Patient-reported health not associated with keratinocyte carcinoma treatment choice in a Medicare cohort of older adults

TY - JOUR

T1 - Patient-reported health not associated with keratinocyte carcinoma treatment choice in a Medicare cohort of older adults

AU - Wehner, M. R.

AU - Kwong, P. L.

AU - Kurichi, J. E.

AU - Xie, D.

AU - Hennessy, S.

AU - Margolis, D. J.

N1 - Funding Information: M.R. Wehner mwehner@mdanderson.org P.L. Kwong J.E. Kurichi D. Xie S. Hennessy D.J. Margolis Department of Dermatology Perelman School of Medicine University of Pennsylvania Philadelphia PA U.S.A Biostatistics, Epidemiology and Informatics Perelman School of Medicine University of Pennsylvania Philadelphia PA, U.S.A Department of Health Services Research MD Anderson Cancer Center Houston TX 77030 U.S.A Dermatology MD Anderson Cancer Center Houston TX 77030, U.S.A National Institutes of Health R01HD074756 National Institute of Arthritis and Musculoskeletal and Skin Diseases T32 AR7465 Funding sources: This research was supported by the National Institutes of Health [R01HD074756, Principal Investigator (PI): S.H.]. M.R.W. is supported by NIAMS/NIH Dermatology Research Training grant T32 AR7465 [Multiple PIs (MPIs): D.J.M. and Elizabeth A. Grice]. Conflicts of interest: none declared. Common treatments include destruction (typically electrodessication and curettage), surgical excision and Mohs micrographic surgery (MMS), all of which can offer cure rates > 90% (highest for MMS, followed by excision, then destruction). These treatments differ: longer procedure times and more follow‐up for MMS and excision, although healing times can be shorter and cosmesis better. In the U.S.A., MMS is approximately 70% more expensive than excision, which is approximately 160% more expensive than destruction. Two recent studies report KC treatment does not differ by age or life expectancy. However, these studies focused on MMS, indicated for higher‐risk KCs, for which excisions or destructions might not be appropriate. Additionally, prior studies did not assess patients’ own health perceptions, which might be important. We hypothesized that patients who perceive their health to be worse might be more likely to choose a faster treatment with slightly lower cure rate and fewer postoperative visits (destruction rather than excision). Dear Editor , Keratinocyte carcinomas [KCs; basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)], are common in older adults, with 2·1 million yearly in U.S. Medicare patients. Medicare is federal insurance for people 65 years of age and older, and some younger patients with chronic conditions. We included participants age ≥ 65 years from 2001 to 2009 with at least one KC treatment. We excluded participants with HIV, organ transplant or non‐Medicare insurance coverage. We collected information including functional status [activities of daily living (ADLs), in stages, from 0 (no difficulty in any ADL) to IV (difficulty in all ADLs)]. Participants also rated their health as excellent, very good, good, fair or poor. Finally, we calculated a Lee Mortality Index value, a validated prognostic index which uses age, comorbidities and function, and is strongly linked to survival. We compared scores ≤ 10 (4‐year mortality ≤ 28%) to > 10. Our outcome was KC treatment: destruction vs. excision. These were defined by CPT We used the U.S. Medicare Current Beneficiary Survey, a nationally representative sample of Medicare patients with insurance claims data and survey data from in‐person interviews. ® (Current Procedural Terminology) codes for destruction (17260–17286) or excision (11600–11606, 11620–11626, 11640–11646, 26117, 11750) plus an ICD‐9 (International Classification of Diseases, Ninth revision) code for KC (232.x or 173.x) within the preceding 90 days. Multivariate logistic regression was performed, accounting for survey weighting and clustering by patient (robust sandwich estimators). We fitted two models: (i) including age, sex, comorbidities (nonskin cancer, diabetes, lung disease, stroke, Alzheimer's/dementia and heart disease); ADL stages (0–IV); patient‐reported health (grouped into excellent, very good, good or fair, poor); race (white, nonwhite); history of skin cancer, KC type (SCC/BCC, SCC in situ ), KC location (torso and extremities, head and neck, unknown); and (ii) including Lee Mortality Index value, race, history of skin cancer, KC type and KC location. We used SAS 9·4 (SAS; Cary, NC, U.S.A.). This study was approved by the University of Pennsylvania Institutional Review Board and funded by the National Institutes of Health. ). In the first multivariate model, we found that compared with BCC/SCC, SCCs There were 3169 treated KCs that met the inclusion criteria in 1546 participants (Table  in situ were more likely to receive destruction [odds ratio (OR) 2·66, 95% confidence interval (CI) 1·85–3·81]. There were no statistically significant associations for age, sex, history of skin cancer, patient‐reported health, comorbidities, ADL stages or KC location. In the second multivariate model, a Lee Mortality Index value > 10 was not statistically significantly associated with destruction vs. excision (OR 0·83, 95% CI 0·61–1·12), although SCC in situ was OR 2·66, (95% CI 1·87–3·78). There were no statistically significant associations for history of skin cancer, KC type and KC location.

PY - 2020/4/1

Y1 - 2020/4/1

UR - http://www.scopus.com/inward/record.url?scp=85075742269&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85075742269&partnerID=8YFLogxK

U2 - 10.1111/bjd.18543

DO - 10.1111/bjd.18543

M3 - Letter

C2 - 31539166

AN - SCOPUS:85075742269

SN - 0007-0963

VL - 182

SP - 1059

EP - 1061

JO - British Journal of Dermatology

JF - British Journal of Dermatology

IS - 4

ER -