Potential Overdiagnosis of Basal Cell Carcinoma in Older Patients With Limited Life Expectancy

Eleni Linos, MD

Note: Eleni Linos, MD, a leader in the field of skin cancer research and prevention, is a CTSI K Scholar and assistant professor in the UCSF School of Medicine. This study was supported by a UCSF-CTSI KL2 grant.

From Jama, September 2014, Vol 312, No. 10:

More patients are diagnosed with basal cell carcinoma (BCC) in the United States each year than all other cancers combined—more than 2.5 million BCCs compared with 1.7 million other cancers.13 Most of these BCCs occur in people aged 65 years and older, and each year, more than 100 000 BCCs are treated in persons who ultimately die within 1 year. Procedures to remove skin cancers have doubled in the last 15 years, and the use of Mohs surgery, histologically guided serial excision, increased by 400% between 1995 and 2009.4 Many clinicians have suggested that this is an epidemic of skin cancer1 attributed to excessive sun exposure, a thinning ozone layer, and indoor tanning. These numbers will likely increase further; as the number of older adults doubles between 2010 and 2030, overall cancer incidence is projected to increase 45%.5

These enormous numbers notwithstanding, BCCs grow slowly, and treated BCCs seldom metastasize and are rarely life threatening.2 In fact, even as the number of diagnosed BCCs has more than doubled in the last 20 years, deaths from this specific cancer are very low. Nonmelanoma skin cancer mortality is estimated at less than 1 in 1000 cases, but these deaths are overwhelmingly from squamous cell carcinoma, not BCC.3 Patients who are diagnosed with BCC during their last year of life will almost certainly die of causes unrelated to these lesions. In this Viewpoint, we suggest a new approach for the care of asymptomatic BCCs in patients with limited life expectancy—especially those in the last year of life.

Elderly patients are more likely to be diagnosed with BCCs, but are also at highest risk for inadvertent harms associated with diagnosis and treatment. Harms include anxiety associated with a cancer diagnosis, fear of metastasis or recurrence (even though this is unlikely), or adverse effects from treatment. Frail elderly patients with other comorbidities are more likely to struggle with skin cancer treatments such as long procedures, difficulty with wound care and dressing changes, or poor wound healing. Patient-reported problems are common in the months following treatment, especially among older patients with multiple comorbidities.6 For example, when asked “Did you experience a complication following treatment?” more than a quarter (236/866) of patients in a prospective cohort of skin cancer patients responded affirmatively.6 Thus, any potential harms of treatment are immediate. Yet treatment patterns are the same, regardless of patient symptoms or life expectancy.7

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