Skin Cancer Epidemics in the Elderly as An Emerging Issue in Geriatric Oncology

Mortality from malignant skin melanoma in elderly Brazilians: 2001 to 2016

BACKGROUND

Malignant skin melanoma is a serious public health problem, especially among the elderly population. Knowing the dynamics of the mortality rates of this disease in Brazil is essential to support the creation of public health policies.

OBJECTIVE

To analyze the temporal trend of mortality from malignant skin melanoma in elderly people in Brazil, from 2001 to 2016.

METHODS

This was a descriptive analytical study of mortality rates from malignant skin melanoma in the elderly. The data were obtained from the Mortality Information System, and information related to the population was obtained from the 2010 population census and population estimates from the Brazilian Institute of Geography and Statistics. Mortality coefficients were calculated and simple linear regression analysis of the coefficients was performed by sex and macro-region.

RESULTS

A total 12,712 deaths due to malignant skin melanoma in the elderly were registered. The majority (56.8%) occurred in the male population. In females, a tendency of increase in mortality rates due to malignant skin melanoma was observed in the Northeast (p ≤ 0.001), Midwest (p = 0.002), and Brazil as a whole (p = 0.003). In males, an upward trend was observed in all regions, except for the Southeast region. For both sexes, there was also an upward trend in all regions, with the exception of the Southeast region.

STUDY LIMITATIONS

Secondary databases are directly influenced by the quality of death certificate completion and their heterogeneous scope in Brazilian regions.

CONCLUSION

The increase in mortality indicates a potential public health challenge for the coming decades. The prevention of skin cancer among the elderly should become a priority, mainly through the implementation of preventive measures.

High-Dose-Rate Brachytherapy for the Treatment of Basal and Squamous Cell Carcinomas on Sensitive Areas of the Face: A Report of Clinical Outcomes and Acute and Subacute Toxicities

Purpose

Basal cell and cutaneous squamous cell carcinoma are common malignancies (keratinocyte carcinomas [KCs]). Surgical resection is the standard of care. Radiation using high-dose rate brachytherapy (HDR-BT) may serve as a superior alternative where surgical scars may be of cosmetic concern or in elderly patients with significant comorbidity. We aim to describe the clinical and cosmetic outcomes as well as posttreatment radiation toxicities associated with HDR-BT in patients who were treated for KCs of the face.

Methods and Materials

Patients with KCs treated with HDR-BT from 2015 to 2018 were included in the study. Patient medical records and clinical photos were reviewed at multiple time points: start of treatment, end of treatment, short-term (2 week) follow-up, 3-month follow-up, and if needed at 6 months. Radiation toxicity was graded using the Radiation Therapy Oncology Grading (RTOG) acute toxicity scale. Median (range) toxicity grades at follow-up intervals were calculated. Clinical outcomes including local recurrence were evaluated for all patients.

Results

The study included 19 patients and 20 KCs. The median radiation dose was 42 Gy (39-42 Gy) over 6 fractions. The median toxicity at completion of treatment was RTOG grade 2 (85% of patients). At short-term follow-up, 50% of patients (n = 10) improved to RTOG grade 1 (0-2). At 3 months, 70% of patients (n = 14) had RTOG grade 0, and by 6 months, 100% of patients (n = 18) had RTOG grade 0. No RTOG grade 3 or higher skin toxicity was observed. With a median follow-up of 7.2 months (range, 1.3-54.4 months), the local recurrence-free survival was 95%.

Conclusions

We demonstrate that HDR-BT can be used as definitive treatment of KCs of the face with excellent cosmetic outcomes and local control. Acute and subacute skin toxicities were most commonly RTOG grade 2 or less with resolution of patient's skin toxicity by 3 months.

Vitamin D Receptor Polymorphisms and Non-Melanoma Skin Cancer Risk: A Case-Control Study

Exposure to sunlight is the major source of vitamin D and the main environmental cause of non-melanocytic skin cancers. Vitamin D, partly mediated through the vitamin D receptor (VDR), has potential therapeutic applications in skin cancer. The aim of this study was to investigate the association of BsmI and ApaI VDR polymorphisms among patients with non-melanoma cancers and controls. An observational case-control study was conducted in a sample of 154 subjects. We observed no significant effects between these polymorphisms and skin cancer risk. When stratified for gender, GG and AG BsmI polymorphisms significantly increased the risk of basal cell carcinomas in males. In relation to ApaI, all three polymorphisms significantly increased the risk of basal cell carcinoma in males. When stratified for age, we found that being 70 years of age or younger was a protective factor against both skin cancers. Being a female and 70 years old or younger was a protective factor for basal cell carcinoma. A comparison of the frequencies of the VDR genotypes in patients older than 70 years vs. 70 years or younger also revealed age-dependent variations in patients with non-melanoma skin cancer. Our study suggests a role for VDR polymorphisms in non-melanoma skin cancer development.

Use of Pericranial Flaps with Dermal Substitute for Scalp Reconstruction: A Case Series

Skin cancer incidence has been rapidly increasing over the past 2 decades, and the resulting defects from excision have significant aesthetic and functional implications. In particular, wound coverage for large scalp and forehead defects with calvarial exposure can lead to hairline distortion, contour irregularities, and alopecia. We describe a 2-stage technique for scalp reconstruction, which preserves the normal hairline, covers exposed bone with vascularized tissue, and restores an aesthetic soft-tissue contour.

Niche rather than origin dysregulates mucosal Langerhans cells development in aged mice

Unlike epidermal Langerhans cells (LCs) that originate from embryonic precursors and are self-renewed locally, mucosal LCs arise and are replaced by circulating bone marrow (BM) precursors throughout life. While the unique lifecycle of epidermal LCs is associated with an age-dependent decrease in their numbers, whether and how aging has an impact on mucosal LCs remains unclear. Focusing on gingival LCs we found that mucosal LCs are reduced with age but exhibit altered morphology with that observed in aged epidermal LCs. The reduction of gingival but not epidermal LCs in aged mice was microbiota-dependent; nevertheless, the impact of the microbiota on gingival LCs was indirect. We next compared the ability of young and aged BM precursors to differentiate to mucosal LCs. Mixed BM chimeras, as well as differentiation cultures, demonstrated that aged BM has intact if not superior capacity to differentiate into LCs than young BM. This was in line with the higher percentages of mucosal LC precursors, pre-DCs, and monocytes, detected in aged BM. These findings suggest that while aging is associated with reduced LC numbers, the niche rather than the origin controls this process in mucosal barriers.

