Delayed Treatment and Inadequate Surgical Margins for Invasive Melanoma in Elderly Patients

As melanoma incidence and mortality rise and as populationsage indevelopedcountries suchasFranceand theUnited States, it becomesparamount fordermatologists tousediminishing resources judiciously to optimize melanoma management. Well-established guidelines of care, however, neither stratify nor adjust primarymelanoma treatment according to patient age.1,2 The article by Ciocan et al3 describes several patient and tumor characteristics of invasive melanoma in an elderly Frenchpopulationcomparedwithayounger cohort.Thestudy alsohighlights significant practice gaps in themanagement of melanoma in patients 70 years or older that present a challenge for dermatologists to understand and overcome. Age-relatedandsocioeconomic factorsmaycauseexplainabledelays indiagnosis. Prioritizinggeriatricprimarycareover dermatologic specialty care likely contributed to themore frequentlydiagnosedthicker,ulcerated, higher-grade category T3 or T4 tumors. The increased frequencyof nodular andacral lentiginousmelanomas is potentially explainable by impaired vision, selfsurveillance, and immunity in older patients. Despite these patient and tumor variances, a fundamental tenet of oncologic management protocols is their universal application toappropriatecases.Ciocanetaldescribeaclear deviation fromsuchanapproach in2 specific areas.First, older patients experienced a significant delay in treatment. Second, andmore important, definitive surgical excisionwas often inadequate. Although more elderly patients underwent an appropriate initial diagnostic excisional biopsy, almost 1 in 4 of them received no additional definitive excision when indicated, a rate 3-foldhigher than that inyoungerpatients.Thosewhounderwent additionalwide excisionwere alsodisadvantagedby inadequate surgical margins. The 5-fold increased incidence of lentigomalignamelanomaand a relative preponderance of head and neck tumors likely factored intomore conservative surgery to limit complications. Many prospective randomized clinical trials, however, have defined excisional margins that clearly reducemortality.4 The possibility that elderly patients may not receive this established standard of care represents a significant practice gap. Furthermore, regardless of the specific treatment, subsequent care was delayed beyond 6 weeks in almost a third of elderly patients. Optimal timing of definitivemelanomaexcisionhasnotbeenas rigorously studiedas surgicalmargins and represents a valuable research opportunity. Prolonged delays in treatment,however, clearly constitute anotherpracticegap. This importantstudybyCiocanetal should increaseawareness that agebias can influencedecisions inpotentially harmful ways. We do not know the dialogue exchanged between physician and patient thatmay have colored these decisions. Perhaps recovery from an illness, use of anticoagulation therapy, lack of desire for sentinel lymph node prognostic information, or the need to care for a disabled spouse strongly influenced the timing, prioritization, and/or aggressiveness of primaryoradjuvant treatment.This studyalsoneitherasksnor answers whether these older patients were satisfied with the quality of their care. The true challenge in bridging these specific melanoma managementpracticegaps in theelderlymirrorsamuchgreater challenge in modern medicine: How do we reconcile outcomes research that defines population-based best practices with our duty to provide humanistic, artful care of individual patients in the context of their age, comorbidities, and socioeconomic situation?