if guidelines stated they should not.
Using life expectancy, rather than fixed aged cutoffs, to guide cancer screening decisions could help certain older adults to continue to get appropriate screening tests. According to the study’s authors, “Continuing to screen for cancer past the age cutoff is most appropriate for older adults who are relatively healthy and expected to live long enough to benefit from further screening. At the same time, using life expectancy to guide screening decisions could also protect less-healthy older adults from getting tests that are unlikely to be helpful because their potential harms outweigh their potential benefits.”
Mohs or no Mohs?
“I’ve had patients who are healthy with no comorbidities in their late 70s, and for all intents and purposes, are acting like they’re in their 50s,” Dr. Butler said. “They have a basal cell on the face, and you bring up the prospect of Mohs surgery and they recoil. I tell them about the other options and then with shared decision-making, they may decide against Mohs surgery. As long as the patients know the risk and they’re following up, then I think that’s a safe plan.”
In cases where Mohs is not appropriate, said Dr. Endo, physicians can discuss the pros and cons of other options, especially as they pertain to what matters most to the patient, which might include excision, topical therapy, electrodesiccation and curettage, radiation therapy, etc. “We cannot take a one-size-fits-all or ageist approach to geriatric dermatology.” A JAAD study found that cosmetic outcome was regularly mentioned as an important treatment experience outcome to older adults, contrary to a preconceived notion that older adults might not care about scar appearance. Their study emphasized that treatment should not be withheld solely because of a patient’s chronological age.
“Conversely, there may be a 90-year-old with a less-risky basal cell or a basal cell with less-risky features,” noted Dr. Butler. “I may bring up the possibility of Mohs surgery, but also treating it with a cream or electrodesiccation and curettage. The patient may elect to go with the Mohs procedure because it’s outpatient, and it’s a one-stop shop with about a 99% cure rate.”
Dr. Butler views the array of skin cancer treatment options on a sliding scale of risk. “Perhaps, getting Mohs surgery for a basal cell is the lowest risk for an extremely high cure rate and low infection rate. However, if we decide to treat with a cream, we know the efficacy isn’t as good as Mohs.”
While the principles of treating skin cancer don’t differ when treating nonmelanoma skin cancer versus melanoma, the sliding scale for risk does. “Since melanoma is a more aggressive cancer, this ramps up the risk of any potential option. Our knowledge of the aggression of the tumor should impact how we communicate where the risks are and how aggressive our treatment plan should be,” Dr. Butler added.
As the number of older adults is rapidly growing, health care becomes more complex with health systems often unprepared for this complexity. To address these challenges, in 2017, the John A. Hartford Foundation and the Institute for Healthcare Improvement developed a practical geriatric care model called the “4Ms” that acknowledges the heterogeneity and complexity of aging.
The 4Ms — What Matters, Mentation, Mobility, and Medication — make care of older adults more manageable. The 4Ms identify core issues that should drive decision-making in the care of older adults. They organize care and focus on the older adult’s wellness and strengths rather than solely on disease.
For Dr. Chang, the first “M,” What Matters, is the most important. “It is about figuring out what matters to the patient, finding out what is bothering them the most, and addressing that while being careful not to interpose our own values and judgements on the care that they’re seeking.”
“A patient may be concerned about side effects of a major surgery. They might be worried about bleeding or, because they’re older, taking longer to heal, prolonged pain, or even scarring. We have to consider all of these things and take more time to listen,” she added.
“I can presume to know what a patient’s care goals are, but often patients will tell me something that’s different than what I anticipated,” said Kelly Nelson, MD, FAAD, a professor in the department of Dermatology at the University of Texas MD Anderson Cancer Center. “I just bring it up and say, ‘Let’s talk about what’s the most important thing for you in taking care of the skin cancer.’”
Dr. Endo likes to ask patients: “‘At this time in your life, what health goals are most important to you?’ It’s helpful to understand if the patient doesn’t want multiple surgeries or maybe wants to focus on other pressing health issues. Some patients might have financial concerns about health care bills or don’t want to chase after every tiny basal cell cancer that pops up in low-risk anatomic sites,” he said.
Keep in mind, however, that patients’ circumstances change over time, and this might impact patient goals. “We dermatologists have the joy of getting to know our patients over time and might sense when care goals might need to be renegotiated,” he continued.