Sentinel lymph node biopsy for high-thickness cutaneous squamous cell carcinoma

Squamous cell carcinomas are among the most common skin tumors and show a risk of metastasis depending on various factors such as tumor thickness, localization, histological subtype and immune status of the patient. Sentinel lymph node biopsy (SLNB) SLNB represents a possibility for assessing the locoregional lymph node status. In this study, the role of the SLNB in lymph node status and survival was analyzed. Retrospectively, 720 patients with high-risk squamous cell carcinoma (tumor thickness > 5 mm) were examined. 150 patients agreed to SLNB, 570 patients did not undergo histologic confirmation of lymph node status and were included directly in follow-up. In 101 patients, a sentinel lymph node was successfully marked and extirpated, followed by regular follow-up examinations.A total of 11.11% of the patients showed lymph node metastasis in the course of their treatment, with no difference in the proportion of patients in the SLNB group (11.9%) and the observation group (11.4%) (p = 0.873). The proportion of distant metastasis also did not differ between the groups (p = 0.898). In 3.96% of the patients in the SLNB group, a metastasis was found in the sentinel lymph node. Tumor-specific death was observed in 7.14% of the patients in the SLNB group and 4.74% in the observation group (p = 0.269). Although SLNB is a principally suitable method for determining lymph node status, the available data do not provide any benefit regarding further metastasis or tumor-specific survival.

Development of a patient decision aid for the management of superficial basal cell carcinoma (BCC) in adults with a limited life expectancy

BACKGROUND

Basal cell carcinoma (BCC) is a slow-growing, rarely lethal skin cancer that affects people 65 years or older. A range of treatment options exist for BCC, but there is little evidence available to guide patients and providers in selecting the best treatment options.

OBJECTIVES

This study outlines the development of a patient decision aid (PDA) for low-risk BCC that can be used by patients and providers to assist in shared decision-making.

METHODS

In accordance with the International Patient Decision Aids Standards (IPDAS) Collaboration framework, feedback from focus groups and semi-structured interviews with patients and providers, an initial prototype of the PDA was developed. This was tested using cognitive interviews and iteratively updated.

RESULTS

We created eighteen different iterations using feedback from 24 patients and 34 providers. The key issues identified included: 1) Addressing fear of cancer; 2) Communicating risk and uncertainty; 3) Values clarification; and 4) Time lag to benefit.

LIMITATIONS

The PDA does not include all possible treatment options and is currently paper based.

CONCLUSIONS

Our PDA has been specifically adapted and designed to support patients with a limited life expectancy in making decisions about their low risk BCC together with their doctors.

Cutaneous Squamous Cell Carcinoma: From Biology to Therapy

Cutaneous squamous cell carcinoma (CSCC) is the second most frequent cancer in humans and its incidence continues to rise. Although CSCC usually display a benign clinical behavior, it can be both locally invasive and metastatic. The signaling pathways involved in CSCC development have given rise to targetable molecules in recent decades. In addition, the high mutational burden and increased risk of CSCC in patients under immunosuppression were part of the rationale for developing the immunotherapy for CSCC that has changed the therapeutic landscape. This review focuses on the molecular basis of CSCC and the current biology-based approaches of targeted therapies and immune checkpoint inhibitors. Another purpose of this review is to explore the landscape of drugs that may induce or contribute to the development of CSCC. Beginning with the pathogenetic basis of these drug-induced CSCCs, we move on to consider potential therapeutic opportunities for overcoming this adverse effect.

Updates and new perspectives in nonmelanoma skin cancer therapy: highlights from 'Immunotherapy Bridge'

Over the last few years, extensive research has improved our understanding of tumor immunology and has enabled the development of novel treatments. The state of the art of immunotherapy in various types of malignancies was exhaustively discussed in the 'Immunotherapy Bridge' meeting, which was held in Naples on 4-5 December 2019. Highlights related to the immunological treatment of nonmelanoma skin cancer are the content of this article.

Identification of master regulator genes of UV response and their implications for skin carcinogenesis

Solar UV radiation is a major environmental risk factor for skin cancer. Despite decades of robust and meritorious investigation, our understanding of the mechanisms underlying UV-induced skin carcinogenesis remain incomplete. We previously performed comprehensive transcriptomic profiling in human keratinocytes following exposure to different UV radiation conditions to generate UV-specific gene expression signatures. In this study, we utilized Virtual Inference of Protein Activity by Enriched Regulon (VIPER), a robust systems biology tool, on UV-specific skin cell gene signatures to identify master regulators (MRs) of UV-induced transcriptomic changes. We identified multiple prominent candidate UV MRs, including forkhead box M1 (FOXM1), thyroid hormone receptor interactor 13 and DNA isomerase II alpha, which play important roles in cell cycle regulation and genome stability. MR protein activity was either activated or suppressed by UV in normal keratinocytes. Intriguingly, many of the UV-suppressed MRs were activated in human skin squamous cell carcinomas (SCCs), highlighting their importance in skin cancer development. We further demonstrated that selective inhibition of FOXM1, whose activity was elevated in SCC cells, was detrimental to SCC cell survival. Taken together, our study uncovered novel UV MRs that can be explored as new therapeutic targets for future skin cancer treatment.

