Download Potential Overdiagnosis of Basal Cell Carcinoma in Older Patients

Opinion
VIEWPOINT
Eleni Linos, MD, MPH,
DrPH
Department of
Dermatology,
University of California,
San Francisco.
Steven A. Schroeder,
MD
Department of
Medicine, University of
California, San
Francisco.
Mary-Margaret Chren,
MD
Department of
Dermatology,
University of California,
San Francisco; and
Dermatology Service,
San Francisco Veterans
Affairs Medical Center,
San Francisco,
California.
Potential Overdiagnosis of Basal Cell Carcinoma
in Older Patients With Limited Life Expectancy
More patients are diagnosed with basal cell carcinoma (BCC) in the United States each year than all
other cancers combined—more than 2.5 million BCCs
compared with 1.7 million other cancers.1-3 Most of
these BCCs occur in people aged 65 years and older,
and each year, more than 100 000 BCCs are treated in
persons who ultimately die within 1 year. Procedures
to remove skin cancers have doubled in the last 15
years, and the use of Mohs surgery, histologically
guided serial excision, increased by 400% between
1995 and 2009.4 Many clinicians have suggested that
this is an epidemic of skin cancer1 attributed to excessive sun exposure, a thinning ozone layer, and indoor
tanning. These numbers will likely increase further; as
the number of older adults doubles between 2010 and
2030, overall cancer incidence is projected to increase
45%.5
These enormous numbers notwithstanding, BCCs
grow slowly, and treated BCCs seldom metastasize
and are rarely life threatening.2 In fact, even as the
number of diagnosed BCCs has more than doubled in
the last 20 years, deaths from this specific cancer are
very low. Nonmelanoma skin cancer mortality is estimated at less than 1 in 1000 cases, but these deaths
are overwhelmingly from squamous cell carcinoma,
not BCC.3 Patients who are diagnosed with BCC during their last year of life will almost certainly die of
causes unrelated to these lesions. In this Viewpoint,
we suggest a new approach for the care of asymptomatic BCCs in patients with limited life expectancy—
especially those in the last year of life.
Symptomatic vs Screening-Detected BCCs
Corresponding
Author: Eleni Linos,
MD, MPH, DrPH,
Department of
Dermatology,
University of California,
San Francisco, 2340
Sutter St, Room N421,
San Francisco, CA
94143-0808 (linose
@derm.ucsf.edu).
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Some BCCs develop with symptoms that are bothersome to patients. As these skin lesions enlarge, they can
ulcerate, threaten vital structures such as eyelids or ears,
and cause physical symptoms including itching, pain, or
bleeding in approximately 12% of patients. When experiencing irritating symptoms or visible tumors, patients
often see their physician. For these patients, dermatologists are invaluable for providing accurate diagnosis and
treatment of these tumors. Many BCCs, however, are not
noticed by patients, but instead are detected by clinicians during screening examinations. Whether or when
these cancers would ultimately cause symptoms if left
untreated is not known.
Harms of Diagnosing an Asymptomatic BCC
Elderly patients are more likely to be diagnosed with
BCCs, but are also at highest risk for inadvertent
harms associated with diagnosis and treatment.
Harms include anxiety associated with a cancer diagnosis, fear of metastasis or recurrence (even though
this is unlikely), or adverse effects from treatment.
Frail elderly patients with other comorbidities are
more likely to struggle with skin cancer treatments
such as long procedures, difficulty with wound care
and dressing changes, or poor wound healing.
Patient-reported problems are common in the
months following treatment, especially among older
patients with multiple comorbidities.6 For example,
when asked “Did you experience a complication following treatment?” more than a quarter (236/866) of
patients in a prospective cohort of skin cancer
patients responded affirmatively.6 Thus, any potential
harms of treatment are immediate. Yet treatment patterns are the same, regardless of patient symptoms or
life expectancy.7
Benefits of Diagnosing and Treating
an Asymptomatic BCC
The reason for treating asymptomatic BCCs is because
some may grow to cause symptoms or require more extensive surgeries later. Although BCCs are considered
slow-growing tumors, it is unclear how slowly a typical
BCC grows. Will it be decades, years, or months before
a tumor causes problems? No data are available to answer this question. What is known is that some patients with small BCCs report they have had them for
years. In addition, most dermatologists would agree with
the original observation by Jacob in 1824, “…the slowness with which this disease proceeds is very remarkable.”
