Not treating, but a watchful waiting policy is a serious option for vulnerable elderly people with basal cell carcinoma, says dermatologist Satish Lubeek (Radboudumc). He bases this position on his experiences with a targeted consultation with the target group and the results of a cohort study among 89 patients.
Over-treatment of patients with basal cell carcinoma has been a topic that has occupied Lubeek for quite some time. It is the most common form of cancer in our country and it often affects the elderly. “It’s a type of skin cancer that grows very slowly in most cases and has a very low risk of metastasis,” he says. “We know about some forms of prostate cancer that more men die from it than from it and I think this may also apply to older people with basal cell carcinoma. We know from the data from the Dutch Cancer Registry that the relative 5- and 10-year survival is 100%.”
The fact that basal cell carcinoma usually produces few complaints in the first few years can be a good reason to sometimes adopt a wait-and-see policy. Nevertheless, Lubeek saw that in most cases patients were treated immediately after the diagnosis was made. He thought there sometimes seemed to be overtreatment, and he wanted to investigate whether this could be changed.
Targeted office hours
Under the name ‘Affordable Better’, Radboudumc has a multi-year quality alliance with health insurer VGZ, to work together on Sense Care alliances that make healthcare better and cheaper. This offered Lubeek the opportunity to set up a geriatric dermato-oncology consultation hour in 2018 as a subsidy project.
“The idea behind this consultation was to gain a better understanding of what is needed to provide the best care for vulnerable elderly people with basal cell carcinoma and what the knowledge gaps are in this,” he says. “More time for the consultation and multidisciplinary collaboration played an essential role in this consultation hour. The consultation has existed for 1 year and has provided a lot of knowledge and experience. It appears to be quite possible to reach a balanced decision in consultation with the patient about the best route to follow after the diagnosis. In that year we actually saw a decrease in the number of operations, without leading to problems for the patients concerned. Important knowledge, because we know that treatment sometimes causes more problems than it solves. The comparatively favorable aspect of basal cell carcinoma is, of course, that it is easily detectable because it manifests itself on the skin. This also makes it easy to prosecute.”
Recommendations and cohort study
We are now a few years further. Lubeek incorporated his findings into a guidebook with recommendations for fellow dermatologists who want to make a decision together with the patient about treatment or active observation on the same basis. A ‘research letter’ has also been published on the subject.1 In addition, the results of an observational cohort study will be published in 20212 in 89 patients with basal cell carcinoma who opted for active observation. It concludes that active observation may be an appropriate choice, especially for patients with asymptomatic nodular or superficial basal cell carcinomas when the patient has a limited life expectancy.
“I notice that these findings have increasingly led to a discussion among dermatologists about sensible action,” says Lubeek. “We are now also seeing that hospitals are starting to screen the frail elderly on a larger scale with frailty screening and more often consider whether active observation is the most appropriate choice for the patient. Therefore, more attention is paid to individual patient characteristics. And that’s a good thing because one 80-year-old patient is not like the other. With a multidisciplinary working group we are now trying to reach a national consensus on the question of which patients it is important to zoom in on the vulnerability. In this way we want to be able to predict in more detail which group of patients will benefit from treatment or from active observation.”
do and don’t
In the healthcare sector, there has been a long-standing discussion about whether medical treatment should be continued until the end of life. “You can really see a shift in that,” says Lubeek, “over the entire spectrum, certainly not just with regard to skin cancer. The point is that you have to consider the entire patient, not just that potentially treatable complaint.”
This requires a culture change, he says. “As a doctor, it’s easier to choose to do something than not to,” he says. “We are also trained to act and the system is geared towards that as well. This is changing now, but the process takes time. From that consultation we learned that the patient likes to know that he has several options and that not treating can also be a serious option. Of course there are still patients who say: ‘You are the doctor, so you say it’. But many patients turn out to be quite capable of making their own decisions. We see people who get skin cancer dozens of times, especially with basal cell carcinoma. Especially if this does not cause any complaints and manifests itself outside the face, for example, it often happens that the patient already says: ‘Do you have to do that again, doctor, operate?’ Of course you have to give a good explanation about the fact that it grows very slowly and that it does not kill the patient, plus that it can still be removed if active observation shows that it does grow. Involving all relevant patient and tumor characteristics in this is important. It makes quite a difference whether a basal cell carcinoma, for example, is on a back or an eyelid, of course. It is important to consider the ‘time-to-benefit’, the time it takes for a treatment to provide significant benefit to the patient.”
Consultation with other professionals
Collaboration of the dermatologist with other medical disciplines can be of great value to arrive at a balanced advice for the patient about whether or not to treat. “There are certainly situations in which I talk to the general practitioner, the geriatrician or the geriatric specialist,” says Lubeek. “The GP knows the patient very well and can therefore think along with me about whether or not treatment is appropriate. In such a contact I sometimes hear that the patient himself thinks that he only has a very short life expectancy, but the GP says: ‘Oh no, that’s still going well’. Or vice versa, that the patient himself does not mention a health complaint that may influence the decision, but the GP does. In addition, there are situations in which a person’s cognitive abilities decrease, for example with the onset of dementia, and the question arises to what extent someone is still mentally competent. That is often difficult for me to estimate and then I certainly think it is important to involve the GP or also the family.”
In addition to a good conversation, it is important to make written information available to the patient. “I almost always put a conversation summary on paper for the patient,” says Lubeek. I also provide an information folder. Sometimes a patient records the conversation, that is also possible. And if the situation is more complex, I suggest that you allow time for reflection. I will then call or book a follow-up consultation.”
The good conversation
Lubeek has never experienced a patient needing a ‘second opinion’ in order to make a decision. “It’s about putting all options on the table honestly, as well as your uncertainties and limitations,” he says. “Then it is always possible to have a good substantive discussion with the patient. It sometimes happens that I get a patient referred from another hospital where, for example, it was advised to treat but the patient does not want this.”
His views on the possibilities of teleconsulting are nuanced. “In any case, in my opinion, doing physical examinations does not work well through images,” he says. “In that case, I cannot properly assess a tumor, but sometimes I also miss important non-verbal information from the patient, for example. Furthermore, teleconsulting may have limitations if someone is hard of hearing or visually impaired. I would also like to see the patient walk from the waiting room to my consulting room. After all, the decision whether or not to give treatment as advice to frail older persons is complex. To do this, I want to see first-hand how a patient is doing. But follow-up conversations do not necessarily have to take place live. So I definitely see room for teleconsulting, also in my field.”
- Van Winden M, Klösters F, Hamaker M et.al. Optimizing shared decision making in elder adults with basal cell carcinoma: experiences from a specialized outpatient clinic. British Journal of Dermatology (2021) Doi: 10.1111/bjd.20833.
- Van Winden M, Hetterschijdt C, Bronkhorst E et.al. Evaluation of watchful waiting and tumor behavior in patients with basal cell carcinoma. An observational cohort study of 280 basal cell carcinomas in 89 patients. JAMA Dermatology published online September 8, 2021. Doi 10.1001/jamadermatol.2021.3020.