The Role of Nicotinamide in Cancer Chemoprevention and Therapy

Nicotinamide (NAM) is a water-soluble form of Vitamin B3 (niacin) and a precursor of nicotinamide-adenine dinucleotide (NAD⁺) which regulates cellular energy metabolism. Except for its role in the production of adenosine triphosphate (ATP), NAD⁺ acts as a substrate for several enzymes including sirtuin 1 (SIRT1) and poly ADP-ribose polymerase 1 (PARP1). Notably, NAM is an inhibitor of both SIRT1 and PARP1. Accumulating evidence suggests that NAM plays a role in cancer prevention and therapy. Phase III clinical trials have confirmed its clinical efficacy for non-melanoma skin cancer chemoprevention or as an adjunct to radiotherapy against head and neck, laryngeal, and urinary bladder cancers. Evidence for other cancers has mostly been collected through preclinical research and, in its majority, is not yet evidence-based. NAM has potential as a safe, well-tolerated, and cost-effective agent to be used in cancer chemoprevention and therapy. However, more preclinical studies and clinical trials are needed to fully unravel its value.

Exome sequencing identifies novel mutation signatures of UV radiation and trichostatin A in primary human keratinocytes

Canonical ultraviolet (UV) mutation type and spectra are traditionally defined by direct sequencing-based approaches to map mutations in a limited number of representative DNA elements. To obtain an unbiased view of genome wide UV mutation features, we performed whole exome-sequencing (WES) to profile single nucleotide substitutions in UVB-irradiated primary human keratinocytes. Cross comparison of UV mutation profiles under different UVB radiation conditions revealed that T > C transition was highly prevalent in addition to C > T transition. We also identified 5'-ACG-3' as a common sequence motif of C > T transition. Furthermore, our analyses uncovered several recurring UV mutations following acute UVB radiation affecting multiple genes including HRNR, TRIOBP, KCNJ12, and KMT2C, which are frequently mutated in skin cancers, indicating their potential role as founding mutations in UV-induced skin tumorigenesis. Pretreatment with trichostatin A, a pan-histone deacetylase inhibitor that renders chromatin decondensation, significantly decreased the number of mutations in UVB-irradiated keratinocytes. Unexpectedly, we found trichostatin A to be a mutagen that caused DNA damage and mutagenesis at least partly through increased reactive oxidation. In summary, our study reveals new UV mutation features following acute UVB radiation and identifies novel UV mutation hotspots that may potentially represent founding driver mutations in skin cancer development.

Inhibition of basal cell carcinoma cells by cold atmospheric plasma‑activated solution and differential gene expression analysis

Basal cell carcinoma is a common skin tumor. Cold atmospheric plasma (CAP) has attracted increasing attention for its antitumor effects. The aim of the present study was to investigate the effects and related mechanisms of two CAP‑activated solutions on the TE354T basal cell carcinoma and HaCat keratinocyte cell lines. Plasma‑activated solution (PAS) was prepared by CAP irradiation of DMEM and PBS. TE354T cells were treated with PAS in vitro and the effect on cell viability was evaluated by an MTT assay. The apoptosis rate was detected by Annexin V/propidium iodide staining. Furthermore, western blotting and RNA‑sequencing were performed. The present results demonstrated that PAS induced apoptotic signaling in basal cell carcinoma cells, and that this effect was associated with the activation of the MAPK signaling pathway. Therefore, the present study demonstrated that PAS may serve as a novel treatment for basal cell carcinoma.

Consensus statement from 2nd International Conference on Controversies in Vitamin D

The 2nd International Conference on Controversies in Vitamin D was held in Monteriggioni (Siena), Italy, September 11-14, 2018. The aim of this meeting was to address ongoing controversies and timely topics in vitamin D research, to review available data related to these topics and controversies, to promote discussion to help resolve lingering issues and ultimately to suggest a research agenda to clarify areas of uncertainty. Several issues from the first conference, held in 2017, were revisited, such as assays used to determine serum 25-hydroxyvitamin D [25(OH)D] concentration, which remains a critical and controversial issue for defining vitamin D status. Definitions of vitamin D nutritional status (i.e. sufficiency, insufficiency and deficiency) were also revisited. New areas were reviewed, including vitamin D threshold values and how they should be defined in the context of specific diseases, sources of vitamin D and risk factors associated with vitamin D deficiency. Non-skeletal aspects related to vitamin D were also discussed, including the reproductive system, neurology, chronic kidney disease and falls. The therapeutic role of vitamin D and findings from recent clinical trials were also addressed. The topics were considered by 3 focus groups and divided into three main areas: 1) "Laboratory": assays and threshold values to define vitamin D status; 2) "Clinical": sources of vitamin D and risk factors and role of vitamin D in non-skeletal disease and 3) "Therapeutics": controversial issues on observational studies and recent randomized controlled trials. In this report, we present a summary of our findings.

S2k Guidelines for Cutaneous Basal Cell Carcinoma - Part 2: Treatment, Prevention and Follow-up

Basal cell carcinoma (BCC) is the most common malignant tumor among fair-skinned individuals, and its incidence had been steadily rising in the past decades. In order to maintain the highest quality of patient care possible, the German S2k guidelines were updated following a systematic literature search and with the participation of all professional societies and associations involved in the management of the disease. Part 2 addresses issues such as proper risk stratification, the various therapeutic approaches, and prevention as well as follow-up of patients with basal cell carcinoma.

Periocular basal cell carcinoma - clinical perspectives

Basal cell carcinoma (BCC) as a non-melanoma skin cancer type is the most common malignant tumor throughout the world. The incidence is higher in age over 60. The intense of exposure to ultraviolet radiation is one of the known risk factors. Over 50% of BCC of the periocular region initially occur on the lower lid and inner angle. Literature review of treatment options for basal cell carcinoma, which consist of surgery, or combined techniques plus vismodegib, radiotherapy and imiquimod. The first consideration for treatment of periocular BCC is radical surgical excision using Mohs micrographic technique. Functional and esthetic outcome in patients are important after clear excisions and reconstruction should be carefully considered. Radical exenteration is considered in the case of orbital invasion of high-risk aggressive BCC.

