Table IV.
Overview of literature on comorbidity
| Study | Type | Participants/age | n | Treatment | Comorbidity score system | Outcome | Limitations |
|---|---|---|---|---|---|---|---|
| Connoly et al. (25) 2017 | Systematic review | Patients with KC | 22 studies | n/a | CCI, ASA, ACE-27 | - The most commonly used comorbidity score was the CCI, followed by the ACE-27 and the ASA score - The ACE-27 seems to be superior to the other scoring systems, as it analyses the most conditions and allows for comorbidity grading |
The included studies were small and heterogeneous |
| Dhiwakar et al. (26) 2007 | Retrospective study | Patients with KC of the head and neck ≥80 years | 152 patients (208 NMSC) Compared to 311 patients (430 NMSC) aged <80 years |
Surgery | CCI, ASA | - CCI and ASA scores were higher in elderly patients - Lesion size at presentation was larger in elderly people (required also larger defect) - Disease-free survival and wound complication rate were comparable in the younger and elderly patients |
- Non-surgical options were not included - Retrospective character |
| Reinau et al. (27) 2014 | Retrospective case control study | Patients with BCC, mean age 69.5 years | 57,123 patients | n/a | n/a | Inflammatory bowel disease, rheumatoid arthritis, extracutaneous malignancies, solid organ transplantation, alcohol consumption and various skin disorders were significantly more often observed in patients with BCC compared with controls | n/a |
| Tseng et al. (28) 2016 | Retrospective cohort study | Patients with DM, compared with non-DM mean age 57.41 years | 41,898 patients with DM and non-DM | n/a | DM and non-DM | -The risk of developing skin cancer was significantly higher in older patients with DM, compared with non-DM. - Males and having chronic obstructive pulmonary disease were also significant risk factors for KC in older adults with DM |
Several information facts were not available, such as body mass index, details of smoking, alcohol consumption, exposure to ultraviolet etc. |
| Chossat et al. (29) 2018 | Retrospective study | Patients with BCC >75 years mean age 81.75 years |
158 patients | Surgically (reconstructive and cosmetic plastic surgery) | n/a | Statistical significant risk factors for major postoperative complications were: Age >85 years, ≥1 comorbidities, long-term use of anticoagulant treatment, conventional hospitalization and the use of general anaesthesia |
The retrospective character of the study |
| Chen et al. (30) 2007 | Prospective cohort study | Patients with KC | 633 patients | ED&C, excision, or MMS | CCI | Less comorbidity (measured by CCI) and better mental health predicted better QOL outcomes | Only patients who responded to the pretreatment questionnaire were included |
| Basu et al. (31) 2019 | Retrospective study | Patients with KC | 927 biopsied KC | No treatment, Cryotherapy, ED&C MMS, excision, topical therapy | n/a | - Patients with ≥4 comorbidities and elderly patients (≥85 years) had significant higher chances of no treatment - No treatment was most likely in patients with impairment in activities of daily living, neurocognitive impairment and hemiplegia |
- The single centre retrospective design - Exclusion of non-biopsied cancers - Potential selection bias; i.e. influences by distance from the hospital and insurance status |
| Bouhassira et al. (32) 2016 | Retrospective study | Patients aged >75 years with BCC, SCC and melanoma, mean age 84.7 years | 241 patients | Surgery | n/a | - Complication rate was 20% - No relation between the number of comorbidities and complication was found - Male gender, histological type (SCC, melanoma) and positive surgical margins were independent predictors for complication after surgery |
Lack of statistical power of the study |
| Arguello-Guerra et al. (33) 2018 | Retrospective study | Patients undergoing surgery for skin cancer | 655 patients | Surgery | n/a | - Complication rate was 4.2% - Dermatological surgery was found to be safe in patients with multiple comorbidities, without discontinuing antithrombotic therapy or antibiotic prophylaxis |
- The retrospective single centre study design - The number of cigarettes consumption before surgery and the size of tumour and surgical defect were not available |
| Lubeek et al. (34) 2017 | Retrospective study | Patients with KC, median age 71 years | 401 patients | Conventional excision, PDT, imiquimod, MMS, radiotherapy, other | CCI | Guideline-adherence/management was not influenced by comorbidity or high age | The single centre retrospective design; population and management differences can occur between different hospitals and countries, non-reporting bias might occurred |
| Linos et al. (8) 2016 | Cross-sectional study | Patients with KC, aged ≥65 years, mean age 79 years | 2,702 patients, 9653 KC | MMS, simple excision or electrodessication and curettage | CCI | Comorbidity status, advanced age, functional status and life expectancy did not influence the choice of treatment | - KC treated with topical therapies, radiotherapy and untreated KC were not included - Information about patient preferences was not available |
KC: keratinocyte carcinoma; n/a: not applicable; CCI: Charlson Comorbidity Index; ASA: American Society of Anesthesiologists risk classification system; ACE-27: Adult Comorbidity Evaluation-27; DM: diabetes mellitus; MMS: Mohs micrographic surgery; ED&C: electrodessication and curettage; QOL: quality of life; SCC: squamous cell carcinoma; PDT: photodynamic therapy.