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Scientific Reports
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10.1038/s41598-024-67740-0
Article
The impact of basal cell carcinoma on the quality-of-life in older patients
Van Coile Laura 12
Meertens Annick 125
Shen Amber 12
Waalboer-Spuij Rick 3
Vossaert Katrien 4
Verhaeghe Evelien 12
Brochez Lieve 12
Hoorens Isabelle Isabelle.Hoorens@ugent.be

12
1 https://ror.org/00xmkp704 grid.410566.0 0000 0004 0626 3303 Department of Dermatology, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium
2 https://ror.org/02afm7029 grid.510942.b Cancer Research Institute Ghent (CRIG), Ghent, Belgium
3 https://ror.org/018906e22 grid.5645.2 0000 0004 0459 992X Department of Dermatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
4 Dermatologie Maldegem (Private Dermatology Practice), Maldegem, Belgium
5 https://ror.org/00cv9y106 grid.5342.0 0000 0001 2069 7798 Department of Public Health and Primary Care, Interuniversity Centre for Health Economics Research (I-CHER), Ghent University, Ghent, Belgium
18 9 2024
18 9 2024
2024
14 2173926 2 2024
15 7 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Basal cell carcinoma (BCC) is the most frequent malignant tumour worldwide and incidences are rising rapidly. BCC grow locally, but can invade surrounding tissues. Little is known concerning their impact on the health-related quality of life (HrQoL), and limited available data reports contradicting results. Measuring HrQoL in BCC patients should be done using disease-specific questionnaires such as the Basal and Squamous cell carcinoma Quality of Life (BaSQoL) questionnaire. The aim of this study was to assess the BCC-related HrQoL by examining all relevant patient, tumour and treatment characteristics to identify the main factors for the BCC-related impact. Specific attention for older BCC patients wass brought forward because of the often complex decisions in this subgroup. Patients ≥ 18 years with a history of BCC were asked to fill in the BaSQoL questionnaire, consisting of 5 subdomains. Multivariable analyses were done using a generalized additive model (GAM) because of the need for incorporation of non-linear functions. The study obtained approval of the Ethics Committee of the Ghent University Hospital (EC/2019/1352). Informed consent was obtained from all subjects. All experiments were performed in accordance with relevant guidelines and regulations. Four hundred patients with a median age of 66 were enrolled. Mean BaSQoL subscores were 0.78 (SD 0.63) for ‘behaviour’, 1.01 (SD 0.73) for ‘diagnosis&treatment’, 0.90 (SD 0.73) for ‘worries’, 0.40 (SD 0.63) for ‘appearance’ and 1.20 (SD 0.75) for ‘other people’, illustrating the low to moderate impact of BCC on the HrQoL. A GAM with subsequent ANOVA testing was done for all relevant variables. In 4 out of 5 BaSQoL subdomains ‘age’ showed a significant correlation (‘behaviour’ p = 0.007; ‘diagnosis&treatment’ p = 0.026; ‘worries’ p = 0.003; ‘appearance’ p = 0.008). Lower BaSQoL scores were seen in older patients, meaning less BCC-impact on their HrQoL. There was a clear non-linear correlation between BaSQoL scores and age, illustrating that the impact of BCC on the HrQoL shows a rapid decrease starting around the age of 70. This study is the first to illustrate the relation between the BCC-related HrQoL and the age of patients with the use of a disease-specific HrQoL instrument. We found a lower BaSQoL score in older adults, with a specific age group of interest starting around the age of 70–75. This is an argument for a potential wait-and-see strategy for BCC in these patients.

Keywords

Basal cell carcinoma
HrQoL
BaSQoL questionnaire
Older adults
Subject terms

Skin cancer
Quality of life
http://dx.doi.org/10.13039/501100003130 Fonds Wetenschappelijk Onderzoek 1S69921N 12Y2420N Van Coile Laura Hoorens Isabelle Innovation and Clinical Research Fund of the Ghent University Hospitalissue-copyright-statement© Springer Nature Limited 2024
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pmcIntroduction

Basal cell carcinoma (BCC) is the most frequent malignant tumour worldwide1. It is a neoplasm that usually grows locally, but causes serious harm when growing into the surrounding tissues especially in the facial area. One out of seven people will experience a BCC before the age of 75 in Belgium and incidences are rising rapidly in Europe2. BCC come with various treatment options such as standard surgical excision (SE), Mohs micrographic surgery (MMS), cryotherapy, topical 5-fluorouracil, topical imiquimod, carbon dioxide laser therapy, photodynamic therapy (PDT), radiotherapy or more advanced systemic treatments. Chosen treatment is usually determined based on various tumour and patient characteristics3.

