Der Anteil der älteren und hochbetagten Menschen nimmt in unserer Bevölkerung stetig zu. Laut statistischem Bundesamt lebten 2013 ca. 4,4 Mio. über 80-Jährige in Deutschland, und für 2050 wird diese Zahl auf ca. 10 Mio. geschätzt. In dieser Altersgruppe besteht auch das höchste Risiko zur Entwicklung von Hautkrebs. Mit dieser Thematik haben sich in den letzten Jahren 5 Arbeiten exemplarisch und mit hoher Praxisrelevanz auseinandergesetzt.
Lubeek und Mitarbeiter entwickelten eine Rangliste von 13 priorisierten Punkten, die bei der adäquaten Auswahl der Hautkrebsbehandlung bei gebrechlichen älteren Menschen mit NMSC (non-melanoma skin cancer) berücksichtigt werden sollten. Merkmale wie z.B. eine stark begrenzte Lebenserwartung, Behandlung ohne gesicherte Heilung, Demenz und kognitive Beeinträchtigungen sowie Komorbiditäten wurden neben den Tumorparametern und einer möglichen funktionellen Beeinträchtigung durch den Eingriff berücksichtigt. Es zeigte sich, dass in den Deutschen Leitlinien von 2013 zum Plattenepithelkarzinom (2/13) und zum Basalzellkarzinom (4/13) nur ein Bruchteil dieser priorisierten Merk- male berücksichtigt worden war.
Ergänzend zu dieser Thematik wird im Artikel von Tan et al. der Fokus auf die möglichen Methoden der Berücksichtigung von Patienten und Angehörigen bei der Entscheidungsfindung für eine medizinische Behandlung gelegt.
Clinotti und Mitarbeiter analysierten die Hautkrebsbelastung und deren Korrelation mit Kennzeichen der intrinsischen und extrinsischen Hautalterung bei 209 Personen aus einer prospektiv erfassten Kohorte von älteren Menschen über 74 Jahren aus Frankreich. Fast 70% der Personen hatten aktinische Keratosen, 6,7% maligne epitheliale und melanozytäre Hauttumoren.
Linos et al. untersuchten anhand einer Extraktion von operativen Prozeduren aus dem Medicare-Register bei 2702 Personen aus der Region um Michigan (USA), ob das Alter der behandelten Menschen eine Auswirkung auf die dermatochirurgischen Behandlungsmodalitäten hatte. Explizit wurde die mehrzeitige Exzision mit histologischer Schnittrandkontrolle (Mohs Surgery) mit der einfachen klinisch orientierten Exzision und der Kombination aus Elektrodesikkation plus Kürettage verglichen. Sie fanden heraus, dass bei einem Alter von 85 Jahren oder mehr und den medizinisch relevanten Komorbiditäten (Erfassung mittels Charlson-Komorbiditätsindex, Liste der Einschränkungen der täglichen Aktivitäten und Lee-Index) als Vergleichsparameter keine relevanten Unterschiede bei der Wahl der operativen dermatochirurgischen Verfahren bei Patienten ohne versus mit eingeschränkter Lebenserwartung bestanden.
Ob deutlich aufwändigere operative Verfahren wie z.B. die plastische Rekonstruktion von Defekten an der Nase mittels regional gestieltem Stirnlappen bei älteren Menschen tolerabel sind, haben Kendler et al. 2014 untersucht. Von 28 Patienten traten nur bei 7 Komplikationen wie Wundinfektionen, Epithelnekrosen, Blutungen, Haare auf der Nase oder ein Hochstand des Nasenflügels auf.
Wo stehen wir also aktuell bei unserem Problem- und-Patienten-orientierten Handeln bei NMSC bei älteren und hochbetagten Menschen? Was definieren wir als adäquate Ziele bei der oft operativen Behandlung dieser Personen in dem Wissen, dass nur Teilaspekte in unseren Leitlinien berücksichtigt sind? Wie stimmen wir die Behandlungsziele im Vorfeld mit den Betroffenen ab? Und ab wann zählt man denn überhaupt zu den älteren gebrechlichen Menschen und nicht mehr zu den vitalen Best Agern im mittleren Lebensalter? Viele Fragen, denen sich diese hier vorgestellten 5 Artikel von verschiedenen Seiten nähern.
Lubeek SFK, Borgonjen RJ, van Vugt LJ, et al.: Improving the applicability of guidelines on nonmelanoma skin cancer in frail older adults: a multidisciplinary expert consensus and systematic review of current guidelines. Brit J Derm 2016;175:1003-1010.
Background: Balancing treatment decisions in frail older adults with nonmelanoma skin cancer (NMSC) can be challenging. Clinical practice guidelines (CPGs) could provide assistance.
Objectives: To collect and prioritize items related to frail older adults with NMSC for integration into CPGs and to assess the current extent of this integration.
Methods: Items were collected and prioritized by a multidisciplinary working group (29 members) using a modified Delphi procedure and a five-point Likert scale. To assess current integration of these items in CPGs, a systematic review was subsequently performed by two independent reviewers using five medical databases (PubMed, Embase, Cochrane Library, SUMsearch and Trip Database), websites of guideline developers/databases, and (inter)national dermatological societies.
Results: Prioritization of a final 13-item list showed that limited life ‘expectancy' (4.5 ± 0.9) and ‘treatment goals other than cure' (4.4 ± 0.7) were most desired to be integrated into CPGs; both were included in six (46%) of the CPGs found (n = 13). Attention to ‘tumour characteristics' and ‘comorbidities' were included in CPGs most often (100% and 77%, respectively).
