Age Is Not Sole Predictor of Post-Surgical Outcomes in Older Patients with BCC

There has been an increasing interest in recent years regarding whether the consideration of patient-related factors may improve personalized management and treatment outcomes in older patients with BCC, the authors wrote in their Journal of the American Academy of Dermatology paper, which first appeared online May 2021.

Lead study author Marieke E.C. van Winden, MD, MSc, of the Radboud University Medical Center in the Netherlands, commented that many dermatologists remain challenged in their ability to weigh patient-level factors as it relates to treatment decision-making in current clinical practice.

“Furthermore, there are no specific guidelines to aid BCC management decisions regarding these patient-related factors,” van Winden said in an email to Dermatology Times. “It is therefore highly necessary to develop more specific recommendations regarding frailty-related aspects, as discussed in our research.”

To identify predictors of treatment burden, outcomes, and overall survival (OS) in older patients surgically treated for BCC, Dr. Winden and colleagues analyzed data from the BATOA study, a prospective, multicenter study comprising patients 70 years of age and older who received treatment for BCC of the head and neck.

In the analysis on treatment burden, the investigators evaluated changes on the visual analog scale (VAS) (0-10 cm) at 2 to 4 months after surgery. Lower scores on the VAS corresponded to a higher treatment burden. A secondary outcome of the analysis included OS.

The cohort included 539 patients (median age, 78 years) from the BATOA study, including 296 who received treatment with Mohs micrographic surgery (MMS) and 243 who received treatment with conventional surgical excision. The median VAS score was 8.6, suggesting a low treatment burden in this population.

Significant predictors of higher treatment burden included instrumental activities of daily living (iADL) dependency (P < .001), female sex (P =.002), presence of complications (P =.018), tumor diameter (P =.024), and polypharmacy (P =.042). These factors, according to the researchers, are frequently associated with and reflect high levels of frailty.

Corresponding study author Satish Lubeek, PhD, of the Radboud University Medical Center, explained that as BCCs are slowly growing tumors which are frequently asymptomatic, active BCC treatment may be too burdensome for some frail and older adults with limited life expectancy, given that these patients will not live long enough to develop symptoms from their disease. “In these cases, watchful waiting or active surveillance might be a more suitable approach,” he said.

More “robust” older patients in the study experienced a low treatment burden, and these patients had a higher OS compared with the general population, van Winden explained. “For robust older patients without a limited life expectancy,” she said, “early BCC treatment will often be beneficial, especially in symptomatic and/or high-risk lesions.”

Approximately 6.5% (n=35) of patients died during follow-up, yet none of these deaths were due to BCC. The predictors of all-cause mortality in this cohort included increasing Charlson comorbidity index score (P <.001) and iADL dependency (P =.003).

“These findings further emphasize our advice to include frailty screening in daily dermatology care,” van Winden stated. “If needed, a geriatrician or home care physician could be consulted to weigh the advantages and disadvantages of certain therapies.”

Given that iADL and dependency are related to frailty, the researchers added that while “frailty screening could aid in estimating patients’ life expectancy in a more holistic approach” to care, current experience with such screening in daily dermatology practice is limited.

The study demonstrated that chronological age was not a significant predictor for any of the evaluated outcomes. “Age should therefore not be a sole reason to base BCC management decisions,” Lubeek noted. “More importantly, frailty-related patient characteristics should be considered, as these were significantly associated with a higher treatment burden and higher non-BCC-related mortality.”

Predictors of complications following surgery included tumor diameter (P =.001) and wound closure technique (healing through secondary intention vs primary closure, P = .017; and reconstructions vs primary closure, P <.001). A multivariable analysis found no difference between MMS and conventional surgical excision in terms of the rates of complications (P =.80).

Although the observational nature of the study may have resulted in selection bias, the investigators noted that the study’s findings likely “represent daily clinical care adequately.”

In addition to the study limitations, Lubeek noted that few data are available to guide clinicians on watchful waiting and active surveillance in cases of untreated BCCs. “Further studies on watchful waiting/active surveillance are needed to provide further guidance, in addition to studies on life expectancy prediction tools for patients with BCC,” he said. “Hopefully, these studies will guide clinicians in identifying those patients for whom BCC treatment is needed, and those patients for whom it is better to refrain from treatment.”

Expert Comments

Jessica A. Savas, MD, assistant professor of dermatology at Atrium Health Wake Forest Baptist, explained that all treatment approaches for BCC typically take into account patient-related factors to guide treatment decisions regardless of age. “While most of our skin cancer patient population falls into an ‘older’ demographic based on chronological age,” she said, “age itself is probably one of the least helpful factors in the discussion of the best treatment options for a particular patient.”

Savas, who wasn’t involved in the study, noted that in cases where integration of these factors into treatment decisions does not occur, it is usually because the patient or the patient’s family member(s) request this approach. “If the patient is unwilling to go through a surgical procedure for whatever reason but they are otherwise a fine surgical candidate,” she said, “then we of course discuss treatment alternatives that may offer a lower cure rate and/or an inferior cosmetic result.”

She added that overall health status, including functional and nutritional status, as well as “the degree of social support available to the patient are paramount when considering all treatment options for BCC, especially in older patients.”

“Maintaining quality of life and the ability to live independently become very important in this phase of life, and fortunately BCC is a relatively slow-growing tumor with low metastatic potential,” Dr. Savas said. “This allows for conversations about more conservative management of BCCs that are asymptomatic and not imminently a threat to function in patients who wish to avoid surgery.”

Disclosures

The study researchers reported conflicts of interest with the pharmaceutical industry.

References

van Winden MEC, Bronkhorst EM, Visch MB, et al. Predictors of surgical treatment burden, outcomes, and overall survival in older adults with basal cell carcinoma: Results from the prospective, multicenter BATOA cohort. J Am Acad Dermatol. 2022;86(5):1010-1019. doi:10.1016/j.jaad.2021.05.041