It is encouraging to see growing attention directed towards the overall wellbeing of patients, significantly influenced by medical interventions and treatments, as determined by the Health-related Quality of Life (HrQoL) of patients. BCC sometimes induce symptoms by their locally invasive growth, but these patients can also suffer from psychological effects such as a tumour in a visible location (e.g. the head and neck area), worries or anxiety about the diagnosis of a skin cancer or possible adverse effects of treatment or frequent follow-up consultations. To date, few knowledge is available concerning the HrQoL in skin cancer patients, specifically in BCC patients, that could help our approach in these patients. In literature, various studies concerning HrQoL in skin cancer patients are available, but not often using a disease-specific questionnaire in BCC patients. However, current available generic instruments used to measure HrQoL do not have sufficient validity4. Our group also demonstrated that comorbidity has a high impact on disability measured with health utility instruments such as the generic EQ-5D-5L questionnaire4. For this reason, measuring the HrQoL in BCC patients should be done using disease-specific questionnaires such as the Basal and Squamous cell carcinoma quality of life (BaSQoL) questionnaire (added as supplementary file).

Non-treatment however, is still not considered as an approach in older patients with limited-life expectancy5. Because of growing interest in possible overtreatment in certain older patients, information on HrQoL concerning BCC in this specific population is essential. The limited data on this topic reports however contradicting results. A cross-sectional study of 2016 found a worse skin-related QoL with younger age (average Skindex-29-score decrease of 2.00 for every increase of ten years in age and an average Skin Cancer Index score increase with 2.20 for every increase of ten years of age)6. This study used two skin-related quality of life questionnaires that are not fully applicable to capture specific effects of keratinocyte cancer (KC)6. To counter this limitation, the authors used six KC-specific questions, however not part of a validated questionnaire. Other studies found no significant relation between age and HrQoL after BCC treatment, however, also these studies did not use KC-specific questionnaires7,8. A smaller study in 2022 specifically in older patients showed no significant improvement of the quality of life after surgical treatment for their BCC using the 36-Item Short Form Survey (SF-36), another generic questionnaire9. Waalboer-Spuij et al. found higher BaSQoL scores related with younger age, meaning younger patients experience a higher impact on their HrQoL due to their BCC, but focused on other aspects and did not investigate further details concerning specific age groups of interest10. Recently, an Australian study examined the health utilities and HrQoL in patients recently treated for multiple KCs compared with patients with history of only one KC or even no KC history. This study showed overall low BaSQoL domain scores, leading the authors to conclude that KCs only had a small impact on HrQoL. However, this study could not differentiate between BCC and squamous cell carcinoma and did not include older adults (maximum age of inclusion was 69 years old)11.

For this reason, this study is the first to examine all relevant patient, tumour and treatment characteristics in relation to the HrQoL (using a disease specific questionnaire) to identify the main influencing factors of the BCC-related impact. Specific attention for the older aged BCC patients is brought forward because of the often complex situation in this BCC subgroup. Examining the HrQoL in older BCC patients could bring clinicians important insights concerning the experience of older BCC patients. It would be helpful to gain this information in order to detect certain age groups of interest that could benefit from a more conservative approach.