Integra in Scalp Reconstruction After Tumor Excision: Recommendations From a Multidisciplinary Advisory Board

Integra is a dermal regeneration template used in the reconstruction of burns, traumatic injuries, or excision lesions in patients who present particular risk factors for traditional surgical procedures. A multidisciplinary advisory board of expert dermatologists and plastic surgeons have discussed the use of Integra in the reconstruction of scalp defects after tumor excision, focusing on the evidence derived from literature and on their experience in the treatment of approximately 400 patients. In this position paper, the authors summarize the main evidence discussed during the board, and the common practice guidelines proposed by the experts. The use of Integra is recommended in elderly patients with multiple comorbidities who have a higher risk for potential complications in traditional surgery; these patients may in fact benefit from a lower anesthetic risk, a less complicated postsurgical care and limited morbidity at the donor site obtained with the dermal template. Integra should also be used in the reconstruction of large and complex wounds and in case of bone exposure, as it helps to overcome the challenges related to wound healing in difficult areas. Notably, Integra has proven to be effective in patients who have undergone previous surgical procedures or adjuvant radiation therapy, in which previous incisions, scarring and radiation damages may hamper the effectiveness of traditional procedures. Finally, Integra is recommended in patients with recurrent and aggressive tumors who need closer tumor surveillance, as it gives easy access to the tumor site for oncologic follow-up examination.

Cemiplimab in locally advanced cutaneous squamous cell carcinoma: results from an open-label, phase 2, single-arm trial

BACKGROUND

Cemiplimab has shown substantial antitumour activity in patients with metastatic cutaneous squamous cell carcinoma. Patients with locally advanced cutaneous squamous cell carcinoma have poor prognosis with conventional systemic therapy. We present a primary analysis of the safety and antitumour activity of cemiplimab in patients with locally advanced cutaneous squamous cell carcinoma.

METHODS

This pivotal open-label, phase 2, single-arm trial was done across 25 outpatient clinics, primarily at academic medical centres, in Australia, Germany, and the USA. Eligible patients (aged ≥18 years with histologically confirmed locally advanced cutaneous squamous cell carcinoma and an Eastern Cooperative Oncology Group performance status of 0-1) received cemiplimab 3 mg/kg intravenously over 30 min every 2 weeks for up to 96 weeks. Tumour measurements were done every 8 weeks. The primary endpoint was objective response, defined as the proportion of patients with complete or partial response, according to independent central review as per Response Evaluation Criteria in Solid Tumors version 1.1 for radiological scans and WHO criteria for medical photography. Data cutoff was Oct 10, 2018, when the fully enrolled cohort reached the prespecified timepoint for the primary analysis. Analyses were done as per the intention-to-treat principle. The safety analysis comprised all patients who received at least one dose of cemiplimab. This study is registered with ClinicalTrials.gov, number NCT02760498.

FINDINGS

Between June 14, 2016, and April 25, 2018, 78 patients were enrolled and treated with cemiplimab. The median duration of study follow-up was 9·3 months (IQR 5·1-15·7) at the time of data cutoff. An objective response was observed in 34 (44%; 95% CI 32-55) of 78 patients. The best overall response was ten (13%) patients with a complete response and 24 (31%) with a partial response. Grade 3-4 treatment-emergent adverse events occurred in 34 (44%) of 78 patients; the most common were hypertension in six (8%) patients and pneumonia in four (5%). Serious treatment-emergent adverse events occurred in 23 (29%) of 78 patients. One treatment-related death was reported that occurred after onset of aspiration pneumonia.

INTERPRETATION

Cemiplimab showed antitumour activity and an acceptable safety profile in patients with locally advanced cutaneous squamous cell carcinoma for whom there was no widely accepted standard of care.

FUNDING

Regeneron Pharmaceuticals and Sanofi.

Epidemiology of Skin Cancer: Update 2019

Melanoma and keratinocyte skin cancer (KSC) are the most common types of cancer in White-skinned populations. Both tumor entities showed increasing incidence rates worldwide but stable or decreasing mortality rates. Rising incidence rates of cutaneous melanoma (CM) and KSC are largely attributed to increasing exposure to ultraviolet (UV) radiation, the main causal risk factor for skin cancer.Incidence rates of KSC, comprising of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), are much higher than that of melanoma. BCC development is mainly the cause of an intensive UV exposure in childhood and adolescence, while SCC development is related to chronic, cumulative UV exposure over decades. Although mortality is relatively low, KSC is an increasing problem for health care services causing significant morbidity.Cutaneous melanoma is rapidly increasing in White populations, with an estimated annual increase of around 3-7% over the past decades. In contrast to SCC, melanoma risk is associated with intermittent and chronic exposure to sunlight. The frequency of its occurrence is closely associated with the constitutive color of the skin and the geographical zone. Changes in outdoor activities and exposure to sunlight during the past 70 years are an important factor for the increasing incidence of melanoma. Mortality rates of melanoma show stabilization in the USA, Australia, and in European countries. In the USA even dropping numbers of death cases were recently reported, probably reflecting efficacy of the new systemic treatments.Among younger cohorts in some populations (e.g., Australia and New Zealand,), stabilizing or declining incidence rates of CM are observed, potentially caused by primary prevention campaigns aimed at reducing UV exposure. In contrast, incidence rates of CM are still rising in most European countries and in the USA. Ongoing trends towards thinner melanoma are largely ascribed to earlier detection.

Novel approaches for managing aged skin and nonmelanoma skin cancer

The process of aging influences every bodily organ and tissue, and those with rapid epithelial cell turnover, are particularly affected. The most visible of these, however, is the skin (including the epidermis), the largest human organ that provides a barrier to external insults, structure to the body and its movements, facilitates thermoregulation, harbors immune cells, and incorporates sensory neurons (including mechanoreceptors, nociceptors, and thermoreceptors). Skin aging has traditionally been categorized into intrinsic and extrinsic, with the latter nearly exclusively restricted to "photoaging," (i.e., aging due to exposure to solar or artificial ultraviolet radiation). However, both intrinsic and extrinsic aging share similar causes, including oxidative damage, telomere shortening, and mitochondrial senescence. Also, like other malignancies, the risk of malignant and nonmalignant lesions increases with age. Herein, we review the most recent findings in skin aging and nonmelanoma skin cancer, including addition to traditional and developing therapies.

