Adapted management regimens after thorough shared decision-making can be less burdensome and provide more appropriate care for older frail patients with basal cell carcinoma (BCC), according to study findings published in the British Journal of Dermatology.

The prospective, observational pilot study assessed the management of patients with BCC in a specialized outpatient clinic for frail older adults. General practitioners and dermatologists referred patients with problematic BCC, including frail patients with limited life expectancy.

The researchers used a standardized, shared decision-making model, in which physicians and patients discussed their medical and personal preferences for all possible BCC management options, including risks and benefits. The patients were followed up at least once, if feasible. Outcomes were compared with the expected regular practice management (ERPM) for each case of BCC, according to current guideline recommendations.


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A total of 85 patients (mean age, 86.4 [SD 5.8] years) were observed from January 2018 to December 2018. After initial consultation, 69% of patients—44% men and 56% women—were diagnosed with 125 BCCs (116 histologically confirmed). Among the 55 patients for whom data were available, 42% had asymptomatic BCCs, and 87% were classified as “(potentially) frail” (Geriatric-8 score ≤14).

Among the cohort, 63% of patients mentioned treatment goals and preferences other than curative treatment (eg, symptom relief, least burdensome treatment, cosmetic goals, no treatment). In 41% of patients with 46% of BCCs, the management differed from ERPM and included 21 (44% differed) frail patients and 2 (29% differed) robust patients (P = .69; 1 missing). During a median follow-up of 29.5 months (interquartile range, 11-33.5), ERPM was initiated for 28% of BCC cases.

No significant differences were found between micronodular/infiltrative vs superficial/nodular BCC and whether ERPM was initiated (P = .36). A patient with 1 BCC needed more extensive surgery than the estimated treatment at the initial presentation.

The investigators estimated that fewer hospital visits were needed after ERPM in 32% of patients with 37 BCCs, most frequently owing to treatment directly after consultation, a shortened treatment schedule, or multidisciplinary consultations during 1 hospital visit. In 14% of patients with 29 BCCs, the researchers estimated that more hospital visits were needed than after ERPM. During the follow-up, 36% of patients died after a mean of 14.1 (SD 9.2) months (none were BCC related), 48% of whom were not treated with use of ERPM.

“Individual treatment goals other than curative treatment were highly relevant among frail older adults, considering that all management options were advised, which might include deviation from clinical guidelines,” stated the investigators.

Study limitations include the small population and observational design, the study authors noted.

“Medical decision-making based solely on age should be avoided, as the heterogeneity in functional status, resilience, and frailty at the same high ages underscore the need for an individualized approach,” the researchers commented.

Disclosure: This pilot study was conducted with financial support from the health insurance company VGZ. Please see the original reference for a full list of disclosures.

Reference

van Winden MEC, Klosters FM, Hamaker M, et al. Optimizing shared decision making in older adults with basal cell carcinoma: experiences from a specialized outpatient clinic. Br J Dermatol. Published online October 26, 2021. doi:10.1111/bjd.20833