Skin Cancer Treatment Options: Is Surgery Necessary For Everyone?

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Non-melanoma skin cancer generally occurs in older patients and does not typically affect either their survival or quality of life. Daoro, Creative Commons

Like other cancers, skin cancer is the uncontrolled growth of abnormal cells. Unrepaired DNA damage to cells can trigger mutations (genetic defects) that prompt the skin cells to swiftly multiply and form malignant tumors. Of the types of skin cancer, non-melanoma skin cancer — usually either squamous cell skin cancer or basal cell skin cancer — is the most common.

Predominantly, non-melanoma skin cancer (NMSC) affects older patients. Because NMSCs do not typically affect survival or even quality of life, the decision about treating older patients who have a more limited life expectancy is a challenge for doctors, especially when their patient has an asymptomatic tumor. Coming to terms with what is in their patient's best interest has become an increasingly common predicament for doctors.

 

Advancing Treatment Options

A recent study investigated skin cancer treatment procedures in the Medicare population from 1996 to 2008. Researchers used the Centers for Medicare and Medicaid Services databases to examine the procedures performed for Medicare beneficiaries. They found that the number of skin cancer treatment procedures increased sharply from 1996 to 2008.

From 1996 to 2008, the total number of skin cancer treatment procedures (malignant excision, destruction, and Mohs micrographic surgery or MMS) increased from 1,480,645 to 2,152,615 — a significant 53 percent increase.

Dermatologists treated the vast majority of skin cancers in the Medicare population, using a mix of treatment modalities, almost exclusively in the office setting. While the number treated by excision and destruction increased modestly over 12 years (a 20 percent and 39 percent increase, respectively), the number of MMS procedures became much more common (248 percent increase). MMS is the most advanced treatment for skin cancer and complications are rare. Nevertheless, bleeding, scarring, reaction to the local anesthesia, infection, damage to nerve endings (temporary or permanent numbness), or itching or shooting-pain sensations have been reported as complications in a very low percentage of cases.

Overall, more than 90 percent of all skin cancers were treated in the office, with the remainder being treated in facility-based settings during 2008. A more recent study presents a more detailed view of the treatment choices made by doctors and their patients diagnosed with non-melanoma skin cancers.

 

Positive Outcomes

Researchers compared treatment patterns and clinical outcomes of NMSC patients with and without limited life expectancy. For this study, the researchers defined limited life expectancy as those patients, either 85 years or older at the time of diagnosis or patients with multiple diseases. The study's cohort consisted of 1,536 consecutive patients diagnosed with NMSC and seen by dermatologists at two clinics: one, a university-based private practice and the other, a Veterans Affairs Medical Center in San Francisco. Patients were recruited in 1999 through 2000 and followed up for a median of nine years. A total of 1,360 patients with 1,739 tumors (90 percent) were included in the final analysis. Their treatment options included no treatment, destruction, or two types of surgery-elliptical excision or Mohs surgery.

Most (just over two-thirds) of the non-melanoma skin cancers were treated surgically, regardless of the patient's life expectancy. Many patients with limited life expectancy (43 percent) died within five years, none of NMSC. Tumor recurrence was rare (3.7 percent at five years) in all patients. Although serious complications were unusual, about 20 percent of patients with limited life expectancy reported complications of therapy, compared with 15 percent of other patients.

"Given the very low tumor recurrence rates and high mortality from causes unrelated to NMSC in patients with [limited life expectancy], clinicians should consider whether these patients would prefer less invasive treatment strategies," write the authors.

When recognized and treated early, skin cancer, even melanoma, is almost always curable. Cancer, though, can advance and spread to other parts of the body where it may be difficult to treat and may even become fatal. Is it in the best interest of an older patient, one with a more limited life expectancy, for a doctor to surgically treat an asymptomatic NMSC tumor? Some physicians clearly believe less-invasive treatment strategies might better serve these patients.

 

Sources: Parvataneni LR, Stuart R, Boscardin WJ, Landefeld CS, Chren MM. Treatment of Nonfatal Conditions at the End of Life: Nonmelanoma Skin Cancer. JAMA Internal Medicine. 2013.

Rogers HW, Coldiron BM. Analysis of Skin Cancer Treatment and Costs in the United States Medicare Population, 1996-2008. Dermatologic Surgery. 2012.

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