Efficacy and Safety of Etanercept in Elderly Patients with Rheumatoid Arthritis: A Post-Hoc Analysis of Randomized Controlled Trials

BACKGROUND

Elderly individuals are disproportionately affected by rheumatoid arthritis (RA), but few studies have addressed the efficacy and safety of treatments in this population.

OBJECTIVE

Our objective was to assess the efficacy and safety of etanercept in elderly patients (aged ≥ 65 years) with RA.

METHODS

The efficacy analysis was a post hoc analysis of data from the open-label period of three phase IV clinical trials of etanercept for RA. Least squares (LS) change from baseline (cfb) in 28-joint Disease Activity Score (DAS28), Health Assessment Questionnaire Disability Index (HAQ-DI), and modified Total Sharp Scores (mTSS) were analyzed by age (< 65 vs. ≥ 65 years) for each study. The safety analyses were of data pooled from the double-blind, placebo-controlled periods of 19 phase I-IV randomized studies of etanercept in patients with RA. The percentage occurrence of adverse events (AEs) in placebo- and etanercept-treated patients was analyzed by age (< 65 vs. ≥ 65 years).

RESULTS

There were no significant differences in LS mean cfb in DAS28 or mTSS between the two age groups. LS mean cfb in HAQ-DI scores was consistently lower in elderly than in non-elderly patients, although significant differences were not observed in all trials. Overall, AE occurrence was higher in elderly than non-elderly patients, regardless of treatment. In etanercept-treated patients, there were small yet statistically significant increases in the occurrence of congestive heart failure, serious infections, and non-melanoma skin cancers in elderly versus non-elderly patients. For most AEs, occurrence did not significantly differ between elderly and non-elderly patients.

CONCLUSION

Overall, there were no substantial differences in the efficacy or safety of etanercept between elderly and non-elderly patients with RA.

Management of Skin Cancer in the Elderly

Over the next 30 years, dermatologists face a rising population of elderly patients, causing a marked increase in the incidence of cutaneous malignancies. For this reason, it is important to review the approach to the management of skin cancer in the elderly. In the current medical environment, there has been debate as to how cutaneous malignancy should be treated in elderly patients, especially those with multiple comorbid conditions. Clinicians should use a comprehensive approach that accounts for functional status, impact on quality of life, cost, and potential adverse outcomes when managing high- and low-morbidity skin cancers in the elderly.

Giant locally advanced and metastatic squamous cell skin carcinoma of head and neck region: case report

Introduction

At the present time, the skin tumors are among the most common cancers. Optimal therapy is based on the extent of the disease and the age of the patient. The need for radiotherapy occurs for inoperable locally advanced tumors and in the event of failure, salvage surgery is applied.

Materials and methods

We provided a case report of an older patient with giant squamous cell skin carcinoma and a review of published articles.

Results

We present a rare case of giant squamous cell skin carcinoma with metastatic satellite tumors that was primarily treated with curative radiotherapy. Five months after radiotherapy, a recurrent tumor was detected at the site of origin and the treatment was completed by salvage surgery. Full remission was achieved for four years.

Conclusion

Despite the seemingly incurable finding it is always necessary to consider radical treatment regardless of the patient´s age. Curative treatment could achieve long term remission in the group of older patients.

Management of keratinocyte carcinoma - Special considerations in the elderly

Keratinocyte carcinomas (KCs) are now an epidemic in The United States of America, especially in elderly patients. KCs, including basal cell carcinoma and squamous cell carcinoma, can lead to disfigurement and occasionally death. However, the lower mortality rate associated with KC compared with melanoma allows for increased flexibility in the selection of treatment. Flexibility in treatment is particularly important in the elderly given that this patient population often has medical comorbidities that should be considered. These patients may have multiple KCs, higher risk tolerance to recurrence, and different concerns about cosmetic outcomes compared with their younger counterparts. We review treatment options for KCs and how the selection of each option may affect the elderly patient.

Melanoma-Bearing Libechov Minipig (MeLiM): The Unique Swine Model of Hereditary Metastatic Melanoma

National cancer databases document that melanoma is the most aggressive and deadly cutaneous malignancy with worldwide increasing incidence in the Caucasian population. Around 10% of melanomas occur in families. Several germline mutations were identified that might help to indicate individuals at risk for preventive interventions and early disease detection. More than 50% of sporadic melanomas carry mutations in Ras/Raf/mitogen-activated protein kinase (MAPK/MEK) pathway, which may represent aims of novel targeted therapies. Despite advances in targeted therapies and immunotherapies, the outcomes in metastatic tumor are still unsatisfactory. Here, we review animal models that help our understanding of melanoma development and treatment, including non-vertebrate, mouse, swine, and other mammal models, with an emphasis on those with spontaneously developing melanoma. Special attention is paid to the melanoma-bearing Libechov minipig (MeLiM). This original swine model of hereditary metastatic melanoma enables studying biological processes underlying melanoma progression, as well as spontaneous regression. Current histological, immunohistochemical, biochemical, genetic, hematological, immunological, and skin microbiome findings in the MeLiM model are summarized, together with development of new therapeutic approaches based on tumor devitalization. The ongoing study of molecular and immunological base of spontaneous regression in MeLiM model has potential to bring new knowledge of clinical importance.

Age, sex and primary care setting differences in patients' perception of community healthcare seeking behaviour towards health services

INTRODUCTION

Understanding the potential determinants of community healthcare seeking behaviour helps in improving healthcare utilisation and health outcomes within different populations. This in turn will aid the development of healthcare policies and planning for prevention, early diagnosis and management of health conditions.

OBJECTIVE

To evaluate patients' perception of community healthcare seeking behaviour towards both acute and preventive physical and psychosocial health concerns by sex, age and type of primary care setting (as a proxy for affordability of healthcare).

METHODS

A total of 3979 patients from 221 public and 239 private clinics in Malaysia were interviewed between June 2015 and February 2016 using a patient experience survey questionnaire from the Quality and Cost of Primary Care cross-sectional study. Multivariable logistic regression analysis adjusted for the complex survey design was used.

