Background: Advanced, neglected skin cancers are frequently seen in the elderly population. Denial is the most frequent reason for delay in the presentation for diagnosis and treatment of non-melanoma skin cancers, accounting for 70% of cases.1 Self-neglecting behaviours associated with dementia, alcoholism, depression and other mental illnesses, physical impairments and health illiteracy may also underlie advanced presentation of skin cancers in older adults.2,3
Case: An 80-year-old nursing home resident with a history of moderate dementia presented for an influenza vaccination when he was noted to have a large 10 cm fungating lesion with rolled edges on his right chest. Histopathological examination from an incisional biopsy showed an ulcerated, moderately differentiated squamous cell carcinoma (SCC). The SCC was classified as high risk for metastasis given the depth of its invasion to subcutaneous fat and diameter of >2 cm.
Discussion: Reasons for denial include factors relating to patients psychological unwillingness to accept the severity of their condition and the need for care.1 In some cases, denial may be indicative of a lack of recognition or understanding of the issue.1 Other factors that can lead to a delay in patients seeking medical advice include male sex, living alone, social and geographical isolation, multiple medical comorbidities, low socioeconomic status, inadequate hygiene, incorrect initial diagnosis and fear of treatment.46
Implications for practice: Knowledge of risk factors including self-neglecting behaviours associated with advanced presentation of skin cancers in the elderly population may enable prompter diagnosis and treatment of patients before more significant morbidity occurs. It is important that general practitioners are familiar with the consequences and management of advanced skin cancers in geriatric patients. The ceiling of care discussion with elderly patients and their families needs to carefully consider skin cancers such as this, which can lead to significant morbidity and untimely death. References 1. Alam M, Goldberg LH, Silapunt S, et al. Delayed treatment and continued growth of nonmelanoma skin cancer. J Am Acad Dermatol. 2011; 64(5): 839-48. doi: 10.1016/j.jaad.2010.06.028 1. Pavlou MP, Lachs MS. Could self-neglect in older adults be a geriatric syndrome? J Am Geriatr Soc. 2006; 54(5): 831-42. doi: 10.1111/j.1532-5415.2006.00661.x 2. Pavlou MP, Lachs MS. Self-neglect in older adults: a primer for clinicians. J Gen Intern Med. 2008; 23(11): 1841-46. doi: 10.1007/s11606-008-0717-7 3. Varga E, Korom I, Rasko Z, et al. Neglected basal cell carcinomas in the 21st century. J Skin Cancer. 2011; 392151. doi: 10.1155/2011/392151