title: Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer.
abstract: OBJECTIVE
  Nonmelanoma skin cancer (NMSC) is the most common cancer and predominantly affects older patients. Because NMSCs do not typically affect survival or short-term quality of life, the decision about whether and how to treat patients with limited life expectancy (LLE) is challenging, especially for asymptomatic tumors.
  
  
  OBJECTIVE
  To compare treatment patterns and clinical outcomes of patients with NMSC with and without LLE.
  
  
  METHODS
  A prospective cohort study of 1536 consecutive patients diagnosed with NMSC at 2 dermatology clinics: a university-based private practice and a Veterans Affairs Medical Center in San Francisco, California. Patients were recruited in 1999 through 2000 and followed up for a median of 9 years. A total of 1360 patients with 1739 tumors (90%) were included in the final analysis. Limited life expectancy was defined as patients either 85 years or older at the time of diagnosis or patients with multiple comorbidities (Charlson Comorbidity Index of ≥ 3). Treatment options included no treatment, destruction, or 2 types of surgery-elliptical excision or Mohs surgery.
  
  
  METHODS
  Treatment type.
  
  
  RESULTS
  Most NMSCs (69%) were treated surgically, regardless of patient life expectancy. The choice of surgery was not influenced by patient prognosis in univariate or multivariable models adjusted for tumor and patient characteristics. Many patients with LLE (43%) died within 5 years, none of NMSC. Tumor recurrence was rare (3.7% at 5 years [95% CI, 2.6%-4.7%]) in all patients. Although serious complications were unusual, approximately 20% of patients with LLE reported complications of therapy, compared with 15% of other patients.
  
  
  CONCLUSIONS
  Most NMSCs are treated surgically, regardless of the patient's life expectancy. Given the very low tumor recurrence rates and high mortality from causes unrelated to NMSC in patients with LLE, clinicians should consider whether these patients would prefer less invasive treatment strategies.
authors.affiliation: Department of Dermatology, 2340 Sutter St, Room N421, Mail Code Box 0808, San Francisco, CA 94143-0808, USA. linose@derm.ucsf.edu
authors.forename: Eleni
authors.initials: E
authors.lastname: Linos
authors.forename: Rupa
authors.initials: R
authors.lastname: Parvataneni
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Stuart
authors.forename: W John
authors.initials: WJ
authors.lastname: Boscardin
authors.forename: C Seth
authors.initials: CS
authors.lastname: Landefeld
authors.forename: Mary-Margaret
authors.initials: MM
authors.lastname: Chren
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012878:Skin Neoplasms / Q000628:therapy*; D019452:Terminally Ill