Materials and methods

Patients aged ≥ 18 years with a history of KC consulting a dermatologist at the Ghent University Hospital (Belgium), the Erasmus University Medical Centre Rotterdam (the Netherlands), a private practice (Belgium) or consulting their general practitioner between July 2020 and July 2023 were asked to fill in HrQoL questionnaires via email or by phone depending on their preference. Patients with a history of other skin cancer types (melanoma, merkel cell carcinoma,…) were excluded. Also patients with a diagnosis older than 10 years were excluded. We recruited a total of 728 patients with KC (which includes BCC and/or squamous cell carcinoma) in all participating study sites for a larger study. To be able to fully assess the BCC-related impact on the HrQoL, we chose for this cohort study to only include patients with a history of one or more BCC (n = 400 patients). Figure 1 illustrates the flow of the study cohort (Fig. 1). Data collection and electronic survey invitation were done via REDCap.Figure 1 Flow of the study cohort.

General medical history and dermatological history information was collected from patients’ medical records. Comorbidities were assessed using the Charlson comorbidity index (CCI). The CCI is a validated comorbidity assessment tool (CCI) which is a weighted index based on the comorbidities of patients and has a maximum score of 3312. In literature, a CCI score of three or more is interpreted as a high comorbidity score with limited life expectancy13. All patients were asked to fill in the BaSQoL questionnaire. The BaSQoL instrument is a disease-specific validated HrQoL questionnaire for patients with KC. It consists of 16 questions in five dimensions (behaviour, diagnosis & treatment, worries, appearance and other people) rated on a four-point Likert scale. BaSQoL subscores range between zero and three, with worse HrQoL in higher scores14. This questionnaire is available as supporting information of this manuscript. In this study, also total BaSQoL scores were calculated based on the five BaSQoL subdomain scores. The calculation of a total score makes it possible to do more valuable analyses with these data on a cohort level. Of course, an individual total BaSQoL score does not inform us on the area of interest in that particular individual. On an individual basis, BaSQoL subdomain scores remain for this reason more appropriate. If patients experienced multiple BCC, data concerning histological subtype, location, size and date of the BCC were only used from the most recent BCC. For analyses with different types of treatment, treatment groups were applied. Patients who received combination therapies with radiotherapy and another treatment were labelled as radiotherapy. Patients who received combination therapies consisting of standard excision or MMS and another treatment were labelled as standard excision or MMS. Treatment with cryotherapy, topical 5-fluorouracil, topical imiquimod, laser therapy and PDT were categorized as locally destructive therapies. Figure 1 illustrates the flow of the study cohort (Fig. 1).

Descriptive statistics were used to display sociodemographic characteristics of the enrolled patients as well as the tumour and treatment characteristics. Unless otherwise mentioned, categorical variables were reported by frequencies and proportions, and continuous variables were displayed by mean and standard deviation. BaSQoL scores were considered to be pseudocontinuous data because of the use of a 4-point Likert scale. Calculating BaSQoL total scores for all participants in this cohort study made the data less discrete in nature, which made it more straightforward to evaluate the data as pseudocontinuous data and to illustrate non-linear effects of the BaSQoL total score. Data was non-normally distributed. Univariate analyses were done using Mann–Whitney U tests and Kruskal Wallis tests. Multivariable analyses were done using a generalized additive model (GAM) with the distribution of the exponential family, because of the need for incorporation of nonlinear functions. Statistical analysis was performed using SPSS (IBM Corp. Released 2021. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp) and R version 4.3.1. Significance was set at an alpha-level of 0.05 (2-sided). Informed consent was obtained from all subjects. All experiments were performed in accordance with relevant guidelines and regulations.

Ethical approval

The study obtained approval of the Ethics Committee of the Ghent University Hospital (EC/2019/1352). Informed consent was obtained from all subjects. All experiments were performed in accordance with relevant guidelines and regulations.

Results

This cohort study comprised 400 patients with one or more BCC. The median age of the study population was 66 (range 36–91). Male/female ratio was 1:1. The majority of the enrolled patients was married and more than half of the patients has successfully fulfilled higher studies (university or college). More than half of the patients (52.7%) experienced more than one BCC. Most frequent BCC subtypes were nodular or superficial BCC and almost half of the enrolled patients experienced a facial BCC. A standard surgical excision was the most frequent treatment, followed by MMS and PDT. All data are tabulated in Table 1.Table 1 Descriptive statistics of the study cohort.

