Cochrane for Clinicians

Putting Evidence into Practice

Basal Cell Carcinoma: Comparison of Surgical and Nonsurgical Interventions

 

Am Fam Physician. 2021 Nov ;104(5):459-460.

Author disclosure: No relevant financial affiliations.

Clinical Question

Which treatments for basal cell carcinoma (BCC) have the lowest recurrence rates and most favorable cosmetic outcomes?

Evidence-Based Answer

The recurrence rate after surgical management of BCC by standard surgical excision or Mohs micrographic surgery is very low (recurrence at five years = 5.2% vs. 3.2%, respectively; 95% CI, 0.9% to 10.7%). Recurrence after management with imiquimod (Aldara) is also low (recurrence at five years = 17.5%) and may result in more favorable cosmetic outcomes. (Strength of Recommendation [SOR]: B, based on moderate-quality patient-oriented evidence.) Other nonsurgical options may have acceptably low rates of recurrence but also have low certainty of evidence.1 (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.)

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SUMMARY TABLE

Recurrence Risk and Cosmetic Outcomes of Various Interventions to Treat Basal Cell Carcinoma

Intervention*Absolute risk of recurrence (95% CI)NNT or NNH for favorable cosmetic outcome reported by observers (95% CI)†

Mohs micrographic surgery

At 5 years: 3.2 (0.9 to 10.7)

Not reported

Imiquimod 5% (Aldara)

At 5 years: 17.5 (6.4 to 48.1)

NNT = 4 (2 to 8)

Photodynamic therapy

At 3 years: 36.4 (4.9 to 1,302.7)

NNT = 3 (2 to 4)

Radiation

At 4 years: 6.4 (0.8 to 48.7)

NNH = 3 (3 to 4)


NNH = number needed to harm; NNT = number needed to treat.

*—For all reported interventions, comparator group was standard (non-Mohs) surgical excision.

†—Favorable cosmetic outcome was defined differently across studies. For imiquimod, favorable cosmetic outcome was defined as 5 or 6 on a 6-point Likert scale. For photodynamic therapy, favorable cosmetic outcome was defined as 3 or 4 on a 4-point scale. For radiation, favorable cosmetic outcome was defined as a score of 3 on a 3-point scale.

SUMMARY TABLE

Recurrence Risk and Cosmetic Outcomes of Various Interventions to Treat Basal Cell Carcinoma

Intervention*Absolute risk of recurrence (95% CI)NNT or NNH for favorable cosmetic outcome reported by observers (95% CI)†

Mohs micrographic surgery

At 5 years: 3.2 (0.9 to 10.7)

Not reported

Imiquimod 5% (Aldara)

At 5 years: 17.5 (6.4 to 48.1)

NNT = 4 (2 to 8)

Photodynamic therapy

At 3 years: 36.4 (4.9 to 1,302.7)

NNT = 3 (2 to 4)

Radiation

At 4 years: 6.4 (0.8 to 48.7)

NNH = 3 (3 to 4)


NNH = number needed to harm; NNT = number needed to treat.

*—For all reported interventions, comparator group was standard (non-Mohs) surgical excision.

†—Favorable cosmetic outcome was defined differently across studies. For imiquimod, favorable cosmetic outcome was defined as 5 or 6 on a 6-point Likert scale. For photodynamic therapy, favorable cosmetic outcome was defined as 3 or 4 on a 4-point scale. For radiation, favorable cosmetic outcome was defined as a score of 3 on a 3-point scale.

Practice Pointers

According to one estimate, about one-half of the 5.4 million nonmelanoma skin cancers diagnosed in 2012 were BCC.2 Numerous surgical and nonsurgical treatment options exist. This Cochrane review summarizes evidence for 15 treatments of BCC from 52 randomized controlled trials (RCTs) involving 6,690 participants.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Thomson J, Hogan S, Leonardi-Bee J, et al. Interventions for basal cell carcinoma of the skin. Cochrane Database Syst Rev. 2020;(11):CD003412....

2. Rogers HW, Weinstock MA, Feldman SR, et al. Incidence estimate of nonmelanoma skin cancer (keratinocyte carcinomas) in the U.S. population, 2012. JAMA Dermatol. 2015;151(10):1081–1086.

3. Kim JYS, Kozlow JH, Mittal B, et al. Guidelines of care for the management of basal cell carcinoma. J Am Acad Dermatol. 2018;78(3):540–559.

4. American Academy of Dermatology. Don't treat uncomplicated, nonmelanoma skin cancer less than 1 centimeter in size on the trunk and extremities with Mohs micrographic surgery. Choosing Wisely. Updated June 20, 2019. Accessed January 9, 2021. https://www.choosingwisely.org/clinician-lists/american-academy-dermatology-mohs-micrographic-surgery-uncomplicated-melanoma/

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at https://www.aafp.org/afp/cochrane.

 

 

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