Older Patients Receiving Mohs Surgery Typically Have Facial Tumors, Are High-Functioning

Most patients over the age of 85 who receive Mohs surgery for nonmelanoma skin cancer have a high functional status and high-risk tumors located on the face, according to a new report.

The findings suggest that the procedure is likely a good fit for many older patients, despite the potential risk and cost associated with the procedure. The study was published in JAMA Dermatology.

Since many patients with skin cancers are over the age of 65, some investigators have raised concerns about the appropriateness of skin cancer surgery on the oldest patients, wrote corresponding author Murad Alam, MD, of the Feinberg School of Medicine at Northwestern University and colleagues. Mohs surgery is a type of precision surgery designed to limit unnecessary removal of healthy tissue surrounding cancers.

“It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs,” Alam and colleagues wrote.

Yet, other evidence has found the surgery is safe and effective even among patients over the age of 90, the authors noted.

Alam and colleagues wanted to better understand how and when Mohs surgery is being used in patients over the age of 85 with nonmelanoma skin cancers, in order to better assess whether the procedure is being used appropriately. To find out, they recruited 1181 patients over the age of 85 who were referred for Mohs surgery at 1 of 22 academic or private-practice skin cancer surgery centers.

The patients were mostly men (61.9%), and most were between the ages of 85 and 88 (57.9%). In addition to patient characteristics, the investigators also evaluated the reasons physicians recommended the surgery, giving doctors a list of 15 possible reasons to choose from.

Of the 1181 patients originally referred for Mohs surgery, 91.3% went through with the procedure, while 8.7% opted for alternative treatments. In most of the cases (68.5%), the tumors in question were located on the patient’s face, and those who received the surgery were 4 times more likely than those who did not to have a high functional status.

When asked why they proceeded with the surgery, surgeons most commonly cited the procedure’s high cure rate (66.0% of cases), the patients’ functional status (57.0%), and/or the histology-based risk associated with the tumor (40.3%). Patient preference was cited as the reason for proceeding with surgery in just 2% of cases, the authors said.

“These findings suggest that patient functional status is associated with decision on how cancers are treated, given that high-functioning status was among the most common reasons for surgery in patients older than 85 years,” Alam and colleagues said.

The investigators noted that patients in the study who were living in nursing homes had a greater mean preoperative tumor diameter than average, suggesting that advanced age and loss of social support may be linked with tumor neglect and growth.

“Tumor removal in this group may preserve quality of life that may otherwise diminish owing to tumor-associated symptoms (eg bleeding or painful non-healing lesions), functional loss, or social embarrassment leading to withdrawal,” they wrote.

The investigators said their study was limited by a lack of information on patient-physician discussions; the reasoning was provided solely by physicians, and thus there is a potential for bias because patients may have reasons and goals that are different from their surgeons’.

In conclusion, while some worry that Mohs surgery may be burdensome on the elderly, the authors said their findings show that the procedure may be particularly appropriate for certain older patients, “given that their tumors can be more aggressive and their social support may be limited.”

Reference:

Maisel-Campbell A, Lin KA, Ibrahim SA, et al. Nonmelanoma skin cancer in patients older than age 85 years presenting for Mohs surgery: a prospective, multicenter cohort study. JAMA Dermatol. Published online May 25, 2022. doi:10.1001/jamadermatol.2022.1733