DS04 Clinical outcomes of the management of basal cell carcinomas in individuals aged 90 years and over

Abstract

Abstract This retrospective cohort study examined our practice for the management of basal cell carcinoma (BCC) in the very elderly, to identify subgroups where intervention could be minimized, based on frailty and trends in survival. All patients aged ≥ 90 years with histologically confirmed BCC during 2017 and 2018 were included within the study (n = 319). Data on lesion characteristics (size, location and subtype), presence or absence of symptoms, patient characteristics (age, comorbidities, frailty score, anticoagulant use and presence of pacemaker) and treatment choice (surgery, radiotherapy, topical, systemic or observation) were collected. Overall survival was the primary endpoint. Age was the most significant predictor of survival [hazard ratio (HR) 1.10, 95% confidence interval (CI) 1.04–1.17; P = 0.001] with a maximum threshold analysis identifying 93 years as the significant age cutoff point. Median survival was 40 months for those aged ≤ 93 years and 28 months for those aged > 93 years (P = 0.002). Patients with dementia had a worse survival than those without [median survival 25 months vs. 35 months (HR 1.92, 95% CI 1.18–3.13); P = 0.009]. None of the 23 individuals with a diagnosis of dementia was alive at 5 years. There was a statistically significant difference in survival for patients who received treatment for their BCC (n = 294) compared with those observed [n = 25; median survival 34 months vs. 21 months (HR 0.54, 95% CI 0.34–0.85); P = 0.007]. There was no difference in survival in individuals with a history of cancer, cardiac or cerebrovascular disease or immunocompromise, compared with those without. Similarly, the use of anticoagulants or presence of pacemaker did not affect survival. Basal cell carcinoma subtype (nodular, infiltrative) did not impact outcomes either, although the difference between lesion size (< 10 mm, ≥ 10 mm) was approaching statistical significance (HR 1.36, 95% CI 0.98–1.87; P = 0.062). No patients required Mohs surgery in the study period. Factors that appeared to influence the preference for primary radiotherapy over surgery were the concurrent use of anticoagulants (P = 0.05) and site of lesion (P = 0.04). All 25 of the lesions treated with radiotherapy were on the head and neck. This study provides evidence in support of the active treatment of BCC in individuals aged ≥ 90 years seen in secondary care. Being fit enough to attend hospital appointments could be seen as a self-selecting process. Conservative options may be preferable in patients with dementia or those > 93 years old. While survival in this cohort is good, accurate assessment of patient frailty is key for selecting those individuals with a poor prognosis to ensure they are not referred for unnecessary intervention.