Variable		Patients % (n)	
Sexa	Male	48.8% (195)	
	Female	51.2% (205)	
Ageb, years		66 (range 36–91)	
Statusa	Married	65.6% (261)	
	Living together with partner	12.3% (49)	
	Living together with others	0.8% (3)	
	Single	15.3% (61)	
	Widow(er)	6.0% (24)	
Educationa	University	20.% (80)	
	College	36.3% (145)	
	Secondary	32.5% (130)	
	Primary	6.0% (24)	
	Other	2.0% (8)	
	None	3.3% (13)	
Number of BCCa	1 BCC	47.3% (189)	
	2–4 BCC	28.2% (113)	
	5–9 BCC	11.8% (47)	
	 > 10 BCC	3.0% (12)	
BCC subtypea*	Superficial	33.8% (135)	
	Nodular	45.1% (180)	
	Infiltrating	20.1% (80)	
	Other	1.0% (4)	
Location of the BCCa	Facial	47.6% (188)	
	Non-facial	52.4% (207)	
Size of the BCCa	 < 1 cm	67.3% (263)	
	 > 1 cm	32.0% (125)	
	Advanced BCC (> 6 cm)	0.8% (3)	
Treatmenta*	Standard excision	52.8% (211)	
	MMS	22.0% (88)	
	Cryotherapy	3.3% (13)	
	Topical 5-FU	1.5% (6)	
	Topical imiquimod	1.3% (5)	
	PDT	17.5% (70)	
	Laser therapy	11.5% (46)	
	Radiotherapy	0.5% (2)	
CCIa	 < 3	91.2% (364)	
	 ≥ 3	8.8% (35)	
Study site of inclusion	Ghent University Hospital (Belgium)	66,0% (264)	
	Erasmus University Medical Centre Rotterdam (the Netherlands)	6,3% (25)	
	Private dermatology practice (Belgium)	23,5% (94)	
	General practitioner (Belgium)	4,3% (17)	
a: %(N), b: median, *Multiple options possible in one patient because of combination therapy.

BCC, basal cell carcinoma; MMS, Mohs micrographic surgery; 5-FU, 5-fluorouracil; PDT, photodynamic therapy; CCI, Charlson comorbidity index.

Mean BaSQoL scores in all BCC patients of this study cohort were 0.78 (SD 0.63) for ‘behaviour’, 1.01 (SD 0.73) for ‘diagnosis&treatment’, 0.90 (SD 0.73) for ‘worries’, 0.40 (SD 0.63) for ‘appearance’ and 1.20 (SD 0.75) for ‘other people’. These mean scores illustrate the usually low to moderate impact of BCC on the HrQoL of the patients. Patients were divided in groups, based on their age. BaSQoL subdomain scores for each age group are illustrated in Table 2.Table 2 Scores for the BaSQoL subdomains per age group.

	Behaviour	Diagnosis & Treatment	Worries	Appearance	Other people	
Age group ≤ 59y (n = 123)	0.88 (0.54)	1.15 (0.78)	0.96 (0.71)	0.50 (0.72)	1.26 (0.75)	
Age group 60y-74y (n = 192)	0.75 (0.66)	0.97 (0.69)	0.92 (0.76)	0.36 (0.57)	1.21 (0.72)	
Age group ≥ 75y (n = 85)	0.68 (0.68)	0.88 (0.72)	0.78 (0.69)	0.33 (0.58)	1.06 (0.81)	

For all subscores of the BaSQoL questionnaire, a descending trend could be observed with higher age groups. To investigate the trend towards impact of BCC on the HrQoL in different age groups, a univariate comparison between the younger age group (age group < 60 years) and the older age group (age group ≥ 75 years old) was done. The subscores behaviour, diagnosis & treatment, appearance and other people showed a significant difference between younger patients and older patients. Exact values and level of significance are shown in Table 3.Table 3 Comparison of the BaSQoL subdomains in younger and older patients.

	Age group < 60y	Age group ≥ 75y	p-Value	
Behaviour	0.88	0.68	0.001*	
Diagnosis & Treatment	1.15	0.88	0.012*	
Worries	0.96	0.78	0.053	
Appearance	0.50	0.33	0.048*	
Other people	1.26	1.06	0.046*	
*p < 0.05.

