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Dr. Robert Norman, DO, MPH, MBA Skin Cancer and Sun Damage in Elderly Patients

September 12, 2015

Recognizing elderly patients who are most susceptible to skin problems, incorporating prevention measures, and identifying optimal treatments.

Sun Damage and Skin Cancer in Elderly Patients

Objectives 1. Identify signs and symptoms of skin care through history taking and physical examination. 2. Discuss prevention strategies and treatment options for skin cancer.

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Disclosures

Amgen

Dr. Robert A. Norman • Clinical Instructor Division of Dermatology Lake Erie College of Osteopathic Medicine

• Clinical Associate Instructor Department of Internal Medicine Division of Dermatology Nova Southeastern University Ft. Lauderdale, Florida

•

Private Practice in Tampa, Florida

Aging Population • As in most developed countries, aging is a result of sustained low fertility and increasing life expectancy. This is resulting in proportionally fewer children (under 15 years of age) in the population. • Over the next several decades, population aging is projected to have significant implications in many spheres, including health, labor force participation, housing and demand for skilled labor

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Introduction • The provider that engages in health care for the elderly is expected to be skilled in the detection and treatment of skin cancers. • The geriatric provider assumes the responsibility of integumental neoplasms.

Effects on Elderly • A sizable demographic percentage of many patient populations are geriatric patients. • The geriatric population is afflicted with a great many dermatology concerns, not only due to the normal aging process but the additional stressors acquired from environmental causes.

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Effects on Elderly • The long term effects of exterior causes such as UV radiation, chemical irritants, temperature, humidity, dryness, pathogens, and so on are compounded for those who have had to endure longer. • This cumulative damage profoundly affects the health of the elderly since they have accumulated more of everything, including quantitative decay, which might be a good definition of ‘aging’ of humans as biologic organisms.

Differences Between Generations • Given the popularity of the “tan” look will probably affect the baby boomers just as the geriatric population had higher amounts of occupational exposure. The generation of yesterday may have spent more time working out of doors than is seen in today’s workforce

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Differences Between Generations • The availability of ultraviolet protection and the education of patients about ultraviolet protection has only come into vogue in the last decade or so. • Using demographic reasoning we can expect an exponential increase in the growth rate of cutaneous malignancies presenting in the ever-increasing pool of geriatric patients.

• Despite the trend in recent years to use sun block and tint auto windows as preventative medicine as extremely important, especially when neoplasms are concerned. • Genetic mutations that eventually lead to neoplastic lesions happen by either a spontaneous event or a mutagenic induction from extrinsic factors.

• The larger the amount of time and the heavier the chronic exposure only serve to increase their incidence.

Extensive Facial Keratoses Often difficult to delineate on inspection alone, the extensive actinic keratoses present on the face of this patient are erythematous because of current treatment with fluorouracil cream.

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Squamous Cell Carcinoma of the Finger This lesion was a skin colored thickening with a slightly rough surface, thought to be a hypertrophic actinic keratosis. However, it did not respond to treatment and a biopsy was done revealing a well differentiated SCC.

Squamous Cell Carcinoma of the Lip The whitening of actinic cheilitis is clearly present as a background for the SCC on the lower lip.

Why Treat? • This thought process stems from both a fear that the treatment could be worse than the disease or that the patient is too old to benefit from treatment of any cancers. Neither line of reasoning is sound. The patient may not live long enough before any such lesion becomes mortally significant but may encounter more than casual morbidity. • Neoplastic lesions are by their very physiologic make-up, pockets of poorly healing tissue.

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Why Treat? • At the very least, the cost that just simple wound care and dressing changes, which are chronic in nature, can be at least limited to a week or two following curative surgery. • Vascular invasion can lead to bleeding while nerve invasion can lead to loss of function. Bone invasion further compounds the already serious issue of brittle bones and instability.

