DS15 Metastatic cutaneous squamous cell carcinoma: how best to develop a skin cancer service for future populations

Abstract

The incidence of cutaneous squamous cell carcinoma (cSCC) is increasing in the White population. Despite a favourable prognosis in the majority, it remains a cause of morbidity and mortality, especially in immunosuppressed and elderly individuals. Large cSCCs can be challenging for surgical clearance, recurrence and metastatic disease, despite guidelines for the management and staging of cSCC. We sought to identify high-risk features of those who develop metastatic disease. Our centre typically manages 300 cSCCs annually, but only cSCCs discussed at our two multidisciplinary team (MDT) meetings (head and neck and skin cancer) at our level 4 hospital over a 3-year period (2019–2021) were included in a retrospective observational study. A total of 124 patients with high-risk cSCC (due to patient or tumour factors) were included. Male sex predominated. Sixteen cases had metastatic disease. Median age at diagnosis was 80 years in the total MDT group and 86.5 years in the metastasis group. Of 16 patients with metastases, eight had complete primary excisions. Five cases had incomplete primary excision (peripheral or deep margins involved), and three cases had a narrow margin of < 1 mm. Primary tumour size was similar in both the MDT and metastasis groups (median size 17 vs. 20 mm). Head and neck sites predominated in both (88%). In the metastatic group, one had chronic lymphocytic leukaemia, but no other patients with immunosuppression were identified, and the majority (81%) suffered with multimorbidity (≥ 2 chronic illnesses). Nine patients with metastatic cSCC received radiotherapy, two systemic chemotherapies, five neck dissections and one immunotherapy. Most patients presenting with metastatic cSCC at our centre were > 85 years old, a group sometimes known as ‘the oldest old’, and many had multimorbidity. This, coupled with tumour location, poses challenges for healthcare professionals in managing the initial cSCC aggressively and implementing a reasonable follow-up and surveillance schedule. In comparing both groups, advanced age was the predominant difference, with twice as many aged > 85 years in the metastasis group vs. the MDT group. Immunosenescence is a process of immune dysfunction that occurs with age and includes remodelling of lymphoid organs, leading to changes in the immune function of the elderly and relates to the development of malignant tumours. It is estimated that 5 million people in the UK will be in this age group by 2050 (www.ageuk.org.uk/globalassets/age-uk/documents/reports-and-publications/reports-and-briefings/health–wellbeing/rb_feb13_understanding_the_oldest_old_improving_later_life.pdf). There is a need to continue to consider this dynamic group (those aged > 85 years) and those with multimorbidity when strategies for the projected management of cSCC are being considered.