It is also clear that incompletely treated BCCs do
not always cause harm; in a study of 121 biopsyconfirmed BCCs that were incompletely excised but
followed up clinically with no further treatment, the
majority (93%) had not grown or recurred after 5
years. 8 This finding suggests that typical BCCs are
likely indolent tumors and implies that many patients
with BCC who are at the end of life may die of unrelated causes before the BCC grows to cause any problems. This subset of patients would be unlikely to benefit from diagnosis or treatment of asymptomatic
BCCs, yet may incur harms of treatment.
Possible Overdiagnosis of Asymptomatic BCCs
Overdiagnosis refers to recognition of an asymptomatic disease that will not progress to symptoms or
death during a patient's remaining lifetime. Overdiagnosis was first described in prostate cancer for which
it is now clear that early detection of low-grade
tumors through screening does not always provide
benefit and, conversely, might cause harm. Although
it may be impossible to recognize overdiagnosis for an
individual patient, rapid increases in diagnoses,
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Opinion Viewpoint
accompanied by death rates that are unchanged, often suggest
overdiagnosis. BCC data from high-quality studies follow this pattern, suggesting overdiagnosis.
Unanswered Questions
Although it is possible that BCCs are overdiagnosed at the end of
life, many questions remain unanswered. How rapidly do
untreated BCCs grow and how rapidly do asymptomatic BCCs
become symptomatic? Is there a window of time during which it
would be safe to monitor patients clinically (ie, watchful waiting
or active surveillance) and intervene only if necessary? How
should clinicians minimize the risk of missing a more dangerous
tumor (eg, the rare but dangerous amelanotic melanoma or
Merkel cell carcinoma)? What is the best way to communicate this
uncertainty and involve patients and their families in treatment
decisions? Would practice guidelines that incorporate patient life
expectancy in BCC treatment decisions improve care? Would
reverting to the older term of basal cell epithelioma allow both an
accurate diagnosis and less harm from patient anxiety than the
term basal cell carcinoma?
ARTICLE INFORMATION
Conflict of Interest Disclosures: The authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest. Dr
Chren reports being a consultant for Genentech.
The other authors report no disclosures.
Funding/Support: This study was supported by the
Dermatology Foundation, the National Center for
Advancing Translational Sciences, National
Institutes of Health, through UCSF-CTSI grant KL2
TR000143, and the National Institute of Arthritis
and Musculoskeletal and Skin Diseases grant K24
AR052667.
Role of the Sponsor: The sponsors had no role in
the preparation, review, or approval of the
manuscript; and decision to submit the manuscript
for publication.
Additional Contributions: The authors would like
to thank the following individuals for their advice
regarding this article: Amy Markowitz, JD, Clinical
and Translational Research Career Development
Program, University of California, San Francisco;
C. Seth Landefeld, MD, Department of Medicine,
University of Alabama at Birmingham; Laura
Esserman, MD, MBA, Carol Franc Buck Breast Care
Center, University of California, San Francisco; Arti
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A Call for More Patient-Centered Care
The Institute of Medicine recently called for changes in the delivery
of cancer care, highlighting patient-centered communication and
shared decision making as its top priority.5 Given the uncertainty
about the natural history of BCCs and their typically indolent nature, patients with BCC will likely vary in their preferences about
whether to have biopsies or treatments. In particular, to help sicker
patients and their families make informed decisions about slowgrowing skin lesions, more evidence and guidelines that incorporate the risks and benefits of diagnosing, referring, and treating these
lesions are needed.
The current treatment approach, which aims to remove every
cancer cell, does not prioritize shared decision making or improving overall patient well-being. While accumulating evidence about
the natural history and clinical course of BCC, physicians should question strategies that diagnose and treat all of these lesions, regardless of patient prognosis and input. Instead, the focus should be on
individualizing the approach to patients at the end of life who have
skin lesions that may be BCCs. Clinicians need to take a step back
from the microscope and look at the patient.
Hurria, MD, Department of Geriatric Oncology, City
of Hope Comprehensive Cancer Center, Duarte,
California; Kenneth Covinsky, MD, University of
California, San Francisco; and H. Gilbert Welch, MD,
MPH, Dartmouth Institute for Health Policy &
Clincial Practice, Hanover, New Hampshire. None of
these individuals were compensated in association
with their contributions to this article.
REFERENCES
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Incidence estimate of nonmelanoma skin cancer in
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2. American Cancer Society. Cancer facts and
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-basalandsquamouscell/detailedguide/skin
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