Melanoma in the Older Patient: Measuring Frailty as an Index of Survival

Abstract

The population continues to age, and with that aging will come increasing numbers of cancer cases diagnosed at older ages, including cutaneous melanoma. The number of people in the United States aged 65 and above is expected to increase from 35 million in 2000 to 86.7 million by 2050. 1 Age-adjusted mortality rates for all cancers in the United States are higher for patients age 65 and above than for patients younger than 65. For melanoma, both the incidence and mortality rates are higher among older patients. 2 The explanation for the difference in melanoma outcomes in older patients is likely to be multifactorial; it could be related to differences in biology of cancer itself in older patients; differences in patient physiology, with older patients more likely to have immune system dysfunction or multiple comorbidities; or differences in access to and application of health care resources. 3 Care of the older melanoma patient presents many challenges, related both to different biology of cancer in older persons and to the different biology of older persons themselves. The risk of being diagnosed with melanoma increases with age. 2 In the United States, men between the ages of 40 and 59 years have a 1 in 157 probability of being diagnosed with melanoma, compared to a probability of 1 in 54 at age 70 and older. For women, the probability of being diagnosed with melanoma is 1 in 181 between 40 and 59 years, and increases to 1 in 123 at 70 years and older. 4 Moreover, older melanoma patients on average possess poorer prognostic factors at diagnosis. Older patients are more likely to have primary melanomas that are thicker, nodular, ulcerated, and located on the head and neck. More new melanoma cases are now diagnosed in people over age 60 and with the aging of the population, this trend is expected to continue, with even greater numbers of melanoma cases being diagnosed in older persons in the coming decades. Improvement in the evaluation and treatment of melanoma in the older person will assume increasing importance. Older patients are not only more likely to be diagnosed with melanoma, but are also more likely to die from this malignancy. In a multivariable analysis of over 17,600 patients, age was an independent poor prognostic factor in patients with stage I–III melanoma. 5 Age is a persistently significant poor prognostic factor among node-positive melanoma patients. In a recent multivariable analysis of 2313 node-positive melanoma patients from the American Joint Commission on Cancer (AJCC) database, patients age C70 years had significantly poorer survival than did younger patients. 6 The reason for poorer outcomes in older