<p>Basal cell carcinoma (BCC) is especially common in older adults, who often face unique treatment challenges. Age-related factors such as comorbidities, life expectancy, and access to care can influence clinical decision making. Understanding how BCC presents and progresses in this population, as well as patient treatment goals, is key to providing effective personalized care.</p>

Older patients often present with more advanced, nodular BCCs in areas that are more challenging to perform surgery on (eg, often the head or neck). The biggest challenge in identifying BCC in older adults is getting them into the office for a full-body skin check, particularly when access to health care and/or mobility may be difficult. My message to my colleagues is to ensure that we take the time to thoroughly evaluate every older patient’s skin from head to toe, even in difficult-to-evaluate areas of the body and in those who use a wheelchair.

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Since BCCs are slow growing, some clinicians consider not treating them in older patients. I think that this often misses the point of understanding a patient’s goals. While curative surgery may not be necessary, other treatment options may improve their quality of life. I believe that every treatment option should be presented to patients with BCC, allowing for a collaborative decision-making process. Some treatments may be more or less appropriate, but that needs to be discussed directly with the patient and their caretakers. Treatment goals vary from patient to patient.

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In older patients with locally advanced BCC, the treatment goal may be to obtain a cure or to simply improve their quality of life. Treatment may involve curative surgery, an HHI (ie, sonidegib or vismodegib), immunotherapy (ie, cemiplimab), or image-guided superficial radiation therapy. In an older nonsurgical patient whose locally advanced BCC is causing drainage that prohibits them from sleeping well, you might use an HHI with a modified dosing regimen to dry up the tumor site so that they can sleep better and have an improved quality of life. For a large BCC on someone’s back, you might perform surgery to debulk the tumor so that the patient can lie down on their back in bed and sleep more comfortably. I encourage all my dermatology colleagues to recognize that there are more treatment options than just curative surgery.

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We must determine if the therapy that we are considering for a patient with BCC will be a viable treatment option. For example, if a patient is unable to manage their polypharmacy, an HHI may be difficult to consider. In that respect, one of the most important therapies is a social support system. Older patients may require someone to come with them to appointments, provide help or encouragement during treatment, and provide assistance with daily functioning during recovery from surgery or because they are experiencing fatigue or other side effects from HHI therapy or immunotherapy.