Skin Cancer Epidemics in the Elderly as An Emerging Issue in Geriatric Oncology
Garcovich Simone1, Colloca Giuseppe2,*, Sollena Pietro1, Andrea Bellieni2, Balducci Lodovico3, Cho William C.4, Bernabei Roberto2, Peris Ketty1
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
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.
Table 1 Prevalence rates of skin cancer and precursors in geriatric populations according to study setting.
Onco-Geriatric Assessment Instrument
Is the patient self sufficient?
Has the patient a cognitive impairment?
How are the Physical Performance?
Compliance and needs?
Is there a Social Network able to protect the patient?
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
Rational for oncogeriatric evaluation and intervention
Excision of primary tumour
Excision margins depend on tumour thickness Insufficient excision margins correlated with old-age Indication for micrographic excision surgery for LMM
Non-invasive treatment for in-situ LM
Topical 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
Risk-benefit analysis of interferon-alpha treatment or other investigational immunotherapies in the old patient, with LLE status
Surgery of distant metastasis
Selection of fit vs. frail patient for surgery to improve overall survival
Immunotherapy of metastatic disease
Inclusion 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 disease
Inclusion 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.
Donaldson MR, Coldiron BM (2011). No end in sight: the skin cancer epidemic continues. Semin Cutan Med Surg, 30(1): 3-5.
Rogers HW, Weinstock MA, Feldman SR, Coldiron BM (2015). Incidence Estimate of Nonmelanoma Skin Cancer (Keratinocyte Carcinomas) in the U.S. Population, 2012. JAMA Dermatol, 151: 1081-6.
Guy GPJr, Machlin SR, Ekwueme DU, Yabroff KR (2015). Prevalence and costs of skin cancer treatment in the U.S., 2002-2006 and 2007-2011. Am J Prev Med, 48(2): 183-7.
Guy GP, Thomas CC, Thompson T, Watson M, Massetti GM, Richardson LC (2015). Vital signs: melanoma incidence and mortality trends and projections - United States, 1982-2030. MMWR Morb Mortal Wkly Rep, 64: 591-6.
Templier C, Boulanger E, Boumbar Y, Puisieux F, Dziwniel V, Mortier L, et al (2015). Systematic skin examination in an acute geriatric unit: Skin cancer prevalence. Clin Exp Dermatol, 40: 356-60.
Fontaine J, Mielczarek S, Meaume S, Senet P (2008). [Incidence of undiagnosed skin cancers in a geriatric hospital] (in French). Ann Dermatol Venereol, 135: 651-5.
Yalçin B, Tamer E, Toy GG, Oztaş P, Hayran M, Alli N (2006). The prevalence of skin diseases in the elderly: analysis of 4099 geriatric patients. Int J Dermatol, 45(6): 672-6.
Smith DR and Leggat PA (2005). Prevalence of skin disease among the elderly in different clinical environments. Australasian Journal on Ageing, 24: 71-76.
Liao YH, Chen KH, Tseng MP, Sun CC (2001). Pattern of skin diseases in a geriatric patient group in Taiwan: A 7-year survey from the outpatient clinic of a University medical center. Dermatology, 203: 308-313.
Fried LP, Hall WJ (2008). Editorial: Leading on behalf of an aging society. J Am Geriatr Soc, 56:1791-5.
Balducci L (2005). Epidemiology of cancer and aging. J Oncol Manag, 14:47-50
Colloca G, Corsonello A, Marzetti E, Balducci L, Landi F, Extermann M, et al (2015). Treating cancer in older and oldest old patients. Curr Pharm Des, 21:1699-705.
Balducci L, Colloca G, Cesari M, Gambassi G (2010). Assessment and treatment of elderly patients with cancer. Surg Oncol, 19:117-23.
Rogers HW, Weinstock MA, Harris AR, Hinckley MR, Feldman SR, Fleischer AB, et al (2010). Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol, 146: 283-7.
Flohil SC, Seubring I, van Rossum MM, Coebergh JW, de Vries E, Nijsten T (2013). Trends in Basal cell carcinoma incidence rates: a 37-year Dutch observational study. J Invest Dermatol, 133(4): 913-8.
Roewert-Huber J, Lange-Asschenfeldt B, Stockfleth E, Kerl H (2007). Epidemiology and aetiology of basal cell carcinoma. Br J Dermatol, 157 Suppl 2: 47-51.