Mentation refers to the patient’s cognitive status and how that might impact decision-making and adherence. The most extreme example of mentation is simply whether the patient is able to understand the risks and benefits of all potential treatment options. “I ask patients to name at least one side effect of a treatment as well as one benefit, which acts as part of the consent process, including when we do surgical procedures,” said Dr. Chang.
“Engagement in an informed consent discussion, which includes the patient’s right to decline treatment if they can articulate why, is critical to gauge,” Dr. Endo said. “A common pitfall is engaging a patient’s friend or family member who is acting as a strong advocate and bypassing the patient who still has decision-making capacity.”
Mentation also involves a patient’s ability to follow through with treatment. For instance, some patients with dementia might not be able to follow instructions and remain still for a long Mohs procedure; or may become more agitated later in the day (“sundowning”). “Or perhaps the patient will need assistance in remembering how to use the prolonged topical medication course to treat the squamous cell carcinoma in situ,” Dr. Endo noted.
Often when treating patients with cognitive impairments, there may be work needed to connect with the patient’s geriatrician, family members, or other caretakers to get a better idea of their goals and where this person is in their life and how treatments may be handled, Dr. Butler noted. “Could this person be a surgical candidate? Do we have to look at nonsurgical options? This is truly an exercise in patience and knowing where you have support as a dermatologist to help understand where the patient is in the medical and social aspects of their lives.”
Mobility can be as simple as whether a patient can come for regular follow-up visits to monitor a suspicious lesion, noted Dr. Chang. “If a patient isn’t able to make those follow-up appointments because they may not be able to drive or move long distances, giving them treatment that requires a lot of follow up may not be the best choice.”
Mobility in the context of cancer treatment can include several examples. “How safely can my patient transfer and position onto my examination table to do an excision? Do I need multiple people to help?” said Dr. Endo. “Some patients have disabilities or arthritis that necessitate someone helping them with dressing changes or applying topicals.”
“Photodynamic therapy treatments can be done in the office where it’s not as dependent on the patient to do something at home,” noted Dr. Nelson. “After speaking with our radiation oncology colleagues, it may be more practical and easier for the patient to drive to a few short radiation oncology treatments if they have a lower-risk skin cancer than to have a surgery or to do a field therapy option. On the flip side, for some patients driving may be the biggest issue. It really becomes this matrix of what’s possible, what’s important, and what are the big barriers to them getting the guideline concordant care that we would recommend for someone who is younger.”
“To the extent that we can use telemedicine, with or without caregiver support, I think that can be beneficial in the right circumstances, or having a patient come into the office with a caregiver if transportation is an issue,” Dr. Chang said.
Each additional medication increases the risk of adverse effects, and many medications viewed as safe in younger persons are not always safe in older persons. “Antihistamines and some pain medications, for example, may cause dizziness, fatigue, and increased fall risk,” Dr. Chang said. Because of anticholinergic adverse effects, including confusion, constipation, and reduced clearance in advanced age, antihistamines are listed on the Beers Criteria of potentially inappropriate medications in older adults (doi: 10.1001/jamadermatol.2018.0286).
“We even have to use systemic prednisone carefully. We have to be aware of drugs that can increase their chance of bleeding from procedures or falls. We should be aware of the risk of polypharmacy since older adults tend to take more drugs in general, and making sure there are no interactions” Dr. Chang said.
Life expectancy and treatment
Life expectancy is not the same as chronological age, noted Dr. Endo, which is also the first principle of caring for older adults noted in a 2018 JAMA Dermatology article. “There can be tremendous heterogeneity with aging, which is much different from childhood when we go through development milestones at certain ages. You’ve probably seen patients who are spry octogenarians and patients barely pushing 60 who are already frail from multimorbidity. We cannot make decisions based solely on chronological age.” One study found that many older adults generally do well with excision and Mohs surgery, but that frailer patients seem to experience higher treatment burden.
The concept of “lag time to benefit” is also a principle that should be considered when treating older adults. This concept includes when will the intervention help the patient and how much? “With our current understanding about the natural history of actinic keratoses, we can educate the patient about treatment options (or even the option to aggressively sun protect and expectantly manage). For some of my especially older ‘snowbird’ patients, field therapy might not be practical or reap much long-term benefit,” Dr. Endo said.
