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Treatment Considerations for Geriatric Patients With Skin Cancer

Eleni Linos, MD, and Daniel C. Butler, MD, review unique factors and important treatment considerations for treating geriatric patients with skin cancers in this video.

Dr Linos is a professor of dermatology and epidemiology at Stanford University.

Dr Butler is an assistant professor of dermatology at the University of California, San Francisco, and a member of the Geriatric Dermatology Expert Resource group.


Dr Eleni Linos:  Hi, everyone. My name is Eleni Linos, and I'm a Professor of Dermatology at Stanford. It's great to be with you today.

Dr Daniel Butler:  Hi, everyone. I'm Daniel Butler. I'm an Assistant Professor in the Department of Dermatology at UCSF. It's great to be with you all today. We're going to talk about the treatment of skin cancers in older adults.

Dr Linos:  Some of the factors you need to consider when treating older patients are not just the skin cancer itself but the patient as a whole, their other medical problems, their life expectancy, their cognitive status, other medical and social issues that may be going on, as well as their preferences.

Ultimately, I think we need to put patient preferences at the center of a decision because, shared decision‑making about any health condition is incredibly important.

Dr Butler:  I'll echo what Dr Linos said, in that this is a difficult patient population to treat regardless because there are a lot of nuances.

What we want to avoid is this, what I call, the conveyor belt approach, which we really want to avoid, where someone gets a diagnosis and that starts a path of X, Y, Z, which are not necessarily tailored to the unique elements of the person, the unique elements of their malignancy.

It's just a rote pattern that we see in all patients. In this population, as with every population, you really want to dig into those nuances that Dr Linos mentioned.

Dr Linos:  Yeah, exactly. Having a tailored approach, having an approach that really is specific to that patient, their family, their social situation, and their preferences and their values is what we're trying to aim for.

I think the first thing to say about treatment options is that we really feel that older adults, just like all patients in dermatology, should be given choices, should be given reasonable options based on their disease.

Sometimes, that range of choices is wider or narrower depending on the tumor location, depending on other medical comorbidities that the patient may be facing. I don't think we can make any absolute statements and say certain treatments are never on the table for a certain population or always the right choice.

I think the most important thing is to meet the patients where they are, understand their background, understand where they're coming from, their unique situation, and offer reasonable choices.

Usually, for each cancer, there's at least one or two, maybe three, options that dermatologists would agree are reasonable options and making sure you bring those choices to the patient and make the decision with their input.

Dr Butler:  Their input is so important in the context of what we as dermatologists can provide them. I think geriatric medicine in general carries this probably better than any other field of medicine, but there really isn't a single right answer. There's nothing that's necessarily a wrong answer in every situation.

Just like Dr Linos said, it's so much a discussion and a shared discussion between what we can provide, what we know about each treatment, what we know about the patient, and what we know about their cancer, and how we can use the things that we can provide within the context of those elements.

I actually find that that's a really fun way to practice. I think sometimes, when this patient population comes in, it could be really challenging. It becomes distressing to the provider, to the family, to the patient because there isn't an absolute answer.

But there is a lot of freedom and flexibility in practice when you can actually make the decision with the patient. It allows you to get to know the patient very well. It allows you to be flexible with your skill set.

I think a challenging case that I've certainly had, and I think a lot of providers have, with this population is when someone comes in for a regular visit. They have multiple lesions that are concerning for a keratinocyte carcinoma. The clinician is put in the difficult position of triaging all of these all at once.

I think this is something that dermatologists see across the country and across the world almost every day, just because these are so prevalent. I think that the step‑back approach to this is really the only way that you can tackle this challenging patient.

When I say the step‑back approach, I mean you take a step back. You ask the patient what is important to them. You ask them which of the lesions or which of the spots is most troubling to them. You tackle one at a time. That may mean in one visit, you take one or two lesions. You focus on those. Then you follow up closely with another visit a couple weeks later.

But it's just important to acknowledge that those patients are always overwhelming. They're overwhelming for every dermatologist. If you have a practical approach about how to treat these patients, they become a little bit less overwhelming, albeit still a challenge clinically and for management in the future. Another patient...


Dr Linos:  ...with what you're saying is yeah, I completely agree, Daniel. Sometimes, you have to balance what you feel is the most worrying of these multiple tumors, and so what you feel is the most urgent one to deal with, with what the patient may feel is the most bothersome or symptomatic to them.

Those two aren't always aligned. Finding that balance to make sure that clinically you're using your medical judgment to make sure the patient is safe but also addressing their priority can be quite challenging.

Dr Butler:  I love that point. That is such a great one because that comes up all the time. It parlays into my next patient. This is a specific patient that I had. It was a patient who had a bleeding exophytic lesion on his back that was very consistent with a keratinocyte carcinoma just from looking at it.

He couldn't rest his back when he was sitting. He could barely walk without feeling pain there. His main comorbidity is that he had dementia. It was very difficult for anyone to have him sit down and be able to manage this in our typical ways.

The reason why this was so difficult is you never want to do harm to a patient, but it was so important, in this circumstance, to talk to the family, to talk to the geriatrician, and other primary providers with this patient and communicate that a lot of his discomfort and a lot of his acting out was because of the comorbidity of pain and bleeding that the keratinocyte carcinoma was offering.

Once we got everyone on the same page as far as treatment, we were able to actually excise it with just a scoop biopsy. The lesion stopped bleeding. It stopped being as painful as it was. He subsequently did go through further work‑up. There was no further elements to the malignancy that needed treatment.

It was just that piece of acknowledging the comorbidities associated with it that ultimately allowed us to fix a lot of his problems that were going on at the time. That was a particularly challenging patient that required a real team effort.

Dr Linos:  I completely agree with that example as a challenge, Dr Butler. Specifically, I liked what you brought up as the team approach because sometimes the challenge is actually not the skin cancer or the biology of the tumor.

The challenge is the time it takes to coordinate and get everyone on the same page and communicate with other providers, other specialists, family members that may not be in the same state and really try and get everyone on the same page. Because once you can coordinate that, things can move much more smoothly, and you can provide much better care for a patient.

I think your example perfectly illustrates that time and coordination and effort that ultimately pays off and can provide much better care for a patient.

Dr Butler:  It's such a good point that you bring up. When we talk about the team, I always like to plug the geriatricians because the geriatricians are a group that particularly focus on these challenges.

I encourage every dermatologist to reach out and introduce yourself to the geriatrician in your network or that sees some of your patients because they can be a tremendous resource when you're trying to find your way through some of these challenging, no‑right‑answer situations. They can be a force to help you navigate some of those nuances of the aging population.

Dr Linos:  I completely agree with that. And can guide you as well in situations where they may know the patient even better and may have known them for many years and understand the family dynamics and the own patient's wishes a lot better. Partnering with geriatricians and having them in close communication is something that truly all of us as dermatology specialists should prioritize.

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