Acta Dermato-Venerelogica Issue No 7, 2017 97-7CompleteContent | Page 16

825 CLINICAL REPORT Impact of High Age and Comorbidity on Management Decisions and Adherence to Guidelines in Patients with Keratinocyte Skin Cancer Satish F. K. LUBEEK 1 , Celia A. J. MICHIELSENS 1 , Rinke J. BORGONJEN 1 , Ewald M. BRONKHORST 2 , Peter C. M. VAN DE KERKHOF 1 and Marie-Jeanne P. GERRITSEN 1 Department of Dermatology, and 2 Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands 1 Appropriate medical decision-making in patients with keratinocyte skin cancer (KSC) can be challenging, es- pecially in those with a limited life expectancy (LEx). Treatment should be beneficial for the individual pa- tient, the risk of both over- and under-treatment should be carefully considered, and deviation from guideline recommendations may be necessary. In this study re- trospective analysis was performed to determine the influence of age and comorbidity, both factors stron- gly related to limited LEx, on KSC management in daily practice. After analysis of 401 patients it was found that management in patients with KSC is not influen- ced, or is only minimally influenced, by high age and comorbidity. Better integration of aspects related to a limited LEx in KSC management might optimize care and prevent overtreatment. Future research on the ge- neral prognostication, prediction of the patient burden caused by tumour and treatment, and time-to-benefit in KSC management is strongly recommended. Key words: keratinocyte skin cancer; limited life expectancy; frail older adults; geriatric dermatology; skin cancer manage- ment; clinical practice guideline. Accepted Apr 6, 2017; Epub ahead of print Apr 17, 2017 Acta Derm Venereol 2017; 97: 825–829. Corr: Satish F. K. Lubeek, Department of Dermatology, Radboudumc, Post Office Box 9101, NL-6500 HB Nijmegen, The Netherlands. E-mail: [email protected] D ermatologists are increasingly likely to be confron- ted with older adults with multiple comorbidities who have keratinocyte skin cancer (KSC), considering: (i) the increasing incidence rates of KSC in general; (ii) the rising incidence rates of KSC with increasing age; (iii) and the ageing world population (1, 2). In general, the majority of KSC has a relatively low malignant potential compared with many other types of cancer. However, potential morbidity and mortality should not be underestimated (1). Adequate medical decision-making in patients with KSC requires physicians to be aware of several important aspects, including patient and tumour characteristics (e.g. tumour subtype, comorbidity, and life expectancy), treatment goals, and the availability of diagnostic and treatment options. Treatment should be beneficial for the individual patient, and the risks of both over- and under-treatment should be carefully weighed. Consequently, management decisions in pa- tients with KSC may be challenging, especially in the growing population of frail older adults with a limited life expectancy (LEx) (3, 4). The main purpose of clinical practice guidelines (CPGs) is to assist physicians in medical decision- making, based on the best evidence available, thereby optimizing healthcare (5). However, CPG recommen- dations might not be applicable to every individual, and CPG guidance for older adult patients and patients with multiple comorbidities is limited (6–8). Therefore, pro- perly reasoned deviation from CPG recommendations may be in the best interest of a patient and should be considered in some situations. Estimating a patient’s LEx is difficult. In addition to age, a patient’s LEx may be influenced by s everal factors, of which comorbidity is considered the strongest and best-studied predictor (9–13). It might be expected that a limited LEx and influencing factors might contribute to the extent of deviation from CPG in KSC, but little is known regarding these decisions from daily practice. Hence, the aim of this study was to determine the in- fluence of high age and comorbidity on management in patients with KSC in daily clinical practice. METHODS Setting and patient selection Patients with KSC seen in the outpatient dermatology department of Radboud University Medical Centre, Nijmegen, the Nether- lands, were analysed retrospectively. Selection of histologically proven basal cell carcinomas (BCCs) or squamous cell carcinomas (SCCs) diagnosed in 2012 or 2013 took place using the national pathology database (Pathologisch-Anatomisch Landelijk Geauto- matiseerd Archief; PALGA) combined with patient charts. Patients were sorted into 2 age groups (< 80 or ≥ 80 years), based on the United Nations (UN) age stratification (2) and the Dutch LEx data by Statistics Netherlands (mean residual LEx of 4.5 years at an age of 80 years) (14, 15). Since every lesion suspicious for KSC is histopathologically confirmed in our hospital, it is assumed that no cases were missed. In case multiple tumours per patient were found, only the first tumour was included. Exclusion criteria were: (i) tumours other than BCC or SCC (including basosqua- mous carcinoma); (ii) non-cutaneous tumours (e.g. mucosal); (iii) patients using chronic immunosuppressive medication; (iv) patients having a genetic disorder resulting in an increased risk of developing KSC (e.g. basal cell naevus syndrome, oculocutaneous albinism, and epidermodysplasia verruciformis); (v) clinical trial subjects; and (vi) patients in whom diagnosis and/or treatment was not performed within our hospital. This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta Journal Compilation © 2017 Acta Dermato-Venereologica. doi: 10.2340/00015555-2670 Acta Derm Venereol 2017; 97: 825–829