Local anesthesia allows for surgical intervention using methods done in the office setting or even at bedside. ED&C, cryotherapy, wide excision, and MOHS micrographic surgery can be utilized for almost every patient. Topical agents such as 5flourouracil, blistering agents, escharic agents, and even some immune modulators designed for warts can also be utilized. The expected efficacy may not always approach 100% but the tolerability and ease of application can be attractive

Immunologic Compound Treatment • The immunologic class differs only in the way the treatment compound interacts with the tissue. These interfere with molecular pathways and are tumor-cell specific. • 5-fluorouracil, Aldara (imiqumod), Condylox, Picato, and other receptor specific treatment creams are very available but sometimes more expensive than the escharic type.

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Immunologic Compound Treatment Furthermore, only a few types of lesions can be treated. Squamous cell in situ, Bowenoid, actinic keratosis, superficial basal cell carcinoma, and possibly morpheaform type as well are the only real candidates.

• The geriatric patient is also concerned about the cosmetic implications of any treatment. Surgical repair considerations as well as collateral damage from destruction oriented procedures are very important aspects as well. • The geriatric patient is at a higher risk of developing cutaneous neoplasms and will benefit from prompt diagnosis and treatment. Quality of life for our patients is the real target.

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An 81 year old women presented to our office with a purple mass on her middle finger that measured about 2 cm in length and width. She explained that the mass has been expanding rapidly, within the last couple of months. She insisted that it was painless. The mass resembled an indurated, solitary nodule that was violaceous in color. She explained that in her youth she had a lot of sun exposure.

Based on the case description and the photograph, what is your diagnosis?

Differential Diagnosis: • Squamous cell carcinoma • Basal cell carcinoma • Melanoma • Metastasis • Kaposi’s sarcoma • Hemangioma • Dermatofibroma • Lymphoma • Merkel Cell Carcinoma

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• As recently as Jaunary 2008, it was discovered that Merkel cell carcinoma may be associated with a virus called the polyoma virus, found at the University of Pittsburgh . Researchers discovered that the DNA from the virus was incorporated into the tumor in 8 out of the 10 tumors they studied. This was in contrast with the control group, which found the DNA in 8-16% of tumors. • Greater than 90% of patients with this syndrome have it in sun exposed areas, such as in the head and neck. • There is no difference in prognosis with regards to location; however, the difference in prognosis based on size is still quite controversial.

• The 5 year survival rate of the Stage I disease is 60-70 percent. In the new staging system, people that have Stage I have a prognosis that differs based on whether they have sentinel lymph node that is positive. If it is negative, they have a greater than 90% survival rate; if positive, survival is 50%. • MCC is most often not first suspected in biopsies. The clinician rarely suspects it, thinking its usually squamous cell carcinoma, or a benign cyst. Clinically, they appear on the head and neck, and may be a red to violet in color. They can be quick in growth. • The risk of developing it for patients greater than 65 is 24x than those younger than that. Only 5% percent of patients diagnosed with Merkel cell are younger than 50 years old, and many of these patients are immunosuppressed.

• In one study, where they performed surgery 5mm surgical margins, there was 100% recurrence. An additional study showed than when margins were 2.5cm or greater, there was still over a 49% chance of recurrence. Margins don’t seem to be well delineated. • The optimal thing to perform would be a sentinel node biopsy, followed by Mohs surgery; if not possible, a wide local excision. Sentinel node biopsy is essential in order to get both prognostic information, and information on how to pursue further therapy.

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The patient showed a dark and irregular lesion in an area of chronically sun exposed skin on her left temple. He had no previous treatment. A biopsy was performed.

Based on the case description and the photograph, what is your diagnosis?

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Differential Diagnosis: • • • • •

Solar Lentigo Fixed Drug Eruption Lentigo Maligna Post-inflammatory Hyperpigmentation Pigmented Basal Cell Carcinoma

Diagnosis: Lentigo Maligna is a melanoma-in-situ that occurs in chronically sun-exposed skin of the elderly. An irregular, linear pattern is fairly common.

