Potential Overdiagnosis of Basal Cell Carcinoma in Older PatientsWith Limited Life Expectancy

patients are diagnosed with basal cell carci-noma (BCC) in the United States each year than all other cancers combined—more than 2.5 million BCCs compared with 1.7 million other cancers.1-3 Most of these BCCs occur in people aged 65 years and older, and each year, more than 100 000 BCCs are treated in persons who ultimately die within 1 year. Procedures to remove skin cancers have doubled in the last 15 years, and the use of Mohs surgery, histologically guided serial excision, increased by 400 % between 1995 and 2009.4 Many clinicians have suggested that this is an epidemic of skin cancer1 attributed to exces-sive sun exposure, a thinning ozone layer, and indoor tanning. These numbers will likely increase further; as the number of older adults doubles between 2010 and 2030, overall cancer incidence is projected to increase 45%.5 These enormous numbers notwithstanding, BCCs grow slowly, and treated BCCs seldom metastasize and are rarely life threatening.2 In fact, even as the number of diagnosed BCCs has more than doubled in the last 20 years, deaths from this specific cancer are very low. Nonmelanoma skin cancer mortality is esti-mated at less than 1 in 1000 cases, but these deaths are overwhelmingly from squamous cell carcinoma, not BCC.3 Patients who are diagnosed with BCC dur-ing their last year of life will almost certainly die of causes unrelated to these lesions. In this Viewpoint, we suggest a new approach for the care of asymptom-atic BCCs in patients with limited life expectancy— especially those in the last year of life. Symptomatic vs Screening-Detected BCCs Some BCCs develop with symptoms that are bother-sometopatients.As these skin lesionsenlarge, theycan ulcerate, threatenvital structures suchaseyelidsorears, andcausephysical symptoms including itching, pain, or bleeding in approximately 12%ofpatients.Whenexpe-riencing irritating symptoms or visible tumors, patients oftensee theirphysician. For thesepatients,dermatolo-gists are invaluable forprovidingaccuratediagnosis and treatmentof thesetumors.ManyBCCs,however,arenot noticed by patients, but instead are detected by clini-cians during screening examinations.Whether orwhen these cancers would ultimately cause symptoms if left untreated is not known