Weekly radiotherapy for basal cell carcinoma in the frail and elderly

The therapeutic dilemma of basal cell carcinoma in older adults: A review of the current literature

Skin cancer is known to be a significant health care threat due to the massively increasing numbers of diagnoses. In 2019, 4 million basal cell carcinoma (BCC) cases were diagnosed globally, making BCC the most frequent of all cancers worldwide in fair skinned populations. Given the increasing life-expectancy for all countries worldwide (by 2050, the world's population of people aged 60 years and older will have doubled), the incidence of BCC is expected to keep increasing in the future. Management of BCCs is challenging, especially among older adults, as mortality due to BCCs is extremely rare, whereas locally destructive growth can cause significant morbidity in certain cases. Therapeutic management in this population is further hampered because of the presence of comorbidities, frailty, and the heterogeneity of these aspects in older patients, leading to treatment dilemmas. A literature review was conducted to identify relevant patient, tumour, and treatment related factors that should be considered in the decision making for BCC treatment in older adults. This narrative review synthesizes all aspects concerning BCC treatment in older adults and aims to make some specific suggestions considering BCC treatment in older adults that can be used in daily practice. We found that nodular BCC was found to be the most common subtype in older adults, most frequently located in the head and neck region. In non-facial BCCs, current literature has shown no significant impact on the quality of life (QoL) in older patients. Besides comorbidity scores, functional status should guide clinicians in treatment decisions. Taking all aspects into account when making treatment decisions is of great importance. When treating superficial BCCs on difficult-to-reach lesions in older adults, a clinician-administered treatment should be suggested because of possible impaired mobility in these patients. Based on current literature, we recommend assessing the comorbidities, the functional status, and frailty in older patients with BCC to evaluate life expectancy. In patients with low-risk BCCs and a limited life expectancy (LLE), an active surveillance or watchful waiting strategy can be suggested.

Non-stereotactic radiotherapy in older cancer patients

Old or very old oncological patients represent a heterogeneous and frail population due to concomitant comorbidities. Whether radiotherapy alone or in combination with novel cancer drugs may provide a clear benefit in this setting of patients is still a matter of debate.

The aim of our review is to analyze the evaluation process and the different therapeutic possibilities in older cancer patients, focusing on the different and most disparate applications of radiotherapy. We reviewed the most recent literature on radiotherapy in older patients providing clinical evidence of treatment related toxicity, tolerance and outcomes using standard fractionated and/or hypofractionated irradiation alone or in combination with chemotherapy, targeted and immunotherapy.

In older cancer patients unfit for systemic therapy or surgery, radiotherapy represents a valid therapeutic approach, both with curative and palliative intents, ensuring excellent patient compliance in terms of local toxicity and adherence to therapy.

[Place of radiotherapy in the treatment of cutaneous carcinomas]

Basal cell carcinomas and cutaneous squamous cell carcinomas are among the most common cancerous tumors in the world. Their treatment is most often based on surgery. Adjuvant radiotherapy may be indicated in case of risk factors for recurrence or as an alternative to surgery if surgery is not feasible due to the patient's advanced age and/or co-morbidities or as an alternative to potentially mutilating surgery. Radiotherapy is also part of the therapeutic arsenal for rarer skin tumors such as Merkel cell carcinoma, cutaneous lymphomas, Kaposi's disease and cutaneous adnexal carcinomas.

Treatment of keratinocyte carcinoma in elderly patients - a review of the current literature

A large percentage of the patients with keratinocyte carcinoma (KC, formerly known as non‐melanoma skin cancer) is of advanced age and often too frail for standard therapies. However, no specific treatment recommendations are given for this population. This review aimed to give an overview of the current literature on the best practice for the treatment of elderly patients with KC. A literature search was performed in MEDLINE, using ‘keratinocyte carcinoma’, ‘elderly’, ‘treatment’ and various synonyms. Case reports, reviews, comments, non‐English literature and studies with a sample size <15 were excluded. After selection, a total of 47 studies were reviewed. Two types of studies were identified, focusing on (I) the effect of age on treatment outcomes and (II) alternative treatment schedules for elderly patients. Studies on surgery, the gold standard, describe larger lesions and defect size in the elderly population. Recurrence rate, complication rate and disease‐specific survival were not affected by age. Depending on the expected morbidity of a suggested (re‐)excision and patient preferences, a conservative watchful waiting policy can be agreed upon as a shared decision. Other common treatment modalities, such as adjuvant radiotherapy, photodynamic therapy and systemic therapy for basal cell carcinoma (BCC), show comparable results in the elderly and younger population. Alternative treatment schedules for elderly patients include primary hypofractionated radiotherapy, which seems effective and well‐tolerated, although research is limited to case series. Additionally, localized and topical treatments seem safe and effective especially for low‐risk tumours. Data are lacking on the efficacy of systemic therapies of metastatic KC in elderly patients. Efficacy of most treatments (with the exception of photodynamic therapy) is not dependent on age. There is need for more research on the efficacy of adjusted treatment modalities, such as hypofractionated radiotherapy and palliative or curative systemic treatment.

Current Role of Radiotherapy in Non-melanoma Skin Cancer

Non-melanoma skin cancer (NMSC) represents the most frequently diagnosed malignancy worldwide, most being cutaneous basal cell and squamous cell carcinoma. The global incidence of NMSC continues to increase as the global population ages. Numerous treatment options are available for NMSC patients, with radiotherapy an efficacious and tissue-preserving non-surgical option. External beam radiotherapy and brachytherapy are modalities with specific indications and advantages in treating NMSC. Where excision is not an option (medically/technically inoperable) or considered less ideal (e.g. cosmetic or functional outcome), radiotherapy offers an excellent alternative. Inoperable elderly and/or co-morbid patients of poor performance status can benefit from short-course hypofractionated radiotherapy, with very acceptable toxicity. Adjuvant radiotherapy in patients with unfavourable pathology can decrease the risk of local and regional recurrence and associated morbidity and mortality. Radiotherapy has advantages and disadvantages and it is important for clinicians to understand these. Managing patients with NMSC is carried out by clinicians from multiple disciplines but it is imperative that they are all aware of the role of radiotherapy in their patients in various clinical settings. Here we aim to discuss the role and indications for recommending radiotherapy in patients with NMSC.

Efficacy of hypofractionated radiotherapy in patients with non-melanoma skin cancer: Results of a systematic review

Radiation oncologists are increasingly tasked with the management of elderly patients with non-melanoma skin cancer, unsuitable for surgical intervention due to inoperable lesions and/or poor performance status. In this cohort, hypofractionated radiotherapy, delivered either daily, alternative daily or once weekly is highly effective. A systematic literature search was conducted of PUBMED, MEDLINE and EMBASE databases using the algorithm ('radiotherapy' OR 'radiation therapy' OR 'brachytherapy') AND ('hypofraction' OR 'hypofractionated' OR 'hypofractionation') AND ('skin neoplasms' OR 'carcinoma' OR 'malignancy') AND ('skin' OR 'epidermis' OR 'epidermal' OR 'cutaneous'). Forty relevant publications (1983-2017) encompassing 12,337 irradiated lesions were retrieved. Studies documented a mean age of 71.73 years and male predilection (54.5%). Both external beam radiotherapy and brachytherapy were utilized. Tumour subtype was squamous cell carcinoma (23.5%), basal cell carcinoma (75.2%) or others (1.3%). Irradiated lesions were primary (or denovo) (92.6%), located on the head and neck (95.7%) and received definitive therapy (96.5%). Analysis demonstrated a mean weighted total radiotherapy dose (38.15 Gy), dose per fraction (7.95 Gy) and treatments per week (2.98). Despite significant heterogeneity in the study population, the radiotherapy delivered and follow-up, local recurrence rate (crude or Kaplan-Meier analysis) did not exceed 7.9% in all but three of the 36 publications providing these data. Twenty-nine publications documented local control exceeding 90%. There is a body of evidence documenting the efficacy of hypofractionated radiotherapy as an option that confers no obvious disadvantage in local control when compared to traditional more protracted radiotherapy schedules.

Malignant skin tumors: Kids are not just little people

Skin tumors are a clinically heterogeneous group of dermatologic conditions that affect both children and adults. Although similar types of skin tumors can affect both children and adults, the epidemiology, pathogenesis, and treatment of these skin neoplasms can vary drastically in children compared with adults. Despite the clear need for literature elucidating the differences of skin tumors in children compared with adults, there is a serious dearth of scientific contributions addressing this area. This contribution highlights the types of differences that can occur between adults and children with skin neoplasms, as well as the special considerations that need to be recognized when managing skin tumors in children by providing a comparative analysis of basal cell carcinoma, squamous cell carcinoma, and Kaposi sarcoma occurring in adults with these same tumors occurring in children. Specifically, we examine the aforementioned tumors with a focus on (1) epidemiology, (2) etiology, (3) clinical presentation, (4) workup, and (5) treatment.

Orthovoltage radiotherapy for nonmelanoma skin cancer (NMSC): Comparison between 2 different schedules

BACKGROUND

Radiotherapy is an established treatment for some types of patients with nonmelanoma skin cancer. A hypofractionated schedule has been proposed as a valuable option for elderly disabled patients to minimize the number of hospital visits.

OBJECTIVE

We sought to compare a weekly hypofractionated orthovoltage radiotherapy regimen with a standard daily one for the treatment of nonmelanoma skin cancer.

METHODS

A retrospective cohort study was performed on 436 tumors. Overall survival, disease-free survival, and cosmetic outcome were measured. Life-table analysis, Kaplan-Meier survival analysis, and multivariate Cox regression model were performed.

RESULTS

The hypofractionated regimen was not associated with increased recurrence rates and mortality, or with a poorer cosmetic outcome, when compared with the daily schedule.

LIMITATIONS

Absence of complete information about acute treatment toxicity and a shorter follow-up time for patients receiving the weekly schedule are limitations of this study.

CONCLUSIONS

A weekly hypofractionated regimen of orthovoltage radiotherapy seems to be the most appropriate approach in elderly disabled patients with nonmelanoma skin cancers.