About the disease: • The overall incidence of cutaneous melanoma is increasing faster than that of any other neoplasm. Melanoma is the most frequent cancer in white women aged 25-29 years and the second most frequent (after breast cancer) in white women aged 24-30 years with fair skin. Lentigo maligna (LM) is 1 of the 4 main subtypes of invasive melanoma and represents 5-15% of cases. The other types of melanoma are superficial spreading (70%), nodular (1015%), and acral lentiginous melanoma (5%). • Lentigo maligna melanoma is most often located in the head and neck areas.

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Treatment: The lesion was treated with surgical excision.

References: • Mcleod, M., Choudhary, S., Giannakakis, G. and Nouri, K. (2011), Surgical Treatments for Lentigo Maligna: A Review. Dermatologic Surgery, 37: 1210–1228. • Newton Bishop, J. A. (2010) Lentigos, Melanocytic Naevi and Melanoma, in Rook's Textbook of Dermatology, Eighth Edition (eds T. Burns, S. Breathnach, N. Cox and C. Griffiths), Wiley-Blackwell, Oxford, UK. • Smalberger, G. J., Siegel, D. M. and Khachemoune, A. (2008), Lentigo maligna. Dermatologic Therapy, 21: 439–446.

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• A 85 year-old African American female patient presented to the office asking for evaluation of a skin lesion on her scalp. The patient is pleasant and is in no apparent distress. • The patient explained that the lesion started as a small red lump about a year and a half ago. Since then, it has been growing steadily. At the time of her visit, the lesion was measured to be about 10 cm. • The patient says that it may have been related to a fall she experienced, causing her to bump her head. The patient has not had any prior treatments to the lesion. • She is not on any medications and her past medical history is unremarkable.

Based on the case description and the photograph, what is your diagnosis?

Differential Diagnosis: • Pyogenic Granuloma • Angiosarcoma • Malignant Melanoma • Fibrosarcoma

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Diagnosis: Angiosarcomas are classified as aggressive, vascular, soft tissue tumors that most often arise on the scalp and neck. The two major forms of angiosarcomas are cutaneous (the most common form) and epithelioid (more rare).

Treatment: • Surgical resection is the first line in the treatment of patients with an angiosarcoma of the scalp, especially with low-grade tumors. No treatment has been consistently successful with high grade angiosarcomas. Due its ability to spread extensively through the scalp, achieving clear margins is often the most difficult task; some researchers have described it as near impossible. • Postoperative radiation therapy, coupled with doxorubicin, has showed promise as it may lead to better survival rates, especially when used in conjunction with surgery.

References: • Itakura, E., Yamamoto, H., Oda, Y. and Tsuneyoshi, M. (2008), Detection and characterization of vascular endothelial growth factors and their receptors in a series of angiosarcomas. J. Surg. Oncol., 97: 74–81. • Calonje, E. (2010) Soft-Tissue Tumours and Tumour-like Conditions, in Rook's Textbook of Dermatology, Eighth Edition (eds T. Burns, S. Breathnach, N. Cox and C. Griffiths), WileyBlackwell, Oxford, UK. • Guadagnolo, B. A., Zagars, G. K., Araujo, D., Ravi, V., Shellenberger, T. D. and Sturgis, E. M. (2011), Outcomes after definitive treatment for cutaneous angiosarcoma of the face and scalp. Head Neck, 33: 661–667.

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• A 61 year-old female patient presented to the office asking for evaluation of a rash that was located on the left breast. She expressed the fact that the condition has existed for approximately 10 months. She explains that the rash has worsened over time, with more inflammation and itchiness, along with development of surrounding red lesions. There was no history of any trauma to that aspect of the breast. The patient was on previous medications for eczema, but articulated the fact that none of the medications had helped her symptoms. She noted no decrease in appetite. The patient has admitted an allergy to sulfa drugs.

Based on the case description and the photograph, what is your diagnosis?

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Differential Diagnosis: • • • • • • • • •

Mastitis Eczema Contact Dermatitis Nipple Duct Adenoma Chronic Breast Wound Paget's Disease of Breast Erosive adenomatosis of the nipple Benign Toker cell hyperplasia Malignant melanoma in situ

About the disease: • Mammary Paget ’s disease is a condition that represents cancer of the breast. It’s a malignant disease that is often confused with eczema, due to the superficial manifestation it formulates on and around the nipple. Patients suffering from Pagets disease of the breast often present eczematous rash that causes crusting of the nipple, which may extend to the bordering areolar skin. •

These skin cells are actually called Paget’s cells, and are considered malignant; in fact, their existence on the breast signifies the presence of a incredibly severe underlying condition -- breast carcinoma.

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Case Study • This is the case of a 94 year old woman who noticed a pinkish, flat growth on the left side of her cheek, which was no larger than a centimeter. For about a month, the size, color and duration of the lesion remained constant; however, after two months, the pinkish appearance changed into a darker, blacker color. • The lesion began to worry fellow family members who brought her into our office. The week after the visit the patient began to feel a throbbing pain in her left cheek. A week later, the lesion was excised and sent to a laboratory for further analysis.

Differential Diagnosis: • • • • • • • • •

Squamous cell carcinoma Atypical Fibroxanthoma Basal cell carcinoma Pyogenic granuloma Melanoma Merkel cell carcinoma Cutaneous metastasis Leiomyosarcoma Dermatofibrosarcoma protuberans

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Case Study Upon further investigation, the patient admitted to having a history of unprotected sun exposure. She grew up in Florida and often swam on the beach without the utilization of any type of sun screen or protection. This went on for many years growing up.

• The treatment for Atypical Fibroxanthoma, a low-grade carcinoma, typically entails complete excision of the nodule through surgery. The incidence rate of local reoccurrence is minimal, and metastasis has only been found in exceptional cases. • Currently, the patient is being treated with radiation therapy.

References: • Luzar, B. and Calonje, E. (2010), Morphological and immunohistochemical characteristics of atypical fibroxanthoma with a special emphasis on potential diagnostic pitfalls: a review. Journal of Cutaneous Pathology, 37: 301–309. • Iorizzo, III, L. J. and Brown, M. D. (2011), Atypical Fibroxanthoma: A Review of the Literature. Dermatologic Surgery, 37: 146–157. • Zheng, R., Ma, L., Bichakjian, C. K., Lowe, L. and Fullen, D. R. (2011), Atypical fibroxanthoma with lymphomatoid reaction. Journal of Cutaneous Pathology, 38: 8–13. • Wollina, U., Schönlebe, J., Koch, A. and Haroske, G. (2010), Atypical fibroxanthoma: a series of 25 cases. Journal of the European Academy of Dermatology and Venereology, 24: 943–946.

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Skin Cancers of the Epidermis Hyperplastic

Atypical Squamous Proliferation Cell Carcinoma

Basal Cell Carcinoma

Keratoacanthoma Pseudoepitheliomatous Hyperplasia

Actinic Keratosis •Hypertrophic •Acantholytic •Lichenoid

Superficial •Sclerosing •Morpheaform Nodular •Mulitifocal •Basosquamous

In situ Invasive •Well Differientiated •Poorly Differentiated •Bowen’s •Erythroplasia of Queryat •Epithelioma of Jadassohn

Chronic sun exposure and squamous cell carcinoma This gentleman was in his 60s when he presented to the clinic because of the frequent development of skin cancers. You can see his scarred skin from the multiple previous procedures. On the superior aspect of the left breast is a crusted lesion which to palpation is firm. Biopsy confirms SCC.

Cutaneous horn surmounting actinic keratosis Actinic keratoses are one of the more common causes of cutaneous horn. Squamous cell carcinoma may also be surmounted by cutaneous horn, therefore the base of cutaneous horn is biopsied for diagnosis.

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After Treatment • Despite the limitations that can be encountered when using one of the topical treatments they can still be attractive options for some patients. • Often in geriatric medicine we must provide treatment for patients who are not good surgical candidates.

After Treatment • Not only being elderly with medical reasons either; sometimes it can be a matter of transportation, follow up, and other psychosocial issues as well. It is also important that a decision might be made to stop the treatment and the decision to do so is made clinically. • The lesion can present as clinically clear and be so diagnosed or a biopsy can be done after appropriate healing time.

Other Treatment Options The next treatment options are considered mechanical destruction. The physician causes destruction of the diseased tissue by a variety of means: • Liquid nitrogen cryotherapy has been utilized with some anecdotal effectiveness especially is superficial tumor growth. • Electric desiccation and curettage has been a standby for many years. In the hands of a skillful physician this can be quite successful. • Lasers have allowed for even more skillful application in the place where hyfracators and Boveys have been used. Using local anesthesia, the procedure cauterizes and nearly vaporizes the tissue. Effectiveness relies solely on whether or not all the cancerous cells are desiccated. This is determined by the operator and with expertise can have a high curative rate. Postoperative wound care is very important, as healing will be by secondary intention.

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Squamous cell carcinoma of the lip Sun damage on the lower lip can result in actinic cheilitis and even squamous cell carcinoma as shown here.

Radiation Treatment • Radiation has been used for many years with a great degree of success and is still a viable option. • Radiation therapy is increasing in use for strictly cutaneous lesions. • Also to be noted that some radiation treatments can cause squamous cell atypia some years post op, and radiation burns are not uncommon.

Surgery • Surgical excision is the final option and very often an excellent choice. The high curative rates and high tolerability make surgical possibilities very attractive. Extra consideration should be given not only the patients candidacy for surgery but the pharmacological aspects as well both prescription and OTC products. • A wide excision with appropriate margins and a good surgical eye such as what is needed for electric desiccation and curettage is one of two methods.

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The Gray is the Physical Unit of Radiation • 1 GRAY, the unit of absorbed dose (1 joule / Kg), - Causes 1-2 x 105 ionization events / cell - 1% in DNA - A single cobalt 60 ray will deposit about 1mGy in a cell

• Rad (Radiation Absorbed Dose) is the old unit = cGy

Dose • The X-ray machines need to be calibrated annually • This requires a qualified medical physicist (Certified by the American Board of Radiology in the US) • Dose Calculations should also be done by a qualified medical physicist.

The Modern Use of SRT Fractionation • Various fractionation schemes from 5 fractions up to 30 • Small number of fractions larger dose per fraction and much more skin reaction • More fractions means the patient comes in more often

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How much Dose, how many Fractions? • The total dose is not driving the cure, it is the Biological Equivalent dose • 30 fractions at 1.8 Gy /fx - BED = 64 Gy (for skin)

• 15 fractions at 3.2 Gy/fx with same BED • 8 fractions at 5.25Gy/fx with same BED

What we use • We use 15 fractions • Minimize toxicity without having the patient come for 30 treatments • Some patients are elderly and can’t make it through 15 treatments without a break. • So we compromised

Tumor Margin, Energy, Fractionation Guidelines Treatment margins, energy, and fractionation schemes are selected based upon certain parameters to insure optimal dosage is delivered across the tumor and marginal volume. Factors influencing prognosis of NMSC:  

Tumor size (increasing size confers higher risk of recurrence) Tumor site (location of lesions on the central face, especially around the eyes, nose, lips and ears, are at higher risk of recurrence)

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Tumor thickness

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Definition of clinical margins (poorly defined lesions are at higher risk of recurrence)

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Histological subtype (certain subtypes confer higher risk of recurrence)

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Histological features of aggression (perineural and ⁄ or perivascular involvement confers higher risk of recurrence)

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Failure of previous treatment (recurrent lesions are at higher risk of further recurrence)

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Immunosuppression (possibly confers increased risk of recurrence)

1. Nonmelanoma skin cancer Current Treatment Options in Oncology 2002, Volume 3, Issue 3, pp 193-203 Tri H. Nguyen MD, Diana Quynh-Dao Ho MD

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Versatile Solution

Treatment Applicators/RAD Check •

8 Standard sizes – 1.0,1.5, 2.0, 2.5, 3.0, 4.0, 5.0 and 10cm – Safety X-Ray Port Block – Ease of use – Turn & Lock – Size display – Console

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Replaceable safety contact shields – Treated area visibility – Margin clearance – Clinical safety

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Dual collimated design – Precise X-ray delivery

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Applicator Port Ring and Sensors

Position Locking Knob

RAD Check – same design for pretreatment verification

Versatile X‐Ray Port • 180 degree Horizontal & Vertical

180

180 Auto Filter Magazine Control

• Articulation • Turn & Lock • Electromagnetic Applicator Sensor • Auto Filter Assembly • Interchangeable Applicators • Elevator Controlled • Precise Arm Locking in Position

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Field Proven  Mobile Platform Under-Seat Inverter

Lift Sliding Side Door

Lift Actuator Patient Treatment Bench Electrical Panel in Upper Bulkhead Wall

Extracting Laptop Table

SRT-100™ Operator Console 36” x 24” Bench with Storage Access

Patient Treatment Area

Overhead Cabinet Storage

120v/30A Inlet

2 Under-Floor Batteries

A/C and Vent Unit

Lead-Lined Shielded Area

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Identify the lesion

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Path report demonstrating this is BCC or SCC

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Image the cancer and delineate the lesion

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Make a lead cutout to protect the normal tissue • Treating in the head and neck area shield the eyes and the thyroid Get a dose calc

Preparing for Treatment

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The physicist will perform the dose calc Need to know treatment depth (typically 3 – 5 mm, but can be more) Need to know the dimensions of the lesion The physicist will calculate exposure to the surface or the beam on time for the X-ray Unit

Preparing to Treat

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SCC in‐situ

Preparing for Treatment

Lead Cutout for treatment: Note how large the cutout is to protect the patient

Case Report

{

MULTIPLE BASAL CELL  CARCINOMAS CASE  STUDY

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•

•

•

The patient is a 56-year-old male with a history of basal cell carcinomas on his back, scalp and face. He was scheduled for initial evaluation of skin lesions experiencing bleeding, crustiness and scaliness in these areas. This condition existed for one year, and he reported that the lesions were increasing in size. The patient had no past treatments for this condition. After performing biopsies to his multiple lesions, they were diagnosed as basal cell carcinomas.

Patient History

•

•

The patient presented with a 10 mm diameter lesion on his mid upper back, a crusty and scaly 10 mm diameter lesion on his upper scalp and a 3.0 x 2.0 mm lesion on the right hairline (forehead). The options discussed for treatment with the patient were wide local excision and superficial radiation therapy. The patient opted for superficial radiation therapy as treatment for his lesions.

Patient Management

Treatment Parameters For The  Mid Upper Back Lesion •

•

The upper mid back clinical lesion was identified and circled. A 5 – 7 mm border was drawn around the lesion. The tumor depth was estimated to be < 5 mm. A 0.762 mm thick lead shield was utilized to include 2 cm field and placed over the lesion and extended field. Radiation was administered with the SRT-100 machine with a 3 cm cone, 15 fractions/treatments of 300 cGy at 70 kVp, 10 ma. The patient received total doses of 4500 cGy to the area over a three week period. Treatments were delivered Monday to Friday with weekends off.

