Why Are Non-Melanoma Skin Cancers Untreated in the Elderly

The incidence of non-melanoma skin cancers (NMSCs) has steadily risen in recent years, especially within the geriatric community. Data in the past indicated that elderly and younger patients with NMSC received similar treatment, but that may not be the whole story.

Authors of an analysis published in The Journal of American Academy of Dermatology recently investigated potential treatment differences among age groups. They reviewed biopsy-proven NMSCs among adults who had been treated in the dermatology department between 2017 and 2018. The study excluded any case in which patients had both treated skin cancers and untreated skin cancers. Untreated patients were defined as those who received no treatment during the 12 months prior to onset of the study. Patients who were age 85 or older were classified as elderly. Fisher’s exact test and logistic regression in STATA version 15 (StataCorp, TX) were used to analyze data.

Of 1,048 skin cancers confirmed by biopsy among 515 unique patients, 927 met the criteria to be included in the study.

The most common treatment provided was Mohs Micrographic surgery. Rates of skin cancer that went untreated varied substantially between elderly and younger patients (13.0% vs 4.2%, X <0.0001). When categorizing patient age by decade, those who were 85 years or older had remarkably higher univariate odds of going untreated (OR 3.62, p=0.018). The reasons most commonly documented for missing treatment included loss to follow up (35%), negative biopsy margins (23%), refusal due to age, or comorbidities (21%), and management at outside hospital (10%).

Among the elderly, female patients (OR 7.43, p=0.012) were more likely to be untreated than male patients, and the two elderly non-white patients were also untreated (p<0.0001). Having four or more comorbidities (OR 3.91, p=0.036) also correlated with a higher risk of not being treated, especially if neurocognitive impairment was present (OR 3.91, p=0.036), if there was impairment of activities involved in daily living (OR 10.0, p<0.0001), and if patients had hemiplegia (p<0.0001).

Conversely, those patients who had a previous history of skin cancer were more likely to get treatment (OR 0.10, p=0.001).

ADL impairment (OR 48.6, p=0.007) and previous skin cancer (OR 0.03, p=0.003) were especially significant after multivariate analysis.
Unlike the results from previous studies, non-treatment rates between elderly and non- elderly patients with biopsy-proven NMSCs were divergent. We also observed that in those treated, the same common treatments were utilized at the same rates.

This was one of the first, if not the first, retrospective study that compared clinical characteristics of treated elderly patients and those who were untreated. Univriate characteristics associated with untreated NMSC in the elderly included female sex, absence of prior skin cancer, a high number of comorbidities, and functional or neurologic impairments.