From the Journals

AAD guidelines favor surgery for nonmelanoma skin cancers


 

FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY

Surgical therapies remain the preferred treatment for the management of basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC), according to new practice guidelines issued by the American Academy of Dermatology.

Nonsurgical approaches such as cryotherapy, photodynamic therapy, and radiation may be considered for low-risk cancers if surgery is contraindicated, but these methods have lower cure rates, according to the guidelines. Christopher K. Bichakjian, MD, professor of dermatology, University of Michigan, Ann Arbor, and Murad Alam, MD, professor of dermatology, Northwestern University, Chicago, cochaired the work groups that developed the guidelines.

Dr. Murad Alam of Nothwestern University in Chicago

Dr. Murad Alam

The guidelines for BCC and cSCC, published online in two separate papers (J Am Acad Dermatol. 2018 Jan. 10. doi: 10.1016/j.jaad.2017.10.006; J Am Acad Dermatol. 2018 Jan. 10. doi: 10.1016/j.jaad.2017.10.007), also discuss biopsy techniques, tumor staging, and prevention of recurrence of nonmelanoma skin cancers.

The most suitable stratification for localized BCC and cSCC is the framework provided by the National Comprehensive Cancer Network, the authors said in the guidelines.

For suspected BCC and cSCC, recommended biopsy techniques are punch biopsy, shave biopsy, and excisional biopsy. Biopsy technique is “contingent on the clinical characteristics of the suspected tumor, including morphology, expected histologic subtype and depth, natural history, and anatomic location; patient-specific factors, such as bleeding and wound healing diatheses; and patient preference and physician judgment,” the guidelines state. If the initial biopsy proves insufficient for diagnosis, a repeat biopsy may be considered.

For surgical treatment of BCC, curettage and electrodessication may be considered for low-risk tumors in nonterminal hair-bearing locations. Surgical excision with 4-mm clinical margins and histologic margin assessment is recommended for low-risk primary BCC. For high-risk BCC, Mohs micrographic surgery is recommended, the authors said.

Surgical options for cSCC also include curettage and electrodessication and standard excision for low-risk disease, and Mohs micrographic surgery for high-risk cSCC. In both BCC and cSCC, standard excision may be considered for high-risk tumors in some cases, but “strong caution is advised when selecting a treatment modality” for high-risk tumors “without complete margin assessment,” the guidelines state.


Nonsurgical therapies are generally not recommended as first-line treatment, especially in cSCC because of possible recurrence and metastasis. In cases where nonsurgical therapies are preferred, options may include cryosurgery, topical therapy, photodynamic therapy, radiation, or laser therapy, “with the understanding that the cure rate may be lower,” the authors wrote.

Patients with diagnosed nonmelanoma skin cancer should continue to undergo screening for new primary skin cancers (including BCC, cSCC, and melanoma) at least once per year, the guideline states. They should also be counseled on sun protection, tanning bed avoidance, and regular use of broad-spectrum sunscreen.

Although the new guidelines mainly “reaffirm common knowledge and current practice,” they offer a reminder of “alternative therapeutic or preventive options when insufficient evidence is available to support new therapies or previously dogmatic practice patterns,” the authors said.

These are the first guidelines of care for BCC and cSCC published by the AAD. Commonly used guidelines for the management of BCC and cSCC are published by the National Comprehensive Cancer Network, which are frequently referenced throughout the new AAD guidelines, Dr. Bichakjian said in an interview. While the aim of the cancer network is to develop multidisciplinary guidelines, reflected by the composition of the panel members, “AAD guidelines of care are established primarily by dermatologists for dermatologists,” he pointed out. “However, the work group recognizes that a variety of health care providers outside of dermatology take care of patients with BCC and cSCC, and acknowledges the importance of multidisciplinary care,” he added. “With these considerations in mind, reviewers from specialties outside of dermatology, including plastic surgery, otolaryngology/head and neck surgery, medical oncology, radiation oncology, and family medicