As the population continues to age, the healthcare system will be faced with the prospect of caring for an increasing number of elderly individuals with diagnoses of cancer. In 2019, more than a fifth (20.3%) of the population of the European Union (EU) was 65-years of age or older. Projections indicate that the percentage of people aged 80 or over in the EU population will multiply by 2.5 between 2019 and 2100, from 5.8% to 14.6%.1

Although the incidence and mortality of cancer are generally higher in the older age groups, few studies have dealt primarily with elderly patients with melanoma. The incidence of melanoma and related mortality has been steadily increasing since 1970 in most developed countries.2 In the United States, more than 40% of melanomas are diagnosed in patients older than 65-years.3

In Spain, incidence rates are estimated to be 16 per 100,000 in 2022. By age, the data indicates that the group that will have a higher incidence is that of ≥65-years, with 44% of the cases; followed by the group of 45- to 64-years, with 39%; and, finally, the one from 0 to 44-years old, with 17%.4

Although the number of melanoma cases among the elderly (>65-years) is expected to increase owing to the aging population, the influence of age on the characteristics of and outcome of melanoma is unclear. In the international literature, classical factors associated with a poorer prognosis in older patients are nodular subtype, tumors with a higher Breslow thickness, a higher mitotic index, and more advanced stages at diagnosis.5–9

Cancers in the elderly population, including melanoma, have features that distinguish them from cancers in younger cohorts and potentially affect the management and outcome of these patients. The present study evaluated to what extent clinical and histologic characteristics of primary cutaneous melanomas and their therapeutic management differed in older patients (≥65) compared with younger ones (<65).

A total of 399 patients with primary cutaneous melanoma were included in the study. A total of 431 primary cutaneous melanomas were analyzed. Between 2007‒2022, 33% of patients with primary cutaneous melanoma were older than 65-years. The number of primary melanomas diagnosed in people over 65-years has been increasing from approximately 10% between 2007‒2009 to an average of 35% in the last years (Fig. 1).

Fig. 1.

Evolution of melanoma incidence between 2007‒2022 in elderly people.

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The present results confirm and extend those of previous reports on the presentation and characteristics of melanoma in the elderly. In accordance with the previous series,5,10,11 the authors observed that the head and neck were the most frequent location in older patients (37.8%). Previous authors have demonstrated that the head and neck location of melanoma increases with age and becomes the most common site after age 70-years.12,13 It was suggested that this high incidence of head and neck melanoma might be attributable to cumulative photodamage, resulting notably in numerous LMM.

As in previous studies, the most relevant difference in terms of baseline prognostic characteristics between older and younger patients was a higher Breslow thickness in the older group.5,10–13 Other classic poor prognostic characteristics such as larger clinical size and ulceration were also observed in the elderly group as in previous studies.5,10–13

While SSM is the most frequent histological subtype in younger age groups,8 in the patients ≥65-years, there is disproportionately an excess of both lentigo malignant (35%) and nodular melanomas (14%), with fewer superficial spreading melanomas (43.4%). In most series, (NM ranks second in frequency5,7; However, in this study, the percentage of lentigo maligna/melanoma (LM/M) is in second position, which is likely significantly related to chronic sun exposure in the studied region. The excess of LMM seen in this study supports the association between LMM, advanced age and chronically sun-exposed skin.14

Stage 0 and more advanced stages (II/III/IV) were observed more frequently in those over 65-years. Among factors that could explain this difference, the frequency of melanomas in situ and the nodular histologic subtype may play an important role. In the present study, melanoma in situ and nodular melanoma occurred 1.3 and 1.5, respectively, as frequently in the older group as in the younger one. The frequency of nodular melanomas, which are highly malignant, and progress rapidly may also explain the higher IV stage in older patients. In addition to nodular melanoma, poor prognosis in the older could be explained because of a delayed diagnosis as a consequence of location in scarcely visible areas (scalp and back), absence of a partner for home examination, poor vision, ignorance of clinical changes, and/or confusion between melanoma and seborrheic keratoses.12

Following initial diagnosis, the management of melanoma also appears to be a challenging issue. Chang et al.15 emphasized that older patients should be treated according to the characteristics and prognostic factors of their tumors and not according to their more advanced age. In contrast to this statement, the authors observed that 28.4% of elderly people, compared with 5.6% of younger ones, had no wide excision.

Among patients typically eligible for SLNB, 17.3% of the older group vs. 2.4% of the younger one underwent this procedure just for the age or comorbidities. This may partly be the result of the limited practical value of SLNB in older patients for whom adjuvant therapies are not an option. However, the role of SLNB in older patients is contentious given their limited life expectancy and the presence of other competing causes of mortality; however, it is recommended that the decision to employ or go SLNB be evaluated on a case-by-case basis.11

Another major difference between older and younger patients was the rate of adjuvant therapy proposed and completed. The 11.9% of older patients compared with 2.1% of younger ones eligible for adjuvant therapy did not undergo the full course of therapy. Many older patients have poor health, making it difficult to prescribe adjuvant therapies. In addition, older patients may be reluctant to accept a treatment with significant adverse effects and little benefit.

There are some limitations to this study. It was a retrospective study and what the authors observed in the area may not be generalized to other territories. Most of the patients of this study have been collected in the last 10-years. Although many of the patients diagnosed before 2012 were discharged and the authors do not have their data, no significant differences were observed between these years for the characteristics of patients, melanomas and main features of management except for an increase in the number of primary cutaneous melanoma diagnosis in the last years. Other factors such as number of nevi, family history of melanoma, and history of nonmelanoma skin cancer or noncutaneous cancer were not collected. Further studies are required to compare such risk factors and characteristics between older and patients younger.

In summary, the number of cases of melanoma in people over 65 has been increasing in the last decade. Compared with the younger group, older patients had primary cutaneous melanomas more frequent in the head and neck with higher Breslow thickness, larger clinical size, and ulceration. Melanomas were diagnosed more frequently in initial (in situ) and advanced (II, III, IV) stages and they have less association with previous lesions. In addition, more interventions and oncological treatments are ruled out solely because of the age despite the fact there are no contraindications.

Stage at diagnosis remains the most important difference between younger and older patients. Further public health campaigns regarding melanoma should focus on access of elderly people to early diagnosis and excision with appropriate margins. An assessment of the patient's comorbidities anticipated life expectancy, frailty, and ability to withstand the proposed treatment should be considered in planning the management of these patients.

None declared.

Juan-Manuel Morón-Ocaña: Preparation and writing of the manuscript; critical literature review.

Isabel-María Coronel-Pérez: Approval of the final version of the manuscript; manuscript critical review.

Ana- Isabel Lorente-Lavirgen: Approval of the final version of the manuscript; manuscript critical review,

Carmen-Victoria Almeida-González: Statistical analysis; study conception and planning.

Amalia pérez-gil: approval of the final version of the manuscript; manuscript critical review.

None of the authors have any conflict of interests to declare.