A generalized additive model (GAM) with subsequent ANOVA testing was done for all relevant independent variables as illustrated in Table 1. Table 4 only shows the significant results of the GAMs. The subscale ‘behaviour’ showed a significant result for the following independent variables: age, sex, education and time between diagnosis & survey. In the BaSQoL subscale ‘diagnosis & treatment’ the independent variables age, sex, histological subtype, facial BCC and status were significant. The subscale ‘worries’ showed age, multiple BCC, education, status and facial BCC as significant independent variables. The subscale ‘appearance’ showed age, sex, multiple BCC, status, education, CCI and time between diagnosis & survey as significant independent variables. The subscale ‘others’ showed only sex as significant independent variables. All data per BaSQoL subscore with independent variables and the corresponding β’s and level of significance are shown in Table 4. For the BaSQoL subscore ‘appearance’ status was a significant independent variable. Single BCC patients seemed to score higher for the BaSQoL score appearance (β 0.39, p < 0.001) compared to BCC patients of the reference value (married), meaning single BCC patients had a 39% higher BaSQoL appearance compared to the reference category. BCC patients that were a widow(er) had a 53% lower BaSQoL appearance score compared to married BCC patients (β − 0.53, p = 0.042).Table 4 Multivariable analyses (Generalized additive model with subsequent ANOVA testing).

BaSQoL subscale	Significant independent variables	p-value (ANOVA)		β (p-value)	
Behaviour	Age	0.007			
		Sex	0.005	Male1	0.17 (0.005)	
		Education	0.016			
				Primary2	 − 0.62 (< 0.001)	
		Time diagnosis-survey (ln-function)	0.033		 − 0.04 (0.033)	
D&T	Age	0.026			
		Sex	 < 0.001	Male1	 − 0.25 (< 0.001)	
		Histological subtype	0.037			
				Nodular3	 − 0.20 (0.011)	
		Facial BCC	0.023	Facial BCC4	0.15 (0.023)	
		Status	0.030	Single5	0.24 (0.002)	
Worries	Age	0.003			
		Multiple BCC	 < 0.001	Multiple BCC6	0.21 (< 0.001)	
		Education	 < 0.001			
				Secondary2	0.24 (0.002)	
		Status	0.039			
				Living with partner5

Single5

	0.19 (0.023) 0.17 (0.024)	
		Facial BCC	0.043	Facial BCC4	0.11 (0.043)	
Appearance	Age	0.008			
		Sex	 < 0.001	Male1	 − 0.39 (< 0.001)	
		Multiple BCC	0.006	Multiple BCC6	0.27 (0.006)	
		Status	 < 0.001			
				Single5	0.39 (< 0.001)	
				Widow(er)5	 − 0.53 (0.042)	
		Education	0.006			
				Primary2	0.57 (0.013)	
				Secondary2	0.52 (< 0.001)	
				College2	0.33 (0.022)	
		CCI	0.015		 − 0.11 (0.015)	
		Time diagnosis-survey (ln-function)	0.009		 − 0.08 (0.009)	
Others	Sex	0.001	Male1	 − 0.21 (0.001)	
1Reference value: female.

2Reference value: university.

3Reference value: infiltrating.

4Reference value: non-facial BCC.

5Reference value: married.

6Reference value: single BCC.

BaSQoL, Basal and Squamous cell carcinoma quality of life questionnaire; BCC, basal cell carcinoma; CCI, Charlson comorbidity index.

In 4 out of 5 BaSQoL subdomains the independent variable age showed a significant correlation with the BaSQoL scores. No β values were displayed in Table 4 for the independent variable age because a smooth function analysis was done for these variables to fully display the effect of age on the BaSQoL subscores. Figures 2, 3, 4 and 5 showed the effect of the independent variable ‘age’ in the BaSQoL subdomains behaviour, diagnosis and treatment, appearance and worries. These figures showed an obvious descending trend of the BaSQoL subscores with higher age. This implies lower BaSQoL scores in older patients, thus less impact of the BCC on the HrQoL of older patients. However, it is important to examine the specific age groups of interest when we discuss the BCC-related impact of the HrQoL. Figures 2, 3, 4 and 5 showed that there is a non-linear relation between the BaSQoL subdomain scores and the age of the patients. Since a linear function would not show the trend of these scores properly and no specific age group of interest would be detected, smooth functions were used. They illustrate clearly the non-linear effect of the BaSQoL subdomain scores with the zero-point of these BaSQoL subscores approximately around the age of 70, meaning that starting around this age the average impact of a BCC on the HrQoL was lower compared to the mean impact on the HrQoL in all patients. After passing the zero-point, these curves showed a rapid decline.Figure 2 Smooth function of the BaSQoL subdomain ‘behaviour’ in relation to the independent variable ‘age’.

