Modifying treatment modalities for elderly

Less aggressive treatments may be more appropriate for the older set. Dermatologists treating patients age 60 and older must be especially clear on what medications patients are taking and their comorbidities, and may even consider communicating differently with a person in his or her eighth or ninth decade in life.

Careful communication

"They have to deal with enough chronic problems in their lives," says Dr. Norman, who is also associate professor, department of internal medicine, Nova Southeastern University, Fort Lauderdale, Fla.

Instead, Dr. Norman describes the cancer as abnormal cells that need to be removed.

"Some people might think that sounds paternalistic, but I think it is just a nice thing to do," Dr. Norman says.

Note complexities

Treating patients who are 60 and older tends to be more complex because they are often on several medications and have other health issues.

"With a 30-year-old patient who has a basal cell carcinoma, we simply shave it off. With an elderly patient, you have to worry about what medications they are on and if there is anything else that could prolong bleeding time," Dr. Norman tells Dermatology Times.

Blood thinners are a particular concern, adds Mark Lebwohl, M.D., dermatologist, professor and chairman, department of dermatology at the Mount Sinai School of Medicine, New York.

Considerations

Textbook medicine does not always apply to patients 60 and older.

"I have gone to nursing homes where I have seen people with melanomas or large squamous cells, and they want to treat it in a palliative way," Dr. Norman says.

Dermatologists have to think about the consequences of treatment and how those consequences could affect a person who might not be healthy and who has a shortened life expectancy.

Excisions can take longer to heal in an elderly patient, Dr. Norman says.

"You cannot say healing should occur in the standard 10 to 14 days, because it might take longer," he says. "We need to make patients and caregivers aware of potentially lengthy healing times."

Older patients respond differently to some medication, according to Dr. Norman. Often, they require lower percentages of active ingredients.

"It is unlikely that an older patient will have the same immune response as a young patient," Dr. Norman says. "The elderly immune system is diminished, and they do not have the same skin thickness for optimum healing. This fragility of the skin, along with certain medications they may be taking, such as blood thinners and steroids, is also a reason why they are more prone to skin tears."

Thinking outside the treatment box

Dr. Lebwohl says that excision, with adequate margin, is the gold-standard treatment for melanoma, and in patients with lesions more than 1 mm deep, sentinel node biopsies are usually performed.

Dermatologists should consider less invasive options for patients who have other health problems or who are frail. He cites an example of an 80-year-old patient who had a deep melanoma and a host of other medical problems.

"We simply excised it, locally," Dr. Lebwohl says.

Lentigo maligna melanoma, which occurs only in older patients, often presents on the face and can require a large excision. How to approach this cancer in the elderly is a source of debate, Dr. Lebwohl says.

"Radiation does not seem to be the answer. Imiquimod may be an adjunctive therapy option. But the most common treatment remains excision," he says.