Conclusions: More attention to items related to frail older adults in NMSC CPGs is broadly desired, but CPG integration of these items is currently limited. More integration might stimulate more holistic, personalized and patient-centred care in frail older adults.
Tan J, Linos E, Sendelweck MA, et al.: Shared decision making and patient decision aids in dermatology. Brit J Derm 2016;175:1045-1048.
Shared decision making combines individual patient interests and values with clinical best evidence under the guiding principle of patient autonomy. Patient decision aids can support shared decision making and facilitate decisions that have multiple options with varying outcomes for which patients may attribute different values. Given the variable psychosocial impact of skin disease on individuals and relative uncertainty regarding best treatments and their adherence in many dermatological conditions, informed shared decision making, supported by patient decision aids, should constitute a central component of dermatological care.
Clinotti E, Perrot JL, Labeille B, et al.: Skin tumours and skin aging in 209 French elderly people: the PROOF study. Eur J Dermatol 2016;26:470-476.
Few studies have evaluated the prevalence of skin tumours in the geriatric population and none have analysed different skin aging parameters for whole-body skin in this population. To evaluate the prevalence of skin tumours and global skin aging in a French cohort of elderly people. In total, 209 subjects, 105 women and 104 men (mean age: 77.5; range: 74-81 years), were enrolled from the PROOF (PROgnostic indicator OF cardiovascular and cerebrovascular events) cohort. SCINEXA (SCore for INtrinsic and EXtrinsic skin Aging) was used to assess the degree of skin aging and the prevalence of skin tumours. Some additional cutaneous parameters were also studied. Skin aging in women and men was compared. Mean global SCINEXA was 24.3 (SD: 4.7; range: 8.2-35.3). Solar elastosis and lax appearance were more severe in women (t test; p<0.0001), whereas pseudoscars (t test; p = 0.0312) and coarse wrinkles (t test; p = 0.0479) were more severe in men. Erythrosis coli (chi-square test; p <0.0001) was more frequent in men, whereas varicous veins (chi-square test; p = 0.0026) and eyelid xanthomas (chi-square test; p = 0.0282) were more frequent in women. Twelve patients presented with cutaneous carcinomas and two patients had early melanomas. This research describes in detail the main indices of skin aging in an old population and the differences related to gender. Moreover, it highlights the utility of systematic screening of old patients by dermatologists in order to diagnose skin cancers early.
Linos E, Chren MM, Stijacic Cenzer I, Covinsky KE: Skin cancer in U.S. elderly adults: does life expectancy play a role in treatment decisions? JACS 2016;64:1610-1615.
Objectives: To examine whether life expectancy influences treatment pattern of nonmelanoma skin cancer, or keratinocyte carcinoma (KC), the most common malignancy and the fifth most costly cancer to Medicare.
Design: Nationally representative cross-sectional study.
Setting: Nationally representative Health and Retirement Study linked to Medicare claims.
Participants: Treatments (N = 9,653) from individuals aged 65 and older treated for basal or squamous cell carcinoma between 1992 and 2012 (N = 2,702) were included.
Measurements: Limited life expectancy defined according to aged 85 and older, medical comorbidities, Charlson Comorbidity Index score of 3 or greater, difficulty in at least one activity of daily living (ADL), and a Lee index of 13 or greater. Treatment type (Mohs micrographic surgery (MMS) (most intensive, highest cost), excision, or electrodesiccation and curettage (ED & C) (least intensive, lowest cost)), according to procedure code.
Results: Most KCs (61%) were treated surgically. Rates of MMS (19%), excision (42%), and ED & C (39%) were no different in participants with limited life expectancy and those with normal life expectancy. For example, 19% of participants with difficulty or dependence in ADLs, 20% of those with a Charlson comorbidity score greater than 3, and 15% of those in their last year of life underwent MMS; participants who died within 1 year of diagnosis were treated in the same way as those who lived longer.
Conclusion: A one-size-fits-all approach in which advanced age, health status, functional status, and prognosis are not associated with intensiveness of treatment appears to guide treatment for KC, a generally nonfatal condition. Although intensive treatment of skin cancer when it causes symptoms may be indicated regardless of life expectancy, persons with limited life expectancy should be given choices to ensure that the treatment matches their goals and preferences.
Kendler M, Averbeck M, Wetzig T: Reconstruction of nasal defects with forehead flaps in patients older than 75 years of age. JEADV 2014;28:662-666.
Background: As the number of elderly patients diagnosed with non-melanoma skin cancer (NMSC) increases, the number of patients receiving dermatologic surgery also increases. Multimorbidity in this patient group is common.
Objective: The aim of this study is to assess the aesthetic and functional outcomes and complications of forehead flap (FHF) in elderly patients with NMSC.
Methods: Between 2006 and 2011, data for 28 patients 75 years of age or older who had been treated with FHFs under tumescent local anaesthesia were analysed.
Results: The median age of the study participants was 81 years (range, 75-95 years). Of the 28 total patients, 16 (57%) were female and 12 (43%) were male. The average defect size was 11 cm2 (5-30 cm2). Cartilage grafts were used in four patients (14%). The average time to takedown was 25 days (17-45). The median follow-up for the patients was 10 months (1-60 months). There were seven treatment-related complications due to infectious causes (2), epidermal necrotic tissue (2), bleeding (1), hair on the flap (1) and alar rim notching (1). No life-threatening complications were detected.
Conclusions: The FHF procedure is a safe and low-risk procedure in patients 75 years of age or older with advanced skin defects. If a defect requires an FHF to obtain a normal and aesthetic appearance, this procedure should be performed. However, dermatologists must weigh the safety of the procedure in relation to the clinical benefits when managing this patient group.