RESULTS

After adjusting for covariates, more women than men perceived that most people would see their general practitioners for commonly consulted acute and preventive physical and some psychosocial health concerns such as stomach pain (adjusted odds ratio (AOR), 1.64; 95% confidence interval (CI), 1.22-2.21), sprained ankle (AOR, 1.29; 95% CI, 1.06-1.56), anxiety (AOR, 1.32; 95% CI, 1.12-1.55), domestic violence (AOR, 1.35; 95% CI, 1.13-1.62) and relationship problems (AOR, 1.24; 95% CI, 1.02-1.51). There were no significant differences in perceived healthcare seeking behaviour by age groups except for the removal of a wart (AOR, 1.41; 95% CI, 1.12-1.76). Patients who visited the public clinics had generally higher perception of community healthcare seeking behaviour for both acute and preventive physical and psychosocial health concerns compared to those who went to private clinics.

CONCLUSIONS

Our findings showed that sex and healthcare affordability differences were present in perceived community healthcare seeking behaviour towards primary care services. Also perceived healthcare seeking behaviour were consistently lower for psychosocial health concerns compared to physical health concerns.

An Overview of Uncommon Cutaneous Malignancies, Including Skin Appendageal (Adnexal) Tumours and Sarcomas

A standardised classification of malignant skin appendageal (adnexal) tumours and sarcomas is required for improved patient management and prognosis. This has been hindered by considerable morphological variation both within and between tumour types, the use of many synonyms for the same tumour types and variation in classification between pathologists. This update uses the improved classification in the 2018 WHO classification of skin tumours as the basis to discuss malignant skin appendageal tumours, sarcomas and cutaneous metastases that regularly present to skin cancer clinicians, multidisciplinary skin cancer teams and tumour boards, with current evidence for management, where appropriate.

Health-Related Quality of Life, Satisfaction with Care, and Cosmetic Results in Relation to Treatment among Patients with Keratinocyte Cancer in the Head and Neck Area: Results from the PROFILES Registry

BACKGROUND

Little is known about the impact of keratinocyte cancer (KC) and its treatment on health-related quality of life (HRQoL).

OBJECTIVES

The objectives of the present study were (1) to evaluate HRQoL among patients with KC in a population-based setting and compare this with an age- end sex-matched normative population and (2) to compare HRQoL, satisfaction with care, and cosmetic results among patients who underwent conventional excision, Mohs' micrographic surgery, or radiotherapy.

METHOD

A random sample of 347 patients diagnosed with cutaneous basal cell or squamous cell carcinoma in the head and neck area between January 1, 2010, and December 31, 2014, were selected from the Netherlands Cancer Registry (NCR) and were invited to complete a questionnaire on HRQoL, satisfaction with care, and cosmetic results. Data were collected within Patient-Reported Outcomes Following Initial Treatment and Long-term Evaluation of Survivorship (PROFILES). Outcomes were compared to an age- and sex-matched normative population.

RESULTS

Two hundred fifteen patients with KC returned a completed questionnaire (62% response). Patients with KC reported better global quality of life (79.6 vs. 73.3, p < 0.01) and less pain (p < 0.01) compared to the normative population. No statistically significant differences in HRQoL, satisfaction with care, and cosmetic results were found between patients with KC who underwent conventional excision, Mohs' micrographic surgery, or radiotherapy.

CONCLUSIONS

The impact of KC and its treatment seems relatively low and more positive than negative as patients reported better HRQoL compared to an age- and sex-matched normative population, probably due to adaptation. No statistically significant differences between treatment types were found concerning HRQoL, patient satisfaction, and cosmetic results. This information could be used by healthcare professionals involved in KC care to improve patients' knowledge about different aspects of the disease as patient's preference is an important factor for treatment choice.

Basal cell carcinoma genetic susceptibility increases the rate of skin ageing: a Mendelian randomization study

BACKGROUND

Onset of basal cell carcinoma (BCC) is connected to skin ageing, but it is unclear whether higher BCC genetic susceptibility drives skin ageing.

OBJECTIVES

To investigate whether loci increasing genetic susceptibility to BCC also drive multiple features of skin ageing, independently of confounding factors, using Mendelian randomization.

METHODS

A Mendelian randomization study was conducted in older adults from the Leiden Longevity Study (N = 604). A total of 25 BCC loci, selected based on a published genome-wide association study on BCC (P-value < 5 × 10^-8 ), were used as genetic instruments for the calculation of a standardized (mean = 0, SD = 1) weighted BCC genetic risk score. Based on facial photographs, we determined perceived age, and skin wrinkling and pigmented spot grading.

RESULTS

A higher BCC genetic risk score was associated with a higher perceived age (adjusted for chronological age and sex) of 0.88 years (95% CI: 0.44, 1.31; P-value = 7.1e^-5 ), greater wrinkling by 0.14 grades (95% CI: 0.05, 0.23; P-value = 2.3e^-3 ), and greater pigmented spots by 0.17 grades (95% CI: 0.08, 0.25; P-value = 1.1e^-4 ). These findings were weakened but still present after exclusion of gene variants in MC1R and IRF4 which have potential pleiotropic effects.

CONCLUSIONS

Mechanisms influenced by genetic loci increasing susceptibility to BCC also drive skin ageing suggesting shared biology and shared targets for interventions.

Cutaneous Melanoma in the Elderly: Review of a Growing Problem

Cutaneous melanoma (CM) causes more deaths than any other skin tumor, and incidence and mortality rates have risen in recent years, especially in patients of advanced age. There are differences in the biological behavior of CM tumors in the elderly as well as differential management of the disease, evidently influenced by such factors as limited life expectancy, the high incidence of concomitant conditions in older patients, and issues of quality of life unrelated to CM itself. We review relevant current literature on the epidemiology, etiology, pathogenesis, and immunology of CM as well as research on the clinical features, prevention, and management of these tumors in the elderly.

