Malignant melanoma in elderly patients: biological, surgical and medical issues

Abstract

Malignant melanoma is an aggressive tumor with a poor prognosis for patients with advanced disease. Over the last decades, its incidence and mortality has increased in elderly population, impacting significantly on healthcare costs, considering the increase in average age of the world population. Older age is recognized as an independent poor prognostic factor for melanoma, but the scientific community now is wondering if elderly melanoma patients have worse outcome because they are not receiving the same treatment as their younger counterparts. This article summarizes current data on elderly melanoma prevention and early detection and its subsequent management, underling the differences observed between older and younger patients. It also describes age-associated alterations in immunity and how these may impact on anti-melanoma response.

Keywords:

• age-related immune system imbalances
• elderly patients
• melanoma
• multimorbidity
• physician prejudice
• practice bias

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Malignant melanoma is an aggressive tumor with a poor prognosis for patients with advanced disease.

• Over the last decades, melanoma’s incidence and mortality has increased in the elderly population.

• Considering the increase in average age of world population, metastatic melanoma is impacting significantly on healthcare costs.

• Anti-melanoma immunity seems to be more efficient in elderly because of age-related immune system imbalances. In very elderly subjects, instead, the imbalance seems to be to effector T-cell disadvantage. The identification of this immunological window will allow the selection of older and oldest melanoma patients for properly enrolling them in immunotherapeutic trials.

• Older age is recognized as a poor prognostic factor for melanoma, but now the scientific community is wondering whether elderly melanoma patients have worse outcomes because they are not receiving the same treatment as their younger counterparts.

• Prolonged delays in definitive excision for primary melanoma and inadequate margins of excision represent two important practice biases in elderly patients.

• It is extremely important to invest resources to strengthen access to early diagnostic services for the elderly.

• Early detection of melanoma by screening in the aging population is essential to reduce melanoma mortality.

• It will be necessary to improve the number of eligible elderly patients in clinical trials to provide better evidence for their treatment.