Variations in Melanoma Treatment May Affect Outcomes in Elderly

Older patients with melanoma were diagnosed with thicker melanomas, and experienced longer time to excision and a higher frequency of insufficient excision margins compared with their younger counterparts in a multicenter study in France.

“It had been suggested previously that specific variations in management of melanoma, although with uncertain impact when studied individually in clinical trials, could have a significant effect on mortality when taking place together in a population setting,” wrote researchers led by Dragos Ciocan, MD, of Unit d’Aide Mthodologique, Hpital Robert Debr, Reims, France. “It may therefore hypothesized that age-related variations in the management of melanoma observed in the present study might contribute to a poorer overall prognosis in the elderly.”

The retrospective population-based study included 1,621 patients with stage I or II melanoma diagnosed between 2004 and 2008. The data were obtained using questionnaires administered to physicians and a survey of cancer registries and pathology laboratories in five regions of France that account for about 13% of the French population. The results were published online in JAMA Dermatology.

About 30% of the study group was aged 70 years or older (n = 487). The median age of the older group was 77 years; the median age of the younger group was 51 years (n = 1,134).

Patients in the older group were more likely to present with thicker melanomas than younger patients. The mean Breslow thickness in older patients was 2.34 mm compared with 1.35 mm in the younger group (P < .001).

A higher proportion of patients in the older group had head and neck melanoma (29.4% vs 8.7%; P < .001), but fewer had melanoma located on the trunk of the body (28.6% vs 41.5%; P < .001) or the lower limbs (24.5% vs 32.8%; P < .001) compared with patients in the younger group.

“Because the head and neck location has been shown to have an independent adverse prognostic effect on survival, this topographic characteristic could play a role in the poorer prognosis of melanoma in the elderly,” the researchers wrote.

The researchers also found that melanoma was more likely to be diagnosed in a general practice setting among elderly patients, with less frequent consultation with dermatologists.

Once diagnosed, 32.1% of patients aged 70 years or older had a time to definitive excision of longer than 6 weeks compared with only 22% of younger patients (P < .001). Furthermore, 16.8% of older patients had total excision margins that were insufficient compared with 5% of younger patients (P < .001). Finally, sentinel lymph node biopsy was only performed in 23.3% of older patients compared with 41.4% of younger patients (P < .001).

In an invited commentary accompanying the study, John G. Albertini, MD, of Wake Forest Baptist Health, Winston-Salem, North Carolina, and Nicholas B. Countryman, MD, of Indiana University, Indianapolis, suggested that the study by Ciocan and colleagues should increase awareness that an age bias may exist in melanoma treatment of the elderly and that it may negatively influence treatment decisions.

“The true challenge in bridging these specific melanoma management practice gaps in the elderly mirrors a much greater challenge in modern medicine: How do we reconcile outcomes research that defines population-based best practices with our duty to provide humanistic, artful care of individual patients in the context of their age, comorbidities, and socioeconomic situation?,” they wrote.