Melanoma in older patients: declining gap in survival between younger and older patients with melanoma

Abstract

Background: Older people have the highest incidence of melanoma and the population in most Western countries is ageing. We evaluated how the gap in incidence and survival between younger and older patients has developed during the past decades. Material and methods: All patients diagnosed with cutaneous melanoma between 1989 and 2015 (n ¼ 84,827) were identified from the Netherlands Cancer Registry. Elderly were defined as aged !70 years. Differences in patient and tumor characteristics were described, age-specific incidence rates were calculated, and relative survival (RS) and multivariable analyses estimating the Relative Excess Rate of dying (RER) were conducted Results: In older men, the melanoma age-standardized incidence increased from 18 to 103/100,000 person-years (py) between 1989 and 2015 and in older women from 23 to 70/100,000 py. In younger men and women, it increased from 8 to 21 and from 13 to 28/100,000 py, respectively. Median Breslow thickness declined from 1.8 to 1.1 mm and from 1.6 to 1.1 mm in older men and women (2003 versus 2015), and from 1.1 to 0.9 mm and 0.9 to 0.8 mm in younger men and women. In older men, 5-year RS increased from 67% (95% CI: 63%-72%) in 1989-1997 to 85% (95% CI: 83%-87%) in 2007-2015 and in older women from 81% (95% CI: 78%-85%) to 89% (95% CI: 87%-91%). In younger men and women, RS increased from 82% (95% CI: 81%-83%) to 90% (95% CI: 90%-91%) and from 92% (95% CI: 92%-93%) to 96% (95% CI: 95%-96%). After case-mix correction , older men and women no longer showed an improved survival over time (RER 2010(RER -2015(RER versus 2003(RER -2009 0.97; 95% CI: 0.81-1.16 and 0.95; 95% CI: 0.79-1.16). Whereas in younger men and women survival remained improved (RER 0.75; 95% CI: 0.67-0.83 and 0.77; 95%CI: 0.67-0.89). Conclusion:The gap in melanoma incidence between younger and older people is increasing due to a strong increase in incidence in older adults. Disparities in survival are declining, related to a narrowing gap in Breslow thickness.

Outcomes for systemic therapy in older patients with metastatic melanoma: Results from the Dutch Melanoma Treatment Registry

“…Higher Breslow thickness is associated with poorer prognosis. Thicker melanoma in older patients was also seen in recent research [33], where in time, a decrease in Breslow thickness melanomas in older patients was observed, suggesting increased awareness of the signs and symptoms of melanoma. We also observed a lower percentage of brain metastases reported in the group of older patients, but this is probably more a matter of underreporting due to less imaging performed in patients aged ≥75 years.…”

Is cancer biology different in older patients?

“…139,140 Therefore, it is not surprising that older patients preferentially develop primary melanoma in habitually sun-exposed areas, such as the head and neck, face, and dorsal-distal side of the extremities. 126,128,131 Notably, several studies indicate that melanoma located on the scalp is associated with a higher incidence of brain metastases 141,142 and represents an independent predictor for worse melanoma-specific survival. 143,144 When comparing the distribution of the histopathological subtypes in different age groups, it is notable that nodular melanoma, an aggressive subtype with a disproportionally high case-fatality rate compared with the incidence rate, 145 is more frequent in the older patient.…”

“…In contrast, superficial spreading melanoma, the most common subtype in young patients, is less frequent at an older age. 126,128,131 Lentigo maligna melanoma, a lentigo maligna that invades the dermis, can be considered the classic subtype associated with chronic sun-damage and is, unsurprisingly, more frequent at an older age. 126,128 Age-related differences in molecular markers BRAF mutation is a molecular hallmark in approximately 50% of primary melanomas.…”

Validation of CP‐GEP (Merlin Assay) for predicting sentinel lymph node metastasis in primary cutaneous melanoma patients: A U.S. cohort study

“…12 Findings are also similar to the discovery cohort, which reported an overall SLNB RR of 42% at an NPV of 96%. 11 Since older patients have an up to four times higher incidence of melanoma with higher risks of complications and comorbidities, 5,8,10,18 we conducted a subgroup analysis of patients 65 years or older. SLNB positivity is lower in the elderly 5,8 as is reflected in our cohort, where the SLNB positivity rate decreased from 21% for the entire cohort to 16.9% in patients 65 years or older.…”

“…[5][6][7] In elderly patients, referral for SLNB surgery must be carefully weighed against their higher risk for surgery-related complications and comorbidities. 5,[8][9][10] Also, while the incidence of melanoma is highest among the elderly, SLNB positivity rates decrease with age, making the elderly a patient population for which decision-making for SLNB can be challenging. 5,8 A tool that can deselect elderly patients for SLNB is beneficial to patients and physicians.…”