Management Options
The choice of options offered to patients regarding treating BCC depends on the following; anatomical location, size, clinical appearance, histological diagnosis and ease of access to treatments. Counselling patients about management options should include the likelihood of complete eradication and cosmetic result.
The management of low-risk basal cell carcinomas in the community include;
- surgical excision
- curettage and cautery/electrodessication
- cryotherapy/cryosurgery
- topical treatment (for example, imiquimod).
Cryotherapy, PDT, imiquimod and radiotherapy produce no histological data therefore prior biopsy/histology is essential.
The importance of counselling regarding cosmetic outcome by research showing high levels of dissatisfaction and outcomes from patients where they weren’t prepared for the extent of a scar. Therefore like any other treatment choices, the healthcare professional’s advice and choice of management, including no treatment, should not be influenced by a person’s age, gender or disabilities unless these have a direct clinical relationship with the success of certain forms of treatment. (13)
Across the UK and Wales 2 potential models of care for management of BCCs
Model 1
Referring low-risk BCC for DES/LES Group 3 GPwSI in dermatology and skin surgery.
Model 2
Referring to local acute health trusts or local health boards running outreach community skin cancer clinics. (14)
Methods of treatment for BCC include surgical excision, Mohs micrographically controlled excision, superficial skin surgery, photodynamic therapy, cryotherapy, imiquiod, 5-fluoruracil and in some cases radiotherapy. The number of different treatment options highlight the need for in-depth counselling regarding treatment choices.
Excision biopsy
- Most appropriate treatment for nodular, infiltrative and morphoeic BCCs
- Should include 3 to 5 mm margin of normal skin around the tumour
- Further surgery is recommended for lesions that are incompletely excised as detailed by the pathology report.
Mohs micrographically controlled excision
A complex surgical procedure, which in brief involves examining carefully marked excised tissue under the microscope, layer by layer, to ensure complete excision. The advantages include high cure rates, able to treat difficult areas such as eyes, lips and nose. It’s suitable for ill-defined, morphoeic, infiltrative and recurrent subtypes.