Figure 3 Smooth function of the BaSQoL subdomain ‘diagnosis&treatment’ in relation to the independent variable ‘age’.

Figure 4 Smooth function of the BaSQoL subdomain ‘appearance’ in relation to the independent variable ‘age’.

Figure 5 Smooth function of the BaSQoL subdomain ‘worries’ in relation to the independent variable ‘age’.

Figure 6 showed the clear non-linear relationship between the total BaSQoL scores and the age of the patients. The zero-point in this graph was achieved around the age of 71, with a steep decline of the BaSQoL scores starting from this age-point. These findings showed that the impact of a BCC on the HrQoL of patients decreased rapidly starting around the age of 70. The graph in Fig. 6 illustrated us that a patient of 83 years old on average experiences a 0.20 lower BaSQoL total score compared to the average in this study population.Figure 6 Smooth function of the BaSQoL total score in relation to the independent variable ‘age’.

Discussion

This study is the first to clearly demonstrate the relation between the impact of BCC on the HrQoL and age by using of a disease-specific HrQoL instrument. Overall BaSQoL scores showed low to moderate impact of BCC on the HrQoL of the patients. Results were in broad terms comparable with the results of a very recent study of Gordon et al.11, however important differences in the patient population need to be noted since the group of Gordon et al. enrolled only patients younger than 70 years old and did not differentiate between KC tumours. It is known that squamous cell carcinoma causes greater impact than BCC10. In older adults, the impact of BCC on the HrQoL decreased (starting around the age of 70–75) compared to younger patients. For all BaSQoL subscales, a descending trend could be detected with higher age groups (Table 2). The highest absolute impact on the HrQoL in older adults was related to the subdomain ‘other people’, however non-significant in multivariable analysis, and the subdomain ‘diagnosis & treatment’. Remarkably, the lowest BaSQoL score in older adults was found in the subdomain ‘appearance’ with only a very low mean BaSQoL score of 0.33, followed by the BaSQoL domainscore of ‘behaviour’ with a mean score of 0.66. This shows that older BCC patients were not that worried concerning their sun-exposure behaviour and their appearance, but did worry about the diagnosis, the period between diagnosis and treatment and the treatment itself. Most important, ‘diagnosis and treatment’ is in fact the subdomain that is a direct result of the diagnosis and the treatment of a BCC. Therefore, eliminating overtreatment and overdiagnosis of BCC could have an overall large impact on the HrQoL in BCC patients. In this light, we could argue if total body examinations to screen for BCC in older patients brings benefit for these patients and if only screening of the head and neck region could be sufficient. Moreover, older patients were less worried about esthetical outcomes. These findings emphasize the possibility that in certain older patients, diagnosis and treatment of a BCC induces more harm than the tumour present itself. The results of our study are of great value for current dermatological practice. It illustrates that older BCC patients have less impact of BCC on their HrQoL, what could be important for clinicians to take into account when treating these patients. Moreover, based on the results of our study, interventions to gain benefit in older BCC patients should be targeted to optimize the BaSQoL subdomains with the highest scores. The higher score for ‘diagnosis & treatment’ in combination with potential adverse effects of BCC treatments should prompt dermatologists to critically evaluate the current treatment landscape of BCC in older adults and offer a more restrained approach in these patients in combination with their overall life expectancy. These BaSQoL findings underscore the need to eliminate unnecessary diagnoses and treatments.

