The Importance of Full-Body Skin Examination in the Geriatric Population
The burden of melanoma and nonmelanoma skin cancer (NMSC) in the elderly population is well known, with basal cell carcinoma (BCC) being the most common malignancy in humans. The mean age for BCC is 65 in women and 67 in men.1 The rate of BCC increased by 96% in women and 145% in men between 1986 to 2006.1 While rarely fatal, undetected BCC can present at more advanced stages, and it is therefore important for thorough examination to detect and treat this malignancy at an early stage.
Likewise, the incidence of squamous cell carcinoma (SCC) increases drastically after age 60.2 It is the second most common form of skin cancer in humans, representing approximately 20% of NMSC with 1.5% of cases resulting in mortality.2 The incidence of SCC has been increasing over time.3
Cutaneous melanoma can present in all age ranges; incidence continues to increase in both men and women in the United States. Mortality from melanoma increases especially in the elderly population. These individuals have a higher lifetime exposure to ultraviolet radiation, resulting in growing incidence of skin cancer. In addition, because of other comorbid conditions (eg, dementia), many of these cancers go undetected until at an advanced stage of disease, which results in higher complication rates.4 It is important to educate the elderly population on proper sunscreen use, avoidance of excessive exposure to sunlight, and regular skin examinations to detect the lesions at an early stage.4
The importance of full-body skin examination in detecting skin cancer is demonstrated by 2 cases of advanced melanoma in patients who did not recognize the presence of cancer until at an advanced stage.
Case 1:
An 86-year-old woman with a history of severe dementia presented at the emergency department with a complaint of epistaxis, but was subsequently noted to have a large mass on the left lower extremity. The patient noted that this lesion had been present for some time and was occasionally bothersome due to persistent oozing and its growing size. Because the tumor was in an area that was readily concealed by clothing, it went unnoticed by family members.
Physical examination. The tumor was a 4 cm x 6 cm malodorous, ulcerated, fungating, exophytic mass on the left lower leg (Figure 1).
Laboratory tests. Biopsy revealed an ulcerated nodular malignant melanoma with at least a Clark level IV and invading to a depth of at least 15.0 mm.
Treatment. The patient was referred to general surgery for wide local excision with sentinel lymph node biopsy. However, at the dermatology clinic follow-up 4 months later, it was discovered that the patient had missed multiple appointments with surgery and there was a new mushroom-like growth with pink and red-purple nodules on the anterior shin. The patient and her family expressed doubt that the surgery was truly necessary since there was evidence of local metastasis, and deferred treatment at that point in time.
Case 2:
A 90-year-old white female presented with a tender mass that bled occasionally and had been growing on her right shin for a number of years. The patient denied any other new or changing lesions and felt well otherwise.
Physical examination. A 5 cm x 6 cm ulcerated exophytic mass that was nonmobile, and firmly adherent to underlying soft tissue, with surrounding erythema was noted (Figure 2). There was no lymphadenopathy in the popliteal fossa.
Laboratory tests. The biopsy revealed ulcerated malignant melanoma with at least a Clark level IV, invading to a depth of at least 2.0 mm with involved margins.
Treatment. The patient was referred to general surgery for wide local excision with 2 cm margins but deferred sentinel lymph node biopsy.
Discussion
Early detection of skin cancer can decrease morbidity and mortality in the elderly population. A complete skin examination should be a primary component of the physical exam. In a recent study conducted over a period of 9 months, 483 patients underwent complete skin examination with detection of 2 cases of nodular malignant melanoma, 1 melanoma in-situ, 16 cases of BCC, 33 patients with actinic keratosis or SCC in situ, and 73 other benign conditions requiring additional treatment. These findings may have gone unnoticed in the absence of a full-body skin examination.5 In another study evaluating 126 cases of melanoma, 56.3% of these cancers were detected in patients presenting with other concerns.6
Full-body skin examinations have the potential to reduce the thickness of melanoma diagnosed in patients. A study from Australia demonstrated that in the 3 years prior to diagnosis of skin cancer, full-body examination increased the diagnosis of thin melanoma and reduced the risk of being diagnosed with melanoma with a thickness greater than 0.75 mm. This is important because morbidity and mortality from melanoma increase with greater thickness of the tumor.7 In another study conducted in Germany, over 360,000 patients (age ≥20) underwent screening with full-body examination; there were 47% and 49% reductions in melanoma mortality in men and women, respectively, during this period.8
When considering the aforementioned case studies, early detection could have prevented the spread of the disease and improved their prognoses.
Population screening by full-body skin examination in the aging population can help to detect cancer at earlier stages, thus reducing morbidity and mortality in the elderly. This is particularly important in those patients with comorbid conditions (eg, dementia) that may prevent them from noticing such lesions until they are at an advanced stage. A routine full-body skin examination takes approximately 5 minutes without tools and just over 8 minutes with the use of dermoscopy.9 When considering the improved prognosis in patients with early detection of skin cancer, this examination is reasonable.
A full-skin examination should be performed by a patient’s primary care physician or dermatologist, particularly when treating elderly patients and individuals who have a prior diagnosis of skin cancer or a comorbid condition that could affect their ability to reasonably recognize growing lesions.
Gregory Walker, MD, MBA, is a dermatology resident at Baylor Scott and White in Temple, TX.
Ashley Sturgeon, MD, is an assistant professor in the department of dermatology at Texas Tech University Health Sciences Center in Lubbock, TX.
Ikue Shimizu, MD, is an assistant professor in the department of dermatology at Texas Tech University Health Sciences Center in Lubbock, TX.
Cloyce Stetson, MD, is the chairman of the department of dermatology at Texas Tech University Health Sciences Center in Lubbock, TX.
References:
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