Asgari MM, Moffet HH, Ray GT, Quesenberry CP (2015). Trends in Basal Cell Carcinoma Incidence and Identification of High-Risk Subgroups, 1998-2012. JAMA Dermatol 2015, 151: 976-81
de Vries E, Trakatelli M, Kalabalikis D, Ferrandiz L, Ruiz-de-Casas A, Moreno-Ramirez D, et al (2012). Known and potential new risk factors for skin cancer in European populations: a multicentre case-control study. Br J Dermatol, 167 Suppl 2: 1-13.
Kauvar AN, Cronin TJr, Roenigk R, Hruza G, Bennett R (2015). Consensus for nonmelanoma skin cancer treatment: basal cell carcinoma, including a cost analysis of treatment methods. American Society for Dermatologic Surgery. Dermatol Surg, 41(5): 550-71.
Crowson AN (2006). Basal cell carcinoma: biology, morphology and clinical implications. Mod Pathol, 19 Suppl 2: S127-47.
Lubeek SF, van Vugt LJ, Aben KK, van de Kerkhof PC, Gerritsen MP (2017). The Epidemiology and Clinicopathological Features of Basal Cell Carcinoma in Patients 80 Years and Older: A Systematic Review. JAMA Dermatol, 153(1): 71-78
Garcia C, Poletti E, Crowson AN (2009). Basosquamous carcinoma. J Am Acad Dermatol, 60(1): 137-43.
Bonilla X, Parmentier L, King B, Bezrukov F, Kaya G, Zoete V, et al (2016). Genomic analysis identifies new drivers and progression pathways in skin basal cell carcinoma. Nat Genet, 48: 398-406.
Zehou O, Valeyrie-Allanore L, Ortonne N, Chazelas K, Hivelin M, Marchac A, et al (2012). [Neglected skin tumors. Three cases]. Ann Dermatol Venereol, 139(3): 194-8.
Mohan SV, Chang AL (2014). Advanced Basal Cell Carcinoma: Epidemiology and Therapeutic Innovations. Curr Dermatol Rep, 3: 40-45.
Goldenberg G, Karagiannis T, Palmer JB, Lotya J, O’Neill C, Kisa R, et al (2016). Incidence and prevalence of basal cell carcinoma (BCC) and locally advanced BCC (LABCC) in a large commercially insured population in the United States: A retrospective cohort study. J Am Acad Dermatol, 75: 957-966.e2.
Dacosta Byfield S, Chen D, Yim YM, Reyes C (2013). Age distribution of patients with advanced non-melanoma skin cancer in the United States. Arch Dermatol Res, 305: 845-50.
Sollena P, Del Regno L, Fargnoli MC, Peris K (2015). Topical and systemic medical treatments of basal cell carcinoma. G Ital Dermatol Venereol, 150: 429-34.
Wiznia LE, Federman DG (2016). Treatment of Basal Cell Carcinoma in the Elderly: What Nondermatologists Need to Know. Am J Med, 129: 655-60.
Trakatelli M, Morton C, Nagore E, Ulrich C, Del Marmol V, Peris K, et al (2014). Update of the European guidelines for basal cell carcinoma management. Eur J Dermatol, 24: 312-29.
Pascual JC, Belinchón I, Ramos JM (2015). Cutaneous surgery complications invindividuals aged 80 and older versus younger than 80 after excision of nonmelanoma skin cancer. J Am Geriatr Soc, 63: 188-90.
Viola K, Jhaveri M, Soulos P, Turner R, Tolpinrud W, Doshi D, et al (2012). Mohs micrographic surgery and surgical excision for nonmelanoma skin cancer treatment in the Medicare population. Arch Dermatol, 148: 473-7.
Clark FL, Sahay A, Bertenthal D, Maddock L, Lindquist K, Grekin R, et al (2008). Variation in care for recurrent nonmelanoma skin cancer in a university-based practice and a veterans affairs clinic. Arch Dermatol, 144: 1148-52.
MacFarlane DF, Pustelny BL, Goldberg LH (1997). An assessment of the suitability of Mohs micrographic surgery in patients aged 90 years and older. Dermatol Surg, 23: 389-392
Bouhassira J, Bosc R, Greta L, Hersant B (2016). Factors associated with postoperative complications in elderly patients with skin cancer: A retrospective study of 241 patients. J Geriatr Oncol, 7:10-4.
