Skin Cancer in U.S. Elderly Adults: Does Life Expectancy Play a Role in Treatment Decisions?
To examine whether life expectancy influences treatment pattern of nonmelanoma skin cancer, or keratinocyte carcinoma (KC), the most common malignancy and the fifth most costly cancer to Medicare.



Nationally representative cross-sectional study.



Nationally representative Health and Retirement Study linked to Medicare claims.



Treatments (N = 9,653) from individuals aged 65 and older treated for basal or squamous cell carcinoma between 1992 and 2012 (N = 2,702) were included.



Limited life expectancy defined according to aged 85 and older, medical comorbidities, Charlson Comorbidity Index score of 3 or greater, difficulty in at least one activity of daily living (ADL), and a Lee index of 13 or greater. Treatment type (Mohs micrographic surgery (MMS) (most intensive, highest cost), excision, or electrodesiccation and curettage (ED&C) (least intensive, lowest cost)), according to procedure code.



Most KCs (61%) were treated surgically. Rates of MMS (19%), excision (42%), and ED&C (39%) were no different in participants with limited life expectancy and those with normal life expectancy. For example, 19% of participants with difficulty or dependence in ADLs, 20% of those with a Charlson comorbidity score greater than 3, and 15% of those in their last year of life underwent MMS; participants who died within 1 year of diagnosis were treated in the same way as those who lived longer.



A one-size-fits-all approach in which advanced age, health status, functional status, and prognosis are not associated with intensiveness of treatment appears to guide treatment for KC, a generally nonfatal condition. Although intensive treatment of skin cancer when it causes symptoms may be indicated regardless of life expectancy, persons with limited life expectancy should be given choices to ensure that the treatment matches their goals and preferences.
Department of Dermatology, University of California at San Francisco, San Francisco, California.
Eleni
E
Linos
Department of Dermatology, University of California at San Francisco, San Francisco, California.
Mary-Margaret
MM
Chren
Division of Geriatrics, Department of Medicine, University of California at San Francisco, San Francisco, California.|San Francisco Veterans Affairs Medical Center, San Francisco, California.
Irena
I
Stijacic Cenzer
Division of Geriatrics, Department of Medicine, University of California at San Francisco, San Francisco, California.|San Francisco Veterans Affairs Medical Center, San Francisco, California.
Kenneth E
KE
Covinsky
D000203:Activities of Daily Living / Q000145:classification; D000368:Aged; D000369:Aged, 80 and over; D002280:Basal Cell Carcinoma / Q000191:economics / Q000401:mortality*; D002294:Carcinoma, Squamous Cell / Q000191:economics / Q000401:mortality* / Q000601:surgery*; D015897:Comorbidity; D003362:Cost-Benefit Analysis; D003430:Cross-Sectional Studies; D003475:Curettage / Q000191:economics; D003661:Decision Support Techniques; D004185:Disability Evaluation; D004598:Electrosurgery / Q000191:economics; D005260:Female; D006801:Humans; D015603:Keratinocytes; D008017:Life Expectancy; D008297:Male; D015580:Mohs Surgery / Q000191:economics; D011379:Prognosis; D012878:Skin Neoplasms / Q000191:economics / Q000401:mortality* / Q000601:surgery*
basal cell carcinoma; end of life; skin cancer; squamous cell carcinoma