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{ FIRST DAY OF  TREATMENT

{ TENTH DAY OF  TREATMENT

Patient Outcome on His Mid  Upper Back Lesion

FOUR WEEKS AFTER  { TREATMENT

Patient Outcome on His  Mid Upper Back Lesion

•

•

The upper scalp clinical lesion was identified and circled. A 5 – 7 mm border was drawn around the lesion. The tumor depth was estimated to be < 5 mm. A 0.762 mm thick lead shield was utilized to include 2 cm field and placed over the lesion and extended field. Radiation was administered with the SRT-100 machine with a 3 cm cone, 15 fractions/treatments of 300 cGy at 70 kVp, 10 ma. The patient received total doses of 4500 cGy to the area over a three week period. Treatments were delivered Monday to Friday with weekends off.

Treatment Parameters For  The Upper Scalp Lesion

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FIRST DAY OF  { TREATMENT

TENTH DAY OF  { TREATMENT

Patient Outcome on His  Upper Scalp Lesion

FOUR WEEKS AFTER TREATMENT

Patient Outcome on His  Upper Scalp Lesion

Treatment Parameters for the Right  Hairline (Forehead) Lesion •

•

The right hairline (forehead) clinical lesion was identified and circled. A 5 – 7 mm border was drawn around the lesion. The tumor depth was estimated to be < 5 mm. A 0.762 mm thick lead shield was utilized to include 3.0 X 2.0 cm field and placed over the lesion and extended field. Radiation was administered with the SRT-100 machine with a 4 cm cone, 15 fractions/treatments of 300 cGy at 70 kVp, 10 ma. The patient received total doses of 4500 cGy to the area over a three week period. Treatments were delivered Monday to Friday with weekends off.

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Treatment Parameters for the Right  Hairline (Forehead) Lesion FIRST DAY OF  TREATMENT

TENTH DAY OF  TREATMENT

Patient Outcome on His Right  Hairline (Forehead) Lesion FOUR WEEKS AFTER TREATMENT

•

The patient tolerated the treatment with minimal side effects. The patient presented with mild redness, erythema and mild desquamation during treatment. The patient has very successful cosmetic results and was able to avoid surgery.

CONCLUSION

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•

•

Mohs micrographic surgery is another alternative. Mapping of concentrically excised tissue that is intraoperatively examined under magnification to dictate surgical removal is the gold standard. This procedure enjoys a high curative rate and facilitates healing by primary intention. This employs local anesthesia and can be done outpatient but not at bedside.

Mohs Micrographic Surgery

Nodular Basal Cell Carcinoma of the Nose A typical lesion presents as a translucent telangiectatic papule or nodule occurring on a sun-exposed surface. The nose is a frequent site of involvement. Note the slight translucency and blush of this lesion.

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•

•

•

Recognizing that skin cancers are going to present more often, and that we are relied upon to manage them collectively is only part of the equation. We must also accept the responsibility of treatment. The geriatric patient is living longer today than the same patient of yesterday and the quality of life is higher. It is therefore more important today than ever to diagnose and treat the elderly. Our geriatric patient is much more likely to be impacted by untreated tumors because they are likely to live long enough to allow for the growth and development and eventual morbidity of cancer.

•

•

•

The psychological impact to the patient is also very real and tangible. Our geriatric patients deserve the best attempts to keep them disease free and maximize quality of life. Draconic and heroic measures need not be employed, especially if lesions are diagnosed early. Chemotherapy and radiation therapy can be effective in some instances. Conservative surgical measures are often very well tolerated.

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•

•

Future Issues

•

The future dermatology practice will increase in the number of geriatric patients. Not only is the geriatric population one of the fastest growing segments of our society but also the baby boomer generation is now at the geriatric doorstep. Not only is the geriatric population one of the fastest growing segments of our society but also the baby boomer generation is now at the geriatric doorstep. The age group 65 + year olds represent a significant fraction of the . total population.

Summary •

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The role of the provider that provides care to the geriatric patient assumes the care for the integument system. The ability to affectively diagnose and treat cancerous lesions with special care given to the needs of the geriatric patient might be considered as indispensable.

• •

Accept the responsibility of skin cancers and perform biopsies with empathy and care.

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