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Original Investigation | Less Is More

Treatment of Nonfatal Conditions at the End of Life:  Nonmelanoma Skin Cancer

Eleni Linos, MD, DrPH; Rupa Parvataneni, MS; Sarah E. Stuart, BA; W. John Boscardin, PhD; C. Seth Landefeld, MD; Mary-Margaret Chren, MD
JAMA Intern Med. 2013;173(11):1006-1012. doi:10.1001/jamainternmed.2013.639.
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Importance Nonmelanoma skin cancer (NMSC) is the most common cancer and predominantly affects older patients. Because NMSCs do not typically affect survival or short-term quality of life, the decision about whether and how to treat patients with limited life expectancy (LLE) is challenging, especially for asymptomatic tumors.

Objective To compare treatment patterns and clinical outcomes of patients with NMSC with and without LLE.

Design, Setting, and Participants A prospective cohort study of 1536 consecutive patients diagnosed with NMSC at 2 dermatology clinics: a university-based private practice and a Veterans Affairs Medical Center in San Francisco, California. Patients were recruited in 1999 through 2000 and followed up for a median of 9 years. A total of 1360 patients with 1739 tumors (90%) were included in the final analysis. Limited life expectancy was defined as patients either 85 years or older at the time of diagnosis or patients with multiple comorbidities (Charlson Comorbidity Index of ≥ 3). Treatment options included no treatment, destruction, or 2 types of surgery—elliptical excision or Mohs surgery.

Main Outcomes and Measures Treatment type.

Results Most NMSCs (69%) were treated surgically, regardless of patient life expectancy. The choice of surgery was not influenced by patient prognosis in univariate or multivariable models adjusted for tumor and patient characteristics. Many patients with LLE (43%) died within 5 years, none of NMSC. Tumor recurrence was rare (3.7% at 5 years [95% CI, 2.6%-4.7%]) in all patients. Although serious complications were unusual, approximately 20% of patients with LLE reported complications of therapy, compared with 15% of other patients.

Conclusions and Relevance Most NMSCs are treated surgically, regardless of the patient's life expectancy. Given the very low tumor recurrence rates and high mortality from causes unrelated to NMSC in patients with LLE, clinicians should consider whether these patients would prefer less invasive treatment strategies.

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Figure 1. Study flowchart.

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Figure 2. Percent of nonmelanoma skin cancers treated with Mohs, excision, destruction, other, or no treatment. LLE indicates limited life expectancy.

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