Literature has previously found no consensus concerning the impact of BCC in older adults6–11. With this study, a sensitive questionnaire specific for KC was used and results illustrate lower impact on the HrQoL in older BCC patients compared with younger BCC patients. Findings were to date contradictory and remained topic of discussion because of the use of generic HrQoL questionnaires, of which we already know that they are not sensitive enough to detect KC-related impact on the quality of life in KC patients4. Interestingly, our study did not find an impact of comorbidities on the HrQoL of patients, which can be explained by the use of a disease-specific questionnaire. This emphasizes again the importance of the use of a disease-specific questionnaire and confirms the limitations of previous research that was done concerning HrQoL in BCC patients6–8.

This study was a large study cohort that only enrolled patients with a BCC history. Since KC patients often have multiple lesions and different types of keratinocyte carcinomas, previous research made it difficult to assess the HrQoL specifically linked to BCC. Moreover, this study used a recent and validated disease-specific questionnaire, making the results of this study cohort clear and easy interpretable. Another important strength of this study was the inclusion of patients in different types of clinical settings (general practice, private dermatological practice and two University hospitals in different countries), however we do need to remark that the amount of patients enrolled by a general practitioner was rather small in our cohort. This study not only included patients with a new diagnosis of BCC, but also patients with a history of BCC in the last ten years. These inclusion criteria diminish possible limitations that are linked to cross-sectional studies and made it possible to assess the effect of time on BCC-related impact on the HrQoL.

Limitations of our study were that despite the relatively large number of 400 patients in this study cohort, BaSQoL subdomains remained discrete in nature because of the use of a 4-point Likert scale. For this reason, the BaSQoL total score was calculated per patient. By doing this latter, the data was more divergent and less discrete in nature, which resulted in a clear and pronounced smooth function of the BaSQoL total score in relation to the age of the patients. The findings of this study cannot be translated to patients with advanced BCC which can possibly affect HrQoL in a more pronounced way, since these patients were underrepresented in our cohort.

Important to address is of course the fact that this study focusses on BCC patients that received a treatment for their BCC. It would be interesting to have HrQoL data in patients who actively decided not to treat their BCC. However, for this latter there is a need for a disease-specific questionnaire for KC that also includes aspects of ‘non-treatment’ such as for example potential symptoms of the tumour itself (bleeding, itch, pain,…) or anxiety concerning tumour growth and/or metastases. To date this remains a topic that is not captured in the current available questionnaires and should be subject of further research.

To conclude, this is the first study to assess the HrQoL in a large group of exclusively BCC patients using the disease-specific questionnaire BaSQoL. Our study illustrates a clear lower BaSQoL score in older adults, with a specific turning point at the age of 70–75. In general, older patients show a significant lower impact of their BCC on their HrQoL and this should be an important topic to keep in mind for physicians in their approach to BCC in older adults.

Supplementary Information

Supplementary Information 1.

Abbreviations

HrQoL Health-related quality of life

BaSQoL Basal and squamous cell carcinoma quality of life

BCC Basal cell carcinoma

SD Standard deviation

GAM Generalized additive model

SE Standard excision

MMS Mohs micrographic surgery

PDT Photodynamic therapy

KC Keratinocyte cancer

CCI Charlson comorbidity index

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-024-67740-0.

Author contributions

L.V.C., A.M., A.S., R.W.S., K.V., E.V. L.B. and I.H. contributed to the conceptualization of this study. L.B. and I.H. supervised the study. L.V.C. performed the formal analysis. L.V.C. performed the writing of the original draft with support of A.M. and I.H. A.M., A.S., R.W.S., K.V., E.V. L.B. and I.H. reviewed and edited the manuscript.

Funding

This research project was funded by the Innovation and Clinical Research Fund of the Ghent University Hospital. The research activities of I. Hoorens are supported by a postdoctoral fellowship of the Scientific Research Foundation-Flanders (number: 12Y2420N). The research activities of L. Van Coile are supported by a predoctoral fellowship of the Scientific Research Foundation-Flanders (number: 1S69921N). The funding sources had no role in the literature study, no role in study design, data collection, data analysis or manuscript preparation; no role in the decision to submit the manuscript for publication.

Data availability

Data available on request from the authors. The corresponding author (Dr. Isabelle Hoorens) should be contacted in this case.

Competing interests

The authors declare no competing interests.

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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