Cross-talk of cutaneous beta human papillomaviruses and the immune system: determinants of disease penetrance

Human papillomaviruses (HPVs) infect the epithelia of skin or mucosa, where they can induce hyperproliferative lesions. More than 220 different HPV types have been characterized and classified into five different genera. Mucosal high-risk HPVs are causative for cancers of the anogenital region and oropharynx. Clinical data from patients with the rare genetic disorder epidermodysplasia verruciformis (EV) indicate that genus beta-HPVs cooperate with ultraviolet (UV) radiation in the development of cutaneous squamous cell carcinoma. In addition, epidemiological and biological findings indicate that beta-HPV types play a role in UV-mediated skin carcinogenesis also in non-EV individuals. However, the mechanisms used by these cutaneous viruses to promote epithelial carcinogenesis differ significantly from those of mucosal HPVs. Recent studies point to a delicate cross-talk of beta-HPVs with the cell-autonomous immunity of the host keratinocytes and the local immune microenvironment that eventually determines the fate of cutaneous HPV infection and the penetrance of disease. This review gives an overview of the critical interactions of genus beta-HPVs with the local immune system that allow the virus to complete its life cycle, to escape from extrinsic immunity, and eventually to cause chronic inflammation contributing to skin carcinogenesis. This article is part of the theme issue 'Silent cancer agents: multi-disciplinary modelling of human DNA oncoviruses'.

Prevalence and associated factors of skin cancer in aged nursing home residents: A multicenter prevalence study

Non-melanoma-skin cancer is an emerging clinical problem in the elderly, fair skinned population which predominantly affects patients aged older than 70 years. Its steady increase in incidence rates and morbidity is paralleled by related medical costs. Despite the fact that many elderly patients are in need of care and are living in nursing homes, specific data on the prevalence of skin cancer in home care and the institutional long-term care setting is currently lacking. A representative multicenter prevalence study was conducted in a random sample of ten institutional long-term care facilities in the federal state of Berlin, Germany. In total, n = 223 residents were included. Actinic keratoses, the precursor lesions of invasive cutaneous squamous cell carcinoma were the most common epithelial skin lesions (21.1%, 95% CI 16.2 to 26.9). Non-melanoma skin cancer was diagnosed in 16 residents (7.2%, 95% CI 4.5 to 11.3). None of the residents had a malignant melanoma. Only few bivariate associations were detected between non-melanoma skin cancer and demographic, biographic and functional characteristics. Male sex was significantly associated with actinic keratosis whereas female sex was associated with non-melanoma skin cancer. Smoking was associated with an increased occurrence of non-melanoma skin cancer. Regular dermatology check-ups in nursing homes would be needed but already now due to financial limitations, lack of time in daily clinical practice and limited number of practising dermatologists, it is not the current standard. With respect to the worldwide growing aging population new programs and decisions are required. Overall, primary health care professionals should play a more active role in early diagnosis of skin cancer in nursing home residents. Dermoscopy courses, web-based or smartphone-based applications and teledermatology may support health care professionals to provide elderly nursing home residents an early diagnosis of skin cancer.

Pigmented Basal Cell Carcinoma Masquerading as a Melanoma

Basal cell carcinoma is the most common skin cancer. Pigmented basal cell carcinoma is an uncommon clinical presentation that can resemble a melanoma. We present the clinical and pathologic features of three individuals whose pigmented basal cell carcinomas masqueraded as melanomas. All of the patients were Hispanic and ranged in age from 63 years to 77 years. They presented with a pigmented lesion that was ultimately diagnosed as a pigmented basal cell carcinoma; one woman had a collision tumor consisting of a pigmented basal cell carcinoma and a seborrheic keratosis. All of the patients had their tumors removed using Mohs micrographic surgery, without recurrence. The clinical differential diagnosis of a black tumor―particularly in patients with darker skin types―should include pigmented basal cell carcinoma in addition to melanoma; a biopsy of the lesion will establish the diagnosis.

Advances in the Research of Risk Factors and Prodromal Biomarkers of Parkinson's Disease

Parkinson's disease (PD) is the second most common neurodegenerative disease in the world. With the advent of an aging population and improving life expectancy worldwide, the number of PD patients is expected to increase, which may lead to an urgent need for effective preventive and diagnostic strategies for PD. Although there is increasing research regarding the pathogenesis of PD, there is limited knowledge regarding the prevention of PD. Moreover, the diagnosis of PD depends on clinical criteria, which require the occurrence of bradykinesia and at least one symptom of rest tremor or rigidity. However, converging evidence from clinical, genetic, neuropathological, and imaging studies suggests the initiation of PD-specific pathology prior to the initial presentation of these classical motor clinical features by years or decades. This latent stage of neurodegeneration in PD is a particularly important stage for effective neuroprotective therapies, which might retard the progression or prevent the onset of PD. Therefore, the exploration of risk factors and premotor biomarkers is not only crucial to the early diagnosis of PD but is also helpful in the development of effective neuroprotection and health care strategies for appropriate populations at risk for PD. In this review, we searched and summarized ∼249 researches and 31 reviews focusing on the risk factors and prodromal biomarkers of PD and published in MEDLINE.

Consensus Guidelines on the Use of Superficial Radiation Therapy for Treating Nonmelanoma Skin Cancers and Keloids

Background: The use of superficial radiation therapy (SRT) has experienced a renaissance for treating nonmelanoma skin cancers (NMSCs) and recurrent keloids; however, published treatment guidelines are lacking. Objective: The objective of this work was to provide consensus guidelines on the use of SRT for treating NMSC and recurrent keloids based on a review of the literature and expert opinion. Methods and Materials: A search of the medical literature was performed to obtain published information on the use of SRT for review. A group of qualified dermatologists convened to discuss their views on the use of SRT for the treatment of NMSCs and recurrent keloids. The various guidelines were considered to have consensus based on a supermajority two-thirds vote. The final consensus guidelines are thus based on the medical literature, when available, and expert opinions. Results: Agreement on consensus guidelines was reached for numerous aspects of SRT use, including appropriate tumor types for SRT; anatomical areas suitable for SRT; energy, fractions, and scheduling recommendations for SRT; use of SRT in the presence of comorbidities; safety factors; and treatment recommendations for recurrent keloids, based the literature and on both the opinions of the expert group and a survey of experienced users. Conclusion: Consensus was reached that SRT is a safe and effective treatment for basal cell and squamous cell carcinomas and should be considered as the first-line form of radiation treatment. Postsurgical treatment of keloid excision suture lines with SRT significantly reduces keloid recurrence rates.

