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Aging and Disease    2017, Vol. 8 Issue (5) : 643-661     DOI: 10.14336/AD.2017.0503
Review |
Skin Cancer Epidemics in the Elderly as An Emerging Issue in Geriatric Oncology
Simone Garcovich1,Giuseppe Colloca2,*,Pietro Sollena1,Bellieni Andrea2,Lodovico Balducci3,William C. Cho4,Roberto Bernabei2,Ketty Peris1
1Institute of Dermatology, Policlinico A. Gemelli University Hospital, Catholic University of the Sacred Heart, Rome, Italy
2Department of Geriatrics, Policlinico A. Gemelli University Hospital, Catholic University of Sacred Heart, Rome, Italy.
3Senior Adult Oncology Program, Moffitt Cancer Center, Tampa, FL, USA
4Department of Clinical Oncology, Queen Elizabeth Hospital, Kowloon, Hong Kong
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Abstract  

Skin cancer is a worldwide, emerging clinical need in the elderly white population, with a steady increase in incidence rates, morbidity and related medical costs. Skin cancer is a heterogeneous group of cancers comprising cutaneous melanoma and non-melanoma skin cancers (NMSC), which predominantly affect elderly patients, aged older than 65 years. Melanoma has distinct clinical presentations in the elderly patient and represents a challenging question in terms of clinical management. NMSC includes the basal cell carcinoma and cutaneous squamous cell carcinoma and presents a wide disease spectrum in the elderly population, ranging from low-risk to high-risk tumours, advanced and inoperable disease. Treatment decisions for NMSC are preferentially based on tumour characteristics, patient’s chronological age and physician’s preferences and operational settings. Several treatment options are available for NMSC, from surgery to non-invasive/medical therapies, but patient-based factors, such as geriatric comorbidities and patient’s life expectancy, do not frequently modulate treatment goals. In melanoma, age-related variations in clinical management are significant and may frequently lead to under-treatment, limiting access to advanced surgical and medical treatments. Clinical decision-making in the care of elderly skin cancer patient should ideally implement a geriatric assessment, prioritizing patient-based factors and efficiently differentiating fit from frail cancer patients. Current clinical practice guidelines for NMSC and melanoma only partially address geriatric aspects of cancer care, such as frailty, limited life-expectancy, geriatric comorbidities and treatment compliance. We review the recent evidence on the scope and problem of skin cancer in the elderly population as well as age-related variations in its clinical management, highlighting the potential role of a geriatric approach in optimizing dermato-oncological care.

Keywords skin cancer      elderly cancer patients      geriatrics      basal cell carcinoma      squamous cell carcinoma      melanoma      geriatric assessment      disease management     
Corresponding Authors: Giuseppe Colloca   
Just Accepted Date: 28 June 2017   Issue Date: 27 September 2017
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Simone Garcovich
Giuseppe Colloca
Pietro Sollena
Bellieni Andrea
Lodovico Balducci
William C. Cho
Roberto Bernabei
Ketty Peris
Cite this article:   
Simone Garcovich,Giuseppe Colloca,Pietro Sollena, et al. Skin Cancer Epidemics in the Elderly as An Emerging Issue in Geriatric Oncology[J]. A&D, 2017, 8(5): 643-661.
URL:  
http://www.aginganddisease.org/EN/10.14336/AD.2017.0503     OR     http://www.aginganddisease.org/EN/Y2017/V8/I5/643
Study settingSkin cancerPrevalence-rate (%)
Pre-malignant skin lesions and AKs10.4-69.4
All malignant skin cancer2-12
BCC2.8
cSCC0.2
Melanoma0.1
Institutional long-term care/nursing homesPre-malignant skin lesions and AKs4.6-29.3
All malignant skin cancer1-5.6
BCC3.9-14.8%
cSCC8%
Melanoma2.3%
Hospital-based geriatric unitsPre-malignant skin lesions and AKs32.8%
All malignant skin cancer4.9%
BCC-
cSCC-
Melanoma-
Hospital/outpatient-based dermatology settingPre-malignant skin cancer and AKs0.5-39%
All malignant skin cancer2-13.2%
BCC11-21%
cSCC2%
Melanoma4%
Table 1  Prevalence rates of skin cancer and precursors in geriatric populations according to study setting.
QuestionsOnco-Geriatric Assessment Instrument
Is the patient self sufficient?ADL, IADL
Has the patient a cognitive impairment?MMSE
How are the Physical Performance?SPPB, TUP
Compliance and needs?InterRAI suite
Is there a Social Network able to protect the patient?InterRAI suite
How to calculate the prognostic value of biological age?Active Life Expectancy
Table 2  Geriatric instruments for an appropriate onco-geriatric assessment.
Figure 1.  Interventions for Basal cell carcinoma (BCC), by treatment modality.
Figure 2.  Interventions for cutaneous squamous cell carcinoma (cSCC), by treatment modality
Treatment decisionRational for oncogeriatric evaluation and intervention
Excision of primary tumourExcision margins depend on tumour thicknessInsufficient excision margins correlated with old-age Indication for micrographic excision surgery for LMM
Non-invasive treatment for in-situ LMTopical immune-modulators as alternative to conventional surgery in selected patients
Sentinel lymph-node biopsy (SLNB)Indication to the staging procedure may be influenced by patients’ characteristics and decreased rate of SLNB positivity with increasing age
Complete lymph-node dissection (CLND)Indication to CLND limited by risk of morbidity and complications in the old patient; less performed in old age
Adjuvant therapyRisk-benefit analysis of interferon-alpha treatment or other investigational immunotherapies in the old patient, with LLE status
Surgery of distant metastasisSelection of fit vs. frail patient for surgery to improve overall survival
Immunotherapy of metastatic diseaseInclusion of old, very old and oldest patients in clinical trials and expanded access programs; improved prevention, surveillance and management of irAEs
Targeted treatment/chemotherapy of metastatic diseaseInclusion of old, very old and oldest patients; identification of pre-frail patients at increased risk of AEs
Table 3  Key areas for oncogeriatric intervention in the clinical management of cutaneous melanoma.
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[1] Massimo De Martinis,Maria Maddalena Sirufo,Lia Ginaldi. Allergy and Aging: An Old/New Emerging Health Issue[J]. A&D, 2017, 8(2): 162-175.
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