Original article
Comorbidity scores associated with limited life expectancy in the very elderly with nonmelanoma skin cancer

Presented at the 75th Annual Meeting of the American Academy of Dermatology, March 4, 2017; Orlando, FL, and the 49th Annual Meeting of the American College of Mohs Surgery, San Francisco, CA; April 27-30, 2017.
https://doi.org/10.1016/j.jaad.2017.12.048Get rights and content

Background

There is controversy regarding treatment of nonmelanoma skin cancer (NMSC) in very elderly individuals, with some suggesting that this population may not live long enough to benefit from invasive treatments. Tools to assess limited life expectancy (LLE) exist, but performance in the population of very elderly individuals with NMSC has not been well defined.

Objective

Define comorbidity scores associated with LLE in very elderly individuals presenting for management of NMSC.

Methods

A retrospective review of 488 patients age 85 or older presenting for NMSC management between July 1999 through December 2014 was performed. Comorbidities were scored by using the Adult Comorbidity Evaluation-27 (ACE-27) and age-adjusted Charlson comorbidity index (ACCI). Dates of death, follow-up, and overall survival were determined.

Results

ACE-27 and ACCI scores were associated with overall survival; at scores of 3 and 7+, respectively, both were associated with less than 50% survival at 4 years. Patients who underwent Mohs micrographic surgery survived a median of 20 months longer than patients who did not.

Limitations

Retrospective study design and referral bias.

Conclusions

ACE-27 and ACCI scores predicted LLE. The cohort presenting for Mohs micrographic surgery had improved survival, despite similar intercohort comorbidity. This suggests that additional factors contributed to survival and that age and comorbidities alone are inadequate for making NMSC treatment decisions in very elderly individuals.

Section snippets

Patient selection

This was a single-center retrospective study of prospectively collected patients age 85 years or older who underwent Mohs micrographic surgery (MMS) for NMSC with 3 surgeons in a dermatologic surgery service between July 1999 and December 2014. A retrospective search using an institutional database was performed to identify patients who presented to the service with NMSC and did not undergo MMS during that time period. Patient demographics, tumor characteristics, and surgical details were

Patient and lesion characteristics

In all, 488 patients age 85 years or older were included in the study. Of these, 371 of 10,103 total patients who presented for MMS were age 85 years or older. An additional 117 patients age 85 years or older were seen for MMS consultation but did not pursue MMS. Characteristics of the study participants and the presenting skin cancer are presented in Table I.17, 18 The mean age was 88.1 years and the majority were female (52.5%). The majority of lesions were located on the head and neck (the

Discussion

Life expectancy is estimated to increase from 6 to 7 years in men and from 7.1 to 8.5 years in women age 85 years between 2012 and 2050.5 With life expectancy and the proportion of the population of very elderly individuals projected to increase in the United States, the management of non–life-threatening illnesses such as skin cancer will increasingly be relevant. In this study, patients presenting to a tertiary cancer center for MMS had a mean age of death of 93.5 years and longer than the

Conclusions

Patients 85 years and older presenting to a dermatologic surgery service surpassed expected survival. Higher comorbidity scores were associated with decreased survival, and both the ACE-27 and ACCI were predictive of LLE at scores of 3 and 7+, respectively. Patients who underwent MMS survived longer despite similarities in comorbidity profiles between groups, implying that additional factors selected for by patients and their physicians may significantly contribute to survival in this cohort.

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    Funding sources: Supported by the National Cancer Institute of the National Institutes of Health (NIH) under award No. R25CA020449 and in part through the National Institutes of Health/National Cancer Institute Cancer Center Support Grant P30 CA008748. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

    Conflicts of interest: None disclosed.

    The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

    Reprints not available from the authors.

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