Study: Best Treatments for Basal Cell Carcinoma

When treating low-risk primary basal cell carcinoma (BCC), surgery and external beam radiation yield a better chance of a cure and a lower recurrence rate compared with other treatment modalities. This is the finding of a recent meta-analysis published in the Annals of Internal Medicine.

Selecting the right therapy for BCC is challenging and should be based on many variables, including patient factors, tumor factors, and patient access to healthcare resources.

“Surgical removal is widely considered the gold standard and is therefore the most common treatment,” wrote the study authors, led by Aaron M. Drucker, MD, ScM, of the University of Toronto and Women's College Hospital in Toronto. “However, despite several dozen randomized controlled trials (RCTs) and nonrandomized comparative studies (NRCSs), the relative performance of various surgical techniques and other therapeutic options is unclear.”

Limited knowledge of BCC treatments could straddle payers with more costly interventions that are not evidence-based, wrote the researchers. The purpose of their analysis was to assess what has been elucidated regarding the safety and efficacy of various BCC treatments by mining various English-language databases for comparative studies.

A total of 40 randomized trials comparing 18 interventions in 9 categories were identified and included in the study. A meta-analysis of mostly low-risk BCC patients was then conducted.

Drucker and colleagues found that the estimated recurrence rates were comparable for excision (3.8%; 95% CI, 1.5%–9.5%), Mohs surgery (3.8%; CI, 0.7%–18.2%), curettage and diathermy (6.9%; CI, 0.9%–36.6%), and external beam radiation (3.5%; CI, 0.7%–16.8%). However, the recurrence rates were increased for cryotherapy, curettage and cryotherapy, 5-fluorouracil, imiquimod, and photodynamic therapy with either methyl-aminolevulinic acid or aminolevulinic acid.

In addition, patients were more satisfied with photodynamic therapy compared with excision or cryotherapy. According to the researchers, too little data existed to conduct an analysis of patient quality of life or mortality measures.

“On the basis of sparse evidence and with substantial imprecision, surgery and external beam radiation have lower recurrence rates than other modalities for the treatment of BCC,” concluded the researchers. “In order for clinicians, patients, and payers to make informed decisions about treating BCC, new RCT or high-quality NRCS evidence is needed.”

Hooman Khorasani, MD, chief of the Division of Dermatologic & Cosmetic Surgery at Icahn School of Medicine at Mount Sinai, cautioned about several limitations of the Drucker et al study. “The meta-analysis is severely constrained by sparse data and imprecise and indirect comparisons,” Khorasani told Cancer Network. He noted that the reviewers examined only 16 RCTs and 2,204 lesions, and “almost all comparisons for all outcomes were based on [a] maximum of 3 trials.”

Additionally, Khorasani questioned the study’s conflation of Mohs micrographic surgery (MMS) with conventional surgery.      

“The comparison of conventional surgery with Mohs micrographic surgery is flawed because Mohs is tissue-conserving by nature, which leads to superior cosmetic results for a given tumor,” he said. “The meta-analysis examined only low-risk superficial and nodular BCC. More aggressive subtypes are best treated with Mohs micrographic surgery, and this is widely regarded as the gold standard.”

Jerry D. Brewer, MD, MS, a professor of dermatology at the Mayo Clinic, provided similar thoughts on the Drucker et al meta-analysis in an interview with Cancer Network.

“Surgery has always been and continues to be the gold standard for the treatment of BCC,” he said. “External beam radiation does have its perks but also has a number of downsides, including increased risk of skin cancer during later years. High-risk BCC is much better treated with lower recurrence rates when a surgical approach is employed, with MMS being the preferred surgical treatment when possible. This current study is limited in the number of tumors studies, and we know from larger studies that surgery, particularly MMS, is associated with a much lower cure rate than many other modalities. We have known for years that surgery is the gold standard, and this study does not offer enough evidence to argue the contrary.”