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

Linos E, Parvataneni R, Stuart SE, et al. — Mon, 10 Jun 2013 00:00:00 GMT

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.

Skin Cancer and Shared Decision Making Comment on “Treatment of Nonfatal Conditions at the End of Life” Skin Cancer and Decision Making

Wenger NS. — Mon, 10 Jun 2013 00:00:00 GMT

Shared decision making between patients and their physicians is optimal for choosing a course of medical care. Decision making is shared because it includes both information from the physician about the medical condition and potential approaches and the perspectives of the patient whose values guide selection among the potential options. Usually, decision making occurs in the context of a conversation between the physician and the patient and optimally includes an iterative series of questions and answers to ensure that the patient understands his or her condition and the upsides and downsides of the treatment choices for him or her to make an informed decision.

JAMA Internal Medicine: Skin Cancer Topic Collection

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

Skin Cancer and Shared Decision Making Comment on “Treatment of Nonfatal Conditions at the End of Life” Skin Cancer and Decision Making