Watchful Waiting and Tumor Behavior in Patients With Basal Cell Carcinoma

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• The authors followed 89 patients with a total of 280 basal cell carcinomas (BCCs) managed with watchful waiting (WW) for at least 3 months. Only 47% of tumors increased in size during the observation period. The estimated diameter increase in 1 year was 4.46 mm for high-risk BCCs vs 1.06 mm for low-risk BCCs. Following WW, 54 patients underwent treatment for 107 BCCs due to reasons including potential tumor burden, reasons for WW resolved, and re-evaluation of patient factors.

• WW could be an appropriate management option for certain patients, including those with limited life expectancy and asymptomatic low-risk BCC subtypes. Regular follow-up is necessary to detect changes that might impact the treatment plan. Additional prospective studies are warranted.

–  Alex Noble, MD

Written by

 

 

Justin Endo MD, MHPE, FAAD

Dermatologists have an ethical duty to treat patients while avoiding harm. Yet over 100,000 patients had surgery for BCC in their final year of life.1 Might there be a point at which aggressive surveillance and surgical intervention of relatively indolent tumors are inappropriate in certain contexts? Similar to the watchful waiting approach with low-grade prostate cancers, Linos et al argue BCCs might be "overdiagnosed" and "overtreated" at the end of life.1 There are diminishing returns on survival. Treatment is not without risk, especially in those with multimorbidities.1

Discussing watchful waiting might create anxiety for patients, caregivers, and dermatologists. A useful framework and patient educational aids for shared decision–making have been published.2,3 When I sense a frail or advanced-age patient seems hesitant about biopsying or treating suspected low-risk BCC, I ask, "What are your healthcare goals at this time?" and periodically revisit at follow-ups. 

The current study is an important contribution about a challenging topic. Strengths included the prospective design and the majority of patients having histological diagnosis. I was surprised by how many patients eventually opted for treatment during the short follow-up period (median, 9 months). This raises the question of how decisions change over time. Generalizability might be limited to other patient populations and countries. We must be cautious about unintentionally creating the perception that care is being withheld, particularly in historically marginalized populations who are still at risk for BCC.4 We should also guard against ageism (holding certain assumptions and biases about older adults). Consider the whole patient—not simply chronological age.

Further studies are needed about dermatologists' attitudes toward watchful waiting as well as streamlining discussions, particularly at busy practices lacking multidisciplinary teams. It remains to be seen if technology (eg, telemedicine and augmented intelligence) might help.

References

1. Linos E, Schroeder SA, Chren MM. Potential overdiagnosis of basal cell carcinoma in older patients with limited life expectancy. JAMA. 2014;312(10):997-998. https://jamanetwork.com/journals/jama/article-abstract/1902239
2. Linos E, Berger T, Chren MM. Point: Care of potential low-risk basal cell carcinomas (BCCs) at the end of life: The key role of the dermatologist. J Am Acad Dermatol. 2015;73(1):158-61. https://www.jaad.org/article/S0190-9622(15)00124-3/fulltext
3. Junn A, Shukla NR, Morrison L, et al. Development of a patient decision aid for the management of superficial basal cell carcinoma (BCC) in adults with a limited life expectancy. BMC Med Inform Decis Mak. 2020;20(1):81. https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/s12911-020-1081-8
4. Kennedy BR, Mathis CC, Woods AK. African Americans and their distrust of the health care system: healthcare for diverse populations. J Cult Divers. 2007;14(2):56-60. https://www.academia.edu/24521355/African Americans and their distrust of the health care system Healthcare for diverse populations

Abstract 

IMPORTANCE

Few studies have examined watchful waiting (WW) in patients with basal cell carcinoma (BCC), although this approach might be suitable in patients who might not live long enough to benefit from treatment.

OBJECTIVE

To evaluate reasons for WW and to document the natural course of BCC in patients who chose WW and reasons to initiate later treatment.

DESIGN, SETTING, AND PARTICIPANTS

An observational cohort study was performed at a single institution between January 2018 and November 2020 studying patients with 1 or more untreated BCC for 3 months or longer.

EXPOSURES

Watchful waiting was chosen by patients and proxies regardless of this study.

MAIN OUTCOME AND MEASURES

The reasons for WW and treatment were extracted from patient files and were categorized for analyses. Linear mixed models were used to estimate tumor growth and identify covariates associated with tumor growth.

RESULTS

Watchful waiting was chosen for 280 BCCs in 89 patients (47 men [53%] and 42 women [47%]), with a median (interquartile range [IQR]) follow-up of 9 (4-15) months. The median (IQR) age of the included patients was 83 (73-88) years. Patient-related factors or preferences (ie, prioritizations of comorbidities, severe frailty, or limited life expectancy) were reasons to initiate WW in 74 (83%) patients, followed by tumor-related factors (n = 49; 55%). Treatment-related and circumstantial reasons were important for 35% and 46% of the patients, respectively. The minority of tumors increased in size (47%). Tumor growth was associated with BCC subtype (odds ratio, 3.35; 95% CI, 1.47-7.96; P = .005), but not with initial tumor size and location. The estimated tumor diameter increase was 4.46 mm (80% prediction interval, 1.42 to 7.46 mm) in 1 year for BCCs containing at least an infiltrative/micronodular component and 1.06 mm (80% prediction interval, -1.79 to 4.28 mm) for the remaining BCCs (only nodular/superficial component/clinical diagnosis). Most common reasons to initiate treatment were tumor burden or potential tumor burden, resolved reason(s) for WW, and reevaluation of patient-related factors.

CONCLUSIONS AND RELEVANCE

In this cohort study of patients with BCC, WW was an appropriate approach in several patients, especially those with asymptomatic nodular or superficial BCCs and a limited life expectancy. Patients should be followed up regularly to determine whether a WW approach is still suitable and whether patients still prefer WW and to reconsider consequences of treatment and refraining from treatment.

JAMA Dermatology

Evaluation of Watchful Waiting and Tumor Behavior in Patients With Basal Cell Carcinoma: An Observational Cohort Study of 280 Basal Cell Carcinomas in 89 Patients

JAMA Dermatol 2021 Sep 08;[EPub Ahead of Print], MEC van Winden, CRM Hetterschijt, EM Bronkhorst, PCM van de Kerkhof, EMGJ de Jong, SFK Lubeek 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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