NMSCs are often asymptomatic and not immediately life threatening. Although NMSCs tend to have a favorable prognosis, studies have found that NMSC may be a marker for other poor health outcomes. A significant increased risk for all-cause mortality was found for patients with a history of SCC, which may be attributed to immune status.11 The aging veteran population has more complex health care needs to be considered when developing surgical treatment plans. These medical problems may limit their life expectancy much sooner than the skin cancer will become symptomatic. We found that individuals aged ≥ 80 years who had CAD, CHF, or dementia had a relative risk of 3 or higher for 5-year mortality. The leading cause of death in the United States in years 2011 to 2015 was heart disease. Alzheimer disease was the sixth leading cause of death in those same years.12-14
Skin cancer excisions do not typically require general anesthesia, deep sedation, or large fluid shifts; however, studies have found that when frail patients undergo low-risk procedures, they tend to have a higher mortality rate than their healthier counterparts.15 Frailty is a concept that identifies patients who are at increased risk of dying in 6 to 60 months due to a decline in their physical reserve. Frail patients have increased rates of perioperative mortality and complications. Various tools have been used to assess the components of physical performance, speed, mobility, nutrition status, mental health, and cognition.16 Frailty screening has been initiated in several VA hospitals, including our own in Gainesville, Florida, with the goal of decreasing postoperative morbidity and mortality in older adult patients.17 The patients are given a 1-page screening assessment that asks about their living situation, medical conditions, nutrition status, cognition, and activities of daily living. The results can trigger the clinician to rethink the surgical plan and mobilize more resources to optimize the patient’s health. This study period precedes the initiative at our institution.
The plastic surgery service’s routine practice is to excise skin cancers in the operating room if sedation or general anesthesia will be needed (Figure 1A), for optimal control of bleeding (Figure 1B) in a patient who cannot safely stop blood thinners, or for excision of a highly vascularized area such as the scalp. Surgery is offered in an office-based setting if the area can be closed primarily, left open to close secondarily, or closed with a small skin graft under local anesthesia only (Figure 2). We prefer treating frail patients in the minor procedure clinic, when possible, to avoid the risks of sedation and the additional preoperative visits and transportation requirements. NMSC with unclear margins (Figure 3A) or in cosmetically sensitive areas where tissue needs to be preserved (Figure 3B) are referred to the Mohs dermatologist. The skin cancers in this study were most frequently found on the face, scalp, hands, and forearms based on referral patterns.
Other treatment options for NMSC include curettage and electrodessication, cryotherapy, and radiation; however, ours is a surgical service and patients are typically referred to us by primary care or dermatology when those are not reasonable or desirable options.18 Published complication rates of patients having skin cancer surgery without age restriction have a rate of 3% to 6%, which is consistent with our study of 5%.19-21 Two bleeding complications that needed to be admitted did not require more than a bedside procedure and neither required transfusions. One patient had been instructed to continue taking coumadin during the perioperative office-based procedure due to a recent carotid stent placement in the setting of a rapidly growing basal cell on an easily accessible location.
The most noted comorbidity in patients with wound complications was found to be DM; however, this was not found to be a statistically significant risk factor for wound complications (P = .10). We do not have a set rule for advising for or against NMSC surgery. We do counsel frail patients and their families that not all cancer is immediately life threatening and will work with them to do whatever makes the most sense to achieve their goals, occasionally accepting positive margins in order to debulk a symptomatic growth. The objective of this paper is to contribute to the discussion of performing invasive procedures on older adult veterans with life-limiting comorbidities. Patients and their families will have different thresholds for what they feel needs intervention, especially if other medical problems are consuming much of their time. We also have the community care referral option for patients whose treatment decisions are being dictated by travel hardships.
Strengths and Limitations
A strength of this study is that the data were obtained from a closed system. Patients tend to stay long-term within the VA and their health record is accessible throughout the country as long as they are seen at a VA facility. Complications, therefore, return to the treating service or primary care, who would route the patient back to the surgeon.
One limitation of the study is that this is a retrospective review from 2011. The authors are limited to data that are recorded in the patient record. Multiple health care professionals saw the patients and notes lack consistency in detail. Size of the lesions were not consistently recorded and did not get logged into our database for that reason.