Paradela S, Pita-Fernández S, Peña C, Fernández-Jorge B, García-Silva J, Mazaira M, et al (2010). Complications of ambulatory major dermatological surgery in patients older than 85 years. J Eur Acad Dermatology Venereol, 24: 1207-13.
Wysong A, Aasi SZ, Tang JY (2013). Update on metastatic basal cell carcinoma: a summary of published cases from 1981 through 2011. JAMA Dermatol, 149:615-6.
Veness MJ (2008). The important role of radiotherapy in patients with non-melanomavskin cancer and other cutaneous entities. J Med Imaging Radiat Oncol, 52: 278-86.
Delishaj D, Laliscia C, Manfredi B, Ursino S, Pasqualetti F, Lombardo E, et al (2015). Non-melanoma skin cancer treated with high-dose-rate brachytherapy and Valencia applicator in elderly patients: a retrospective case series. J Contemp Brachytherapy, 7: 437-44.
Jackson JE, Dickie GJ, Wiltshire KL, Keller J, Tripcony L, Poulsen MG, et al (2009). Radiotherapy for perineural invasion in cutaneous head and neck carcinomas: toward a risk-adapted treatment approach. Head Neck, 31: 604-10
Dessinioti C, Plaka M, Stratigos AJ (2014). Vismodegib for the treatment of basal cell carcinoma: results and implications of the ERIVANCE BCC trial. Future Oncol, 10: 927-36.
Lacouture ME, Dréno B, Ascierto PA, Dummer R, Basset-Seguin N, Fife K, et al (2016). Characterization and Management of Hedgehog Pathway Inhibitor-Related Adverse Events in Patients With Advanced Basal Cell Carcinoma. Oncologist, 21:1218-1229.
Bichakjian CK, Olencki T, Aasi SZ, Alam M, Hoffmann KG, Engh A (2016). Basal Cell Skin Cancer, Version 1.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw, 14(5):574-97.
Lubeek SFK, Borgonjen RJ, van Vugt LJ, Olde Rikkert MG, van de Kerkhof PC, Gerritsen MJP (2016). Improving the applicability of guidelines on nonmelanoma skin cancer in frail older adults: a multidisciplinary expert consensus and systematic review of current guidelines. Br J Dermatol, 175: 1003-1010.
Linos E, Schroeder SA, Chren M (2014). Potential Overdiagnosis of Basal Cell Carcinoma in Older Patients With Limited Life Expectancy. JAMA 312(10): 997-8.
Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Landefeld CS, Chren M-M (2013). Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer. JAMA Intern Med, 173:1006-12.
Linos E, Berger T, Chren MM (2015). Point: Care of potential low-risk basal cell carcinomas (BCCs) at the end of life: The key role of the dermatologist. J Am Acad Dermatol, 73: 158-61.
Delaney A, Shimizu I, Goldberg LH, MacFarlane DF (2013). Life expectancy after Mohs micrographic surgery in patients aged 90 years and older. J Am Acad Dermatol, 68:296-300.
Pascual JC, Belinchon I, Ramos JM (2013). Mortality after dermatologic surgery for nonmelanoma skin cancer in patients aged 80 years and older. J Am Acad Dermatol, 69: 1051-2.
Charles AJ, Otley CC, Pond GR (2002). Prognostic factors for life expectancy in nonagenarians with nonmelanoma skin cancer: Implications for selecting surgical candidates. J Am Acad Dermatol, 47: 419-22.
Leiter U, Eigentler T, Garbe C (2014). Epidemiology of skin cancer. Adv Exp Med Biol, 810: 120-40.
Karia PS, Han J, Schmults CD (2013). Cutaneous squamous cell carcinoma: estimated incidence of disease, nodal metastasis, and deaths from disease in the United States, 2012. J Am Acad Dermatol, 68: 957-66.
Alfonso JH, Martinsen JI, Pukkala E, Weiderpass E, Tryggvadottir L, Nordby KC, et al (2016). Occupation and relative risk of cutaneous squamous cell carcinoma (cSCC): A 45-year follow-up study in 4 Nordic countries. J Am Acad Dermatol, 75(3): 548-55.