The inhibition effect of cold atmospheric plasma-activated media in cutaneous squamous carcinoma cells

AIM

This study investigated the effect and mechanism of cold atmospheric plasma (CAP)-activated media on A431 and HaCaT cells.

MATERIALS & METHODS

Phosphate-buffered saline (PBS) and Dulbecco's Modified Eagle's Medium (DMEM) were treated by CAP to get CAP-activated media. A431 and HaCaT were incubated by CAP-activated media for 2 h. MTT, Annexin-V and propidium iodide (PI), Western blot and reactive oxygen species (ROS) detection assay were utilized to demonstrate the effect.

RESULTS

The CAP-activated media decreased the proliferation of A431 cells in a dose/time-dependent manner. And the CAP-activated media could induce apoptosis in A431 cells. CAP-activated phosphate-buffered saline could increase intracellular ROS level but not CAP-activated DMEM.

CONCLUSION

CAP-activated media could induce apoptosis in A431 cells by production of ROS.

Seasonal Minimum and Maximum Solar Ultraviolet Exposure Measurements of Classroom Teachers Residing in Tropical North Queensland, Australia

The risk of keratinocyte skin cancer, malignant melanoma and ultraviolet radiation (UVR)-induced eye disease is disproportionately higher in Australia and New Zealand compared to equivalent northern hemisphere latitudes. While many teachers are aware of the importance of reinforcing sun safety messages to students, many may not be aware of the considerable personal exposure risk while performing outdoor duties in locations experiencing high to extreme ambient UVR year-round. Personal erythemally effective exposure of classroom teachers in tropical Townsville (19.3°S) was measured to establish seasonal extremes in exposure behavior. Mean daily personal exposure was higher in winter (91.2 J m^-2 , 0.91 Standard Erythema Dose [SED]) than summer (63.3 J m^-2 , 0.63 SED). The range of exposures represents personal exposures that approximate current national guidelines for Australian workers at the study latitude of approximately 1.2 SED (30 J m^-2 effective to the International Commission on Non-Ionizing Radiation Protection). Similar proportions of teachers spent more than 1 h outdoors per day in winter (28.6%) and summer (23.6%) as part of their teaching duties with seasonal differences having little effect on the time of exposure. Personal exposures for teachers peaked during both seasons near school meal break times at 11:00 am and 1:00 pm, respectively.

Antitumor activity of sulforaphane in mice model of skin cancer via blocking sulfatase-2

Although there are many treatment options for skin cancer, the chemotherapeutic agents for skin cancer are linked with many adverse effects as well as the development of multidrug resistance. Sulforaphane is an isothiocyanate, which is found in cruciferous vegetables. Consumption of sulforaphane-rich diet has been linked to inhibition of UV-exposed skin carcinogenesis. Therefore, the goal of this study was to determine the ability of sulforaphane to reduce skin cancer in mice through inhibition of sulfatase-2 enzyme. Epicutaneous application of 7,12-dimethylbenz (a) anthracene was performed on the shaved dorsal skin of mice followed by croton oil. Sulforaphane (9 μmol/mouse/day) was administered to mice orally. Skin was removed from the dorsal area for assessment of sulfatase-2, glypican-3, heparan sulphate proteoglycans (HSPGs), nuclear factor (NF)κB, nuclear factor E2-related factor 2 (Nrf2), tumor necrosis factor (TNF)-α, IL-1β and caspase-3. In addition, skin sections were stained with haematoxylin/eosin, Mallory and cytokeratin immunostaining. We found that, sulforaphane blocked sulfatase-2 activity, leading to significant elevation in HSPGs as well as significant reduction in glypican-3. In addition, sulforaphane significantly activated Nrf2 and reduced both the gene and protein expression of NFκB, TNF-α, IL-1β and caspase-3. In parallel, stained sections obtained from skin cancer mice treated with sulforaphane showed significant reduction in hyperkeratosis, acanthosis and epithelial dysplasia. The collective results indicate that sulforaphane suppresses skin cancer via blocking sulfatase-2 with subsequent elevation in HSPGs and reduction in glypican-3. Moreover, sulforaphane attenuated skin cancer-induced activation of inflammatory and apoptotic pathways.

Skin cancer healthcare impact: A nation-wide assessment of an administrative database

BACKGROUND

Skin cancer is an important health concern, with an increasing incidence worldwide.

OBJECTIVE

To assess the clinical and economic burden of melanoma (MM) and non-melanoma skin cancer (NMSC) at public hospitals in mainland Portugal.

METHODS

We used an administrative database containing a registration of all hospitalizations and ambulatory episodes occurred in Portuguese public hospitals between 2011 and 2015. We assessed all episodes with associated diagnoses of MM or NMSC regarding neoplasm location, metastases occurrence, length of stay, in-hospital mortality and hospital costs.

RESULTS

We assessed 15,913 MM and 72,602 NMSC episodes. 14.3% of MM episodes presented with metastases, compared to 1.9% of NMSC episodes. Patients' median age was lower for MM (66 years) than NMSC (76 years). The trunk was the most common location for MM (32.5%), followed by the lower limbs (26.5%). NMSC presented with higher length of stay than MM (median 5 versus 4 days; p < 0.001), but with lower in-hospital mortality (7.3% versus 11.9%; p < 0.001). MM episodes had higher average hospital costs than NMSC episodes (1197.7 versus 1113.5 €; p < 0.001). Overall, NMSC episodes amounted a total of 80.8 million € in hospital costs versus 19.1 million € for MM episodes.

CONCLUSION

Skin neoplasms have substantial impact on healthcare services. NMSC is an important contributor to this burden. NMSC underreporting should be tackled and it should not be downplayed in skin cancer preventative strategies.