“If we think about someone who is 30, their time horizon for recurrence may be 60 years,” said Dr. Nelson. “But if we’re talking to a patient who is 93, obviously that’s not the same time window for recurrence. It really does become a very different calculation of how we can provide the best benefit for this patient while minimizing risks.”
Dr. Endo discusses another common scenario: A patient diligently comes to their appointments and allows you to do biopsies, but then declines treatment or does not follow up. “It’s easy to label them as ‘noncompliant,’ but another approach is to get curious and empathically listen to understand their care goals. Identify and address potential barriers, including unfounded fears of treatment or health care access issues.”
Dermatologists are experts at pattern recognition and can take a holistic approach to the patient, Dr. Endo said. “For example, you quickly glance at their problem list and notice a terminal condition or recent diagnosis of an advanced stage non-cutaneous malignancy. You can acknowledge and show empathy for it and get curious about understanding what matters most to the patient as it relates to dermatology visit goals. Perhaps you coincidentally note tiny suspected basal cell cancers and a possible squamous cell cancer. Before doing multiple biopsies, consider gauging the patient’s responses as you counsel them about the likely prognosis and treatment options. In some cases, the patient might only want to focus on the more aggressive tumor — or something else.”
Dr. Endo encourages dermatologists to take the free Harvard implicit association test to see your implicit biases (select the “Age” test). “I was surprised to see my implicit biases about aging, and this awareness helps me when caring for older adults.”
Expert Resource Groups
The Academy’s Expert Resource Groups (ERGs), including the Geriatric Dermatology ERG, are made up of individuals who share information and knowledge about a particular topic relevant to dermatology. To join the Academy’s Geriatric Dermatology ERG, contact Allen McMillen at email@example.com.
“We all have patients where if we closed our eyes and pointed at them, we would probably point to a hyperplastic actinic keratosis or something that’s bordering on an early squamous cell carcinoma in situ,” said Dr. Nelson. “For some of these older patients, there’s so much there that it would be impossible to cut everything off. We just watch for things that are breaking away from the herd.”
“That’s very much a discussion to make sure everyone’s on the same page that if the patient were younger, and their health was more robust, we would be doing A, B, and C to try to clear this,” Dr. Nelson added. “However, they’re not. And so instead of putting the patient through all these other treatments, knowing that these are early-stage skin cancers, if we’re all in agreement, let’s just watch and see what happens.”
Dr. Butler recommends using alternatives for life expectancy such as comorbidities, social support, and other psychosocial factors that may help predict how someone will respond to a treatment. “You may have a patient come in who looks really frail and simply ask them what else is going on in their life. If they say, ‘I’m actually getting treatment for breast cancer and I’m really run down,’ you can use your expertise to talk to the patient about how the basal cell is likely not going anywhere for the next few months. You can plan for watchful waiting with a plan for follow up and use that knowledge to guide the conversation in a softer way. Never make assumptions about what a patient would want.”
There’s uncertainty about how best to counsel and follow patients who decline or defer treatment, said Dr. Endo. In an opinion paper by Drs. Linos and Chren, they make the argument that surgical interventions for low-risk basal cell carcinomas probably have low benefit toward the end of life. They cite data that procedure rates increase with age and surgery is often the default mode of treatment, regardless of a patient’s life expectancy. They also point to one of the few studies analyzing the natural history of presumed basal cell carcinomas: only about half of the lesions grew. They suggest some parameters for active surveillance, but further data are needed for evidence-based recommendations.
Another complexity that arises when treating older patients is how to define and predict life expectancy for a patient in order to help them gauge the lag time to benefit. There are tools such as actuarial tables (though these do not include clinical information) and life expectancy calculators, Dr. Endo noted. “The reality, however, is these provide very rough estimates — and life expectancy (i.e., quantity) does not factor in another important concept: quality of life.”
“Dermatologists, unsurprisingly, see and treat a lot of older adults, and we very much care about this population,” Dr. Butler said. “Rest assured there are people, like in our Geriatric Dermatology Expert Resource Group, who are researching this topic and exploring best practices, so that we can continue to optimize how we care for this growing population.”