Belbasis L, Stefanaki I, Stratigos AJ, Evangelou E (2016). Non-genetic risk factors for cutaneous melanoma and keratinocyte skin cancers: An umbrella review of meta-analyses. J Dermatol Sci, 84(3):330-339
Brougham ND, Dennett ER, Cameron R, Tan ST (2012). The incidence of metastasis from cutaneous squamous cell carcinoma and the impact of its risk factors. J Surg Oncol, 106(7): 811-815.
Thompson AK, Kelley BF, Prokop LJ, Murad MH, Baum CL (2016). Risk Factors for Cutaneous Squamous Cell Carcinoma Recurrence, Metastasis, and Disease-Specific Death: A Systematic Review and Meta-analysis. JAMA Dermatol, 152: 419-28.
Haisma MS, Plaat BEC, Bijl HP, Roodenburg JLN, Diercks GFH, Romeijn TR, et al (2016). Multivariate analysis of potential risk factors for lymph node metastasis in patients with cutaneous squamous cell carcinoma of the head and neck. J Am Acad Dermatol, 75: 1-9.
Amin MB, Greene FL, Edge SB, Compton CC, Byrd DR, Winchester DP (2017). The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging. CA Cancer J Clin, 67(2):93-99.
Jambusaria-Pahlajani A, Kanetsky PA, Karia PS, Hwang WT, Gelfand JM, Whalen FM, et al (2013). Evaluation of AJCC tumor staging for cutaneous squamous cell carcinoma and a proposed alternative tumor staging system. JAMA Dermatol, 149: 402-10
Navarrete-Dechent C, Veness MJ, Droppelmann N, Uribe P (2015). High-risk cutaneous squamous cell carcinoma and the emerging role of sentinel lymph node biopsy: A literature review. J Am Acad Dermatol, 73: 127-37.
Stratigos A, Garbe C, Lebbe C, Malvehy J, del Marmol V, Pehamberger H, et al (2015). Diagnosis and treatment of invasive squamous cell carcinoma of the skin: European consensus-based interdisciplinary guideline. Eur J Cancer, 51: 1989-2007.
Chu MB, Slutsky JB, Dhandha MM, Beal BT, Armbrecht ES, Fosko SW (2014). Evaluation of the definitions of "high-risk" cutaneous squamous cell carcinoma using the american joint committee on cancer staging criteria and national comprehensive cancer network guidelines. J Skin Cancer, 2014: 154340.
Chren MM, Linos E, Torres JS, Stuart SE, Parvataneni R, Boscardin WJ (2013). Tumor recurrence 5 years after treatment of cutaneous basal cell carcinoma and squamous cell carcinoma. J Invest Dermatol, 133(5): 1188-96.
Strassen U, Hofauer B, Jacobi C, Knopf A (2017). Management of locoregional recurrence in cutaneous squamous cell carcinoma of the head and neck. Eur Arch Otorhinolaryngol, 274(1):501-506
Ma JH, Wu A, Veness M, Estall V, Hong A, Borg M, James C, et al (2016). In-Transit Metastasis from Squamous Cell Carcinoma. Dermatol Surg, 42: 1285-1292
Bertino G, Sersa G, De Terlizzi F, Occhini A, Plaschke CC, Groselj A, et al (2016). European Research on Electrochemotherapy in Head andNeck Cancer (EURECA) project: Results of the treatment of skin cancer. Eur J Cancer, 63: 41-52.
Nikolaou V, Stratigos AJ (2014). Emerging trends in the epidemiology of melanoma. Br J Dermatol, 170(1): 11-9.
Seidler AM, Pennie ML, Veledar E, Culler SD, Chen SC (2010). Economic burden of melanoma in the elderly population: population-based analysis of the Surveillance, Epidemiology, and End Results (SEER)--Medicare data. Arch Dermatol, 146: 249-56.
Balch CM, Soong SJ, Gershenwald JE, Thompson JF, Coit DG, Atkins MB, et al (2013). Age as a prognostic factor in patients with localized melanoma and regional metastases. Ann Surg Oncol, 20: 3961-8.
Anderson WF, Pfeiffer RM, Tucker MA, Rosenberg PS (2009). Divergent cancer pathways for early-onset and late-onset cutaneous malignant melanoma. Cancer, 115: 4176-4185.
Balch CM (2015). Decreased Survival Rates of Older-Aged Patients with Melanoma: Biological Differences or Undertreatment? Ann Surg Oncol, 22: 2101-3.
