Age matters in new session on non-melanoma skin cancer treatments

Non-melanoma skin cancer is a concern at any age. But a new session on Thursday, July 25, Managing Non-Melanoma Skin Cancer in Very Elderly Patients: Controversies, Conundrums, and a Search for Consensus (U009), will explore those treatment considerations that are unique to an aging population.

Molly Moye, MD

Dermatologist Molly Moye, MD, is the director of the session and a Mohs micrographic skin cancer surgeon at Forefront Dermatology in Louisville, Kentucky. Dr. Moye will summarize the issues affecting older individuals diagnosed with non-melanoma skin cancer and will explore when surgery is not the ideal option.

Ahead of the session, Dr. Moye answered questions regarding skin cancer in elderly patients.

What makes a skin cancer low-risk versus high-risk in elderly patients?

Overall, high-risk tumors in very elderly patients are the same as for other patient populations. Features that make a squamous cell carcinoma (SCC) high risk include its location on the body, such as scalp, lip, or ear; depth of invasion; and moderate or poor differentiation. The important thing is for dermatologists to recognize these high-risk tumors and to treat them effectively right off the bat, usually surgically, rather than attempting less invasive techniques, such as destruction, due to a patient’s advanced age.

The panel of dermatologists contributing to the Thursday session include:

  • Nkanyezi Ngwenyama Ferguson, MD, “When Well-Timed Surgery Is Just Right.”
  • Anne Lynn S. Chang, MD, “When Surgery Is Not Enough: Targeted Therapies and Immunotherapy in Elderly Patients.”
  • Neha Shukla, MD, “Shared Decision Making With Elderly Patients.”

What are treatment options for non-melanoma skin cancer?

Treatment options are similar in both elderly patients and the general population. These include topical therapies, tumor destruction, surgical techniques — including excision and Mohs surgery, radiation when necessary — and the newer, targeted systemic therapies. The main differences are that non-intervention should be considered for low-risk tumors, such as asymptomatic basal cell carcinoma (BCC), and that the patient’s overall health status and personal wishes should be taken into consideration when deciding the best treatment course. While this is certainly true for all patients we treat, for elderly patients it can be important to involve family members in the decision-making process and to discuss realistic expectations for all treatment options. Because cancer is always a scary diagnosis, explaining the high- versus low-risk nature of a given tumor can be helpful for patients and their family members when deciding the best course of action.

When might surgery not be the best choice?

There are several situations in which surgery may not be the best choice for treating non-melanoma skin cancer. For asymptomatic, low-risk BCCs in elderly patients, I always offer the option of observing the tumor and treating in the future if it becomes symptomatic. On the other hand, a patient with a very large or advanced BCC or SCC may be better off pursuing systemic therapy with one of the new targeted therapies, such as vismodegib or a PD-1 inhibitor.

How can we share the decision-making process with elderly patients?

Having a conversation is important. I always sit down in the exam room and include family and/or supportive people in the patient’s life. Explaining the tumor and treatment options in layman’s terms is important. Some patients have expressed specific wishes regarding what treatments they do or do not want at their stage in life, but it is likely they have not considered skin cancer treatments in their planning. Gaining an individual, personalized understanding of a patient’s medical wishes is helpful to try to tailor treatment options in line with their goals of care.