Skin Cancer Overview ; The Challenge of Skin Cancer Overview ; The Challenge of Diagnosing Older PatientsDiagnosing Older Patients

Wendy E. Roberts MD

Is this not a challenge?Is this not a challenge?

Skin cancer overviewchallenges

• Skin barrier• Xerosis• Immunosuppression• Purpura• Photodamage

• All may obscure the diagnosis

Skin cancer in the Older patient• NMSCs are the most common malignancies in the Caucasian population,

more than one third of all adult cancers in the US

• 900,000 to 1,200,000 new cases per year,3 up to 18- to 20-fold more than malignant melanoma.4

• The incidence of NMSC has been steadily increasing worldwide at a rate of 3% to 8% per year since 1964,5 with greater increases nearer the equator.6 In Australia,

• The incidences of squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) rose by 133% and 35%, respectively, between 1985 and 2002.7

• Immunosuppressed transplant patients have an even higher incidence of NMSC (eg, after kidney transplantation, 1-year incidence of SCC is 7%, increasing to 70% after 20 years8). Transplant patients have a 10-fold increased risk of BCC and a 40- to 150-fold increased risk of developing SCC

Actinic keratosis  No way to identify the transformers (SCC )

Field Cancerization- multiple AK’s within a body area

Usually on a sun exposed site

Transplant and Immunosuppressed may

Have more aggressive disease.

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• 20% of actinic keratoses will convert to SCC within a 1-year time course

• SCCs resulting from actinic keratoses rarely metastasize, with an actual risk of between 2% and 6%. However, lesions located on the lips, ears, anogenital region are at increased risk of metastasis. There are no unique morphologic characteristics indicative of lesions that are most likely to convert.

• The lifetime chance of conversion of persistent lesions is believed to increase over time, related to reductions in the immune responsiveness associated with chronologic aging.

• Although continued overexposure to UV radiation increases the risk of photocarcinogenesis, treatment with cytotoxic or immunosuppressive agents can accelerate the conversion of AKs to SCCs

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 Bowen’s disease

• 3% Become invasive and 1/3 metastasize

• may be misdiagnosed as eczema or LSC which causes treatment delayys

• Lesions on lower legs which are poorly vasculalrized and heal slowly

• Malignant transformation in the immunosuppressed renal failure and transplant patients

Squamous Cell carcinoma 

• Lesions which present in ulcers or non healing wounds lead to diagnosis delay and often on poorly vascularized area with thin dermis such as the tibia

• Lesions hidden on the scalp or on the helix which carry higher rates of metastases

The Challenge

• Obstacles to receive a FBSE• Access• Transportation• Mobility• Unwillingness to get undressed

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