Lasithiotakis KG, Petrakis IE, Garbe C (2010). Cutaneous melanoma in the elderly: epidemiology, prognosis and treatment. Melanoma Res, 20:163-70.
Macdonald JB, Dueck AC, Gray RJ, Wasif N, Swanson DL, Sekulic A, et al (2011). Malignant melanoma in the elderly: different regional disease and poorer prognosis. J Cancer, 2: 538-43.
Lasithiotakis K, Leiter U, Meier F, Eigentler T, Metzler G, Moehrle M, et al. (2008) Age and gender are significant independent predictors of survival in primary cutaneous melanoma. Cancer, 112(8): 1795-804.
Whiteman DC, Pavan WJ, Bastian BC (2011). The melanomas: a synthesis of epidemiological, clinical, histopathological, genetic, and biological aspects, supporting distinct subtypes, causal pathways, and cells of origin. Pigment Cell Melanoma Res, 24: 879-97.
Tsai S, Balch C, Lange J (2010). Epidemiology and treatment of melanoma in elderly patients. Nat Rev Clin Oncol, 7:148-52.
Chao C, Martin RC, Ross MI, Reintgen DS, Edwards MJ, Noyes RD, et al. (2004). Correlation between prognostic factors and increasing age in melanoma. Ann Surg Oncol, 11(3): 259-64.
Macdonald JB, Dueck AC, Gray RJ, Wasif N, Swanson DL, Sekulic A, et al (2011). Malignant melanoma in the elderly: different regional disease and poorer prognosis. J Cancer, 2: 538-43.
Balch CM, Thompson JF, Gershenwald JE, Soong SJ, Ding S, McMasters KM (2014). Age as a predictor of sentinel node metastasis among patients with localized melanoma: an inverse correlation of melanoma mortality and incidence of sentinel node metastasis among young and old patients. Ann Surg Oncol, 2: 1075-81.
Conway WC, Faries MB, Nicholl MB, Terando AM, Glass EC, Sim M, et al (2009). Age-related lymphatic dysfunction in melanoma patients. Ann Surg Oncol, 16: 1548-52.
Virós A, Girotti MR, Marais R (2016). So You Can Teach Old Fibroblasts New Tricks. Cancer Discov, 6: 581-3.
Pera A, Campos C, López N, Hassouneh F, Alonso C, Tarazona R, et al. (2015). Immunosenescence: Implications for response to infection and vaccination in older people. Maturitas, 82(1): 50-5.
Weiss SA, Han J, Darvishian F, Tchack J, Han SW, Malecek K, et al (2016). Impact of aging on host immune response and survival in melanoma: an analysis of 3 patient cohorts. J Transl Med, 14: 299.
Grotz TE, Vaince F, Hieken TJ (2013). Tumor-infiltrating lymphocyte response in cutaneous melanoma in the elderly predicts clinical outcomes. Melanoma Res, 23(2): 132-7.
Russo AE, Ferraù F, Antonelli G, Priolo D, McCubrey JA, Libra M (2015). Malignant melanoma in elderly patients: biological, surgical and medical issues. Expert Rev Anticancer, 15:101-8.
Fleming NH, Tian J, Vega-Saenz de Miera E, Gold H, Darvishian F, Pavlick AC, et al (2013). Impact of age on the management of primary melanoma patients. Oncology, 85(3): 173-81.
Ciocan D, Barbe C, Aubin F, Granel-Brocard F, Lipsker D, Velten M, et al (2013). Distinctive features of melanoma and its management in elderly patients: a population-based study in France. JAMA Dermatol, 149: 1150-7.
Garbe C, Peris K, Hauschild A, Saiag P, Middleton M, Spatz A, et al (2012). Diagnosis and treatment of melanoma. European consensus-based interdisciplinary guideline--Update 2012. Eur J Cancer, 48: 2375-90.
Fields RC, Fleming MD, Gastman B, Gonzalez R, Johnson D, Joseph RW, et al (2016). Melanoma, Version 2.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw, 14:450-73.
Lange JR, Kang S, Balch CM (2011). Melanoma in the older patient: measuring frailty as an index of survival. Ann Surg Oncol, 18: 3531-2
Leachman SA, Cassidy PB, Chen SC, Curiel C, Geller A, Gareau D, et al. (2016). Methods of Melanoma Detection. Cancer Treat Res, 167: 51-105.
Read T, Noonan C, David M, Wagels M, Foote M, Schaider H, et al (2016). A systematic review of non-surgical treatments for lentigo maligna. J Eur Acad Dermatol Venereol, 30: 748-53.
Mora AN, Karia PS, Nguyen BM (2015). A quantitative systematic review of the efficacy of imiquimod monotherapy for lentigo maligna and an analysis of factors that affect tumor clearance. J Am Acad Dermatol, 73: 205-12.
Rees MJ, Liao H, Spillane J, Speakman D, McCormack C, Donahoe S, et al (2016). Localized melanoma in older patients, the impact of increasing age and comorbid medical conditions. Eur J Surg Oncol, 42: 1359-66.
Chang CK, Jacobs IA, Vizgirda VM, Salti GI. Melanoma in the elderly patient (2003). Arch Surg, 138:1135-8.
VanderWalde N, Jagsi R, Dotan E, Baumgartner J, Browner IS, Burhenn P, et al (2016). NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016. J Natl Compr Canc Netw, 14(11):1357-1370.
Bilimoria KY, Balch CM, Wayne JD, Chang DC, Palis BE, Dy SM, et al (2009). Health care system and socioeconomic factors associated with variance in use of sentinel lymph node biopsy for melanoma in the United States. J Clin Oncol, 27: 1857-63.
Sabel MS, Kozminski D, Griffith K, Chang AE, Johnson TM, Wong S (2015). Sentinel Lymph Node Biopsy Use Among Melanoma Patients 75 Years of Age and Older. Ann Surg Oncol, 22: 2112-9.
Hieken TJ. Management of regional lymph nodes in the elderly melanoma patient: patient selection, accuracy and prognostic implications (2015). Eur J Surg Oncol, 41: 157-64.
Livingstone E, Windemuth-Kieselbach C, Eigentler TK, Rompel R, Trefzer U, Nashan D, et al (2011). A first prospective population-based analysis investigating the actual practice of melanoma diagnosis, treatment and follow-up. Eur J Cancer, 47: 1977-89.
Shah DR, Yang AD, Maverakis E, Martinez SR (2013). Age-related disparities in use of completion lymphadenectomy for melanoma sentinel lymph node metastasis. J Surg Res, 185: 240-4.
Bilimoria KY, Balch CM, Bentrem DJ, Talamonti MS, Ko CY, Lange JR, et al (2008). Complete lymph node dissection for sentinel node-positive melanoma: assessment of practice patterns in the United States. Ann Surg Oncol, 15: 1566-76.
Burke EE, Portschy PR, Tuttle TM, Kuntz KM (2016). Completion Lymph Node Dissection or Observation for Melanoma Sentinel Lymph Node Metastases: A Decision Analysis. Ann Surg Oncol, 23: 2772-8.
Sabel MS, Lee J, Cai S, Englesbe MJ, Holcombe S, Wang S (2011). Sarcopenia as a prognostic factor among patients with stage III melanoma. Ann Surg Oncol, 18(13): 3579-85.
Bhatt VR, Shrestha R, Krishnamurthy J, Mosalpuria K, Loberiza FR, Ganti AK, et al (2015). Clinicopathologic characteristics and management trends of cutaneous invasive and in situ melanoma in older patients: a retrospective analysis of the National Cancer Data Base, 7(1): 4-11.
Gogas H, Abali H, Ascierto PA, Demidov L, Pehamberger H, Robert C, et al (2015). Who benefits most from adjuvant interferon treatment for melanoma? Am J Ther, 22: 54-60.
Eggermont AM, Chiarion-Sileni V, Grob JJ, et al. (2016). Prolonged Survival in Stage III Melanoma with Ipilimumab Adjuvant Therapy. N Engl J Med, 375(19):1845-1855
Eggermont AM, Maio M, Robert C (2015). Immune checkpoint inhibitors in melanoma provide the cornerstones for curative therapies. Semin Oncol, 42: 429-35.
Elias R, Morales J, Rehman Y, Khurshid H (2016). Immune Checkpoint Inhibitors in Older Adults. Curr Oncol Rep, 18(8):47
Chiarion Sileni V, Pigozzo J, Ascierto PA, Grimaldi AM, Maio M, Di Guardo L, et al (2014). Efficacy and safety of ipilimumab in elderly patients with pretreated advanced melanoma treated at Italian centres through the expanded access programme. J Exp Clin Cancer Res, 33:30.
Freeman M, Weber J (2015). Subset analysis of the safety and efficacy of nivolumab in elderly patients with metastatic melanoma, 3: 2-3.
Friedman CF, Wolchok JD (2017). Checkpoint inhibition and melanoma: Considerations in treating the older adult. J Geriatr Oncol
Freeman M, Weber J (2015). Subset analysis of the safety and efficacy of nivolumab in elderly patients with metastatic melanoma. J Immunother Cancer, 3(Suppl 2): P133.
Fayers P, Machen D (2007). Quality of life. The assessment, analysis and interpretation of patient-reported outcomes (2nd ed). West Sussex. John Wiley & Sons. Ltd
Ellis BH, Shannon ED, Cox JK, Aiken L, Fowler BM (2004). Chronic conditions: results of the Medicare Health Outcomes Survey, 1998-2000. Health Care Financ Rev, 25:75-91.
Baker F, Haffer SC, Denniston M (2003). Health-related quality of life of cancer and non cancer patients in Medicare managed care. Cancer, 97:674-681.
Bellizzi KM, Rowland JH (2007). Role of comorbidity, symptoms and age in the health of older survivors following treatment for cancer. J aging Health, 3(5): 625-635
Reeve BB, Potosky AL, Smith AW, Han PK, Hays RD, Davis WWet al (2009). Impact of cancer on Health-related Quality of life of Older Americans. J Natl Cancer Inst, 2101: 860-868.
Burdon-Jones D, Thomas P, Baker R (2010). Quality of life issues in nonmetastatic skin cancer. Br J Dermatol, 162:147-51
Rhee JS, Matthews BA, Neuburg M, Logan BR, Burzynski M, Nattinger AB (2006). Validation of a quality of life instrument for patients with nonmelanoma skin cancer. Arch Facial Plast Surg, 8: 314-8
Goto H, Yoshikawa S, Otsuka M, Omodaka T, Yoshimi K, Yoshida Y, et al. (2017). Symptom prevalence in patients with advanced skin cancer. J Dermatol, 44(2):123-126.
Ware JE, Sherbourne CD (1992). The MOS 36-item Short-Form Health Survey (SF-36): I. Conceptual framework and item selection. Medical Care, 30: 473-83
Siegrist J, Broer M, Junge A, editors. PLP-profil der lebenqualitat chronisch Kranker. Gottingern: Beltz Test; 1996
Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al (1993). The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst, 85: 365-76.
Rhee JS, Matthews BA, Neuburg M, Logan BR, Burzynski M, Nattinger AB (2007). The skin cancer index: clinical responsiveness and predictors of quality of life. Laryngoscope, 117: 399-405.
Korner A, Garland R, Czajkowska Z, Coroiu A, Khanna M (2016). Supportive care needs and distress in patients with non-melanoma skin cancer: nothing to worry about? Eur J Oncol Nurs, 20: 150-5
Finlay AY, Khan GK (1994). Dermatology Life Quality Index - a simple practical measure for routine clinical use. Clin Exp Dermatol, 19: 210-6
Neumann M, Wirtz M, Ernstmann N, Ommen O, Längler A, Edelhäuser F, et al (2011). Identifying and predicting subgroups of informations needs among cancer patients: an initial study using latent class analysis. Support Care Cancer 2011, 19: 1197-209
Cataldo JK, Paul S, Cooper B, Skerman H, Alexander K, Aouizerat B, et al (2013). Differences in the symptom experience of older versus younger oncology outpatients: a cross-sectional study. BMC Cancer, 13:6
Murray J, Banerjee S, Byng R, Tylee A, Bhugra D, Macdonald A (2006). Primary care professionals perceptions of depression in older people: a qualitative study. Soc Sci Med, 63: 1363-73
Lee EH, Sloan M, Cancer K, Brewer JD, Clinic M, Deborah F (2015). Optimizing Informed Decision Making for Basal Cell Carcinoma in Patients 85 Years or Older. JAMA Dermatol, 151(8): 817-8.
Pottel L, Lycke M, Boterberg T, Pottel H, Goethals L, Duprez F, et al (2014). Serial comprehensive geriatric assessment in elderly head and neck cancer patients undergoing curative radiotherapy identifies evolution of multidimensional health problems and is indicative of quality of life. Eur J Cancer Care (Engl), 23(3): 401-12.