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Age may be a factor in melanoma treatment quality

By Kathryn Doyle

NEW YORK (Reuters Health) - People over age 70 diagnosed with melanoma may wait longer to have the malignant spot removed and receive less comprehensive care and monitoring than younger patients, a French study suggests.

"Age-related variations are observed at every step of melanoma management," lead author Dr. Dragos Ciocan of the Unité d'Aide Méthodologique, Hôpital Robert Debré, Reims, France, and his coauthors write in JAMA Dermatology.

Previous studies have found that older people are less likely to survive melanoma than younger adults, even when their tumor stage at diagnosis is the same.

In the new study, researchers set out to investigate whether care and management of melanoma after diagnosis differs depending on a patient's age.

Ciocan and his team used questionnaire responses from doctors and data from cancer registries in France to examine 1,621 cases of early-stage melanomas. More than two thirds of the cancers occurred in patients younger than 70.

Twenty-two percent of younger patients waited more than six weeks after diagnosis to have the melanoma removed, compared to 32 percent of the older patients.

There are no standards for a maximum length of time between diagnosis and removal, so waiting longer than six weeks is not necessarily dangerous, but it's probably not a good idea, said Dr. John G. Albertini, a dermatologist at The Skin Surgery Center in Winston-Salem, North Carolina, who was not involved in the study.

For 17 percent of older patients and 5 percent of younger patients, the actual amount of skin removed by doctors, surgeons or dermatologists was insufficient according to 2004 French surgical guidelines - which require between one and three centimeters of extra margin depending on the thickness of the tumor.

For the thickest and most dangerous melanomas, doctors biopsied a lymph node to check whether the cancer was spreading to other parts of the body in 23 percent of older patients and 41 percent of younger patients.

A general practitioner diagnosed 44 percent of older patients and 34 percent of younger patients, whereas only 4 percent of older patients were diagnosed at regular skin cancer screenings compared to 15 percent of younger patients.

The age-related differences in treatment are probably similar in the U.S., where skin screening is generally not a high priority for older patients, especially those with multiple other complex or chronic health conditions like diabetes, heart disease or emphysema, according to Albertini.

"I think a lot of it comes down to prioritization of care, which likely leads to delays in (melanoma) diagnosis and possibly treatment," said Albertini, who wrote a commentary accompanying the study.

Once diagnosed, older people might delay or decline further treatment in favor of dealing with other medical issues, Albertini said.

The study did not include information about the patients' skin type, family history of melanoma or personal history of other skin conditions, all of which play a significant role in how doctors and patients decide to proceed with treatment, the study authors point out.

Melanoma is usually diagnosed after the suspicious mole has been removed and biopsied. Often, the surgeon does not remove much extra skin at the margins in that first surgery; for a benign mole removal, the smaller the scar, the better, Albertini said.

When the pathology report indicates that the spot was malignant, the doctor may need to go back and remove more skin around the margins to comply with standards, but some doctors or patients may not go through with this final step since the tumor looks like it is gone and the patient may have other medical priorities, he told Reuters Health.

"In contrast, for young people, this ‘cancer' diagnosis becomes their primary medical issue and certainly becomes a much higher priority to them and their doctor," Albertini said by email.

Skin cancer is the most common cancer in the U.S., according to the Centers for Disease Control and Prevention, and melanoma is its most dangerous form. In 2009, some 61,000 Americans were diagnosed with melanoma and 9,100 died from the disease.

Though primary care doctors have a lot to juggle in caring for older patients, they should try to make time for skin cancer screenings at regular visits and refer all patients to dermatologists when necessary, Albertini said.

SOURCE: http://bit.ly/12kmRIG JAMA Dermatology, online August 14, 2013.

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