Sunday, August 02, 2015

To Treat or Not to Treat: that is the question

Elani Linos and colleagues wrote a milestone paper on the treatment of nonmelanoma skin cancer (NMSC) that was published in JAMA – Internal Medicine in June 2013. In it, they stated:

“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.

“The current standard of care in the United States is to treat NMSCs, and no guidelines exist about whether physicians should consider patient age or functional status in choosing treatments.  Treatment decisions for patients with NMSC with LLE require consideration that the benefits of treatment may not occur within the patient's
remaining life span, but any risks are immediate.”

We saw two such patients recently in our dermatology practice.  They are presented for your thoughts and discussion.

1. The patient is a 94 yo woman, status post CVA (12/24/13) with right hemiparesis.  She has a two year history of a rodent ulcer on the right nasolabial fold measuring 2.4 x 1.4 cm.  It itches and she picks it.  Biopsy shows “infiltrating basal cell carcinioma.”  She is a retired executive secretary, never married with no close relatives nearby.  Mentally, she is alert and oriented.  We discussed active surveillance, surgery and radiotherapy.  She is confined in a nursing home and was not keen on having XRT considering the number of treatments.

2.  This 89 yo man has a tumor of the mid upper lip for ~ 10 months.  The 1.4 cm in diameter lesion is firm with rolled borders.  Clinically, this is BCC, but it has not yet been biopsied.  His general health is good, but he has moderately advanced dementia and lives independently with his wife.  The couple have children who live at some remove.  We discussed active surveillance, XRT and surgery.  The latter would be fairly simple; but we recognize that the tumor may not ever significantly impact on his quality of life or longevity.

Discussion:  Both of these lesions could be treated or watched.  Lesion # 2 would be easy to excise and that may make management easier.  Excision of lesion #1 would entail a long trip for micrographic surgery which is difficult logistically.  In our opinion, how to proceed with these cases is a value judgement and input from the patient and/or the family is important.

Dr. Linos’ article (1) is helpful but each case presents unique management quandaries.  It has been said that “often it is more important to treat the patient with the disease, than it is to treat the disease the patient has.”  These two cases are examples of this conundrum.

An additional thought:   Topical imiquimod can be helpful in the management of superficial and nodular basal cell carcinomas.(2)  The marked inflammatory response is often difficult for patients to tolerate, but less frequent applications may allow for palliation and slowing of tumor progression.

You thoughts will be appreciated.

1. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer.  Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Landefeld CS, Chren MM.  JAMA Intern Med. 2013 Jun 10;173(11):1006-12.
Available Free Full Text.

2.  Surgical excision versus imiquimod 5% cream for nodular and superficial basal-cell carcinoma (SINS): a multicentre, non-inferiority, randomised controlled trial.
Bath-Hextall F, et. al.  Lancet Oncol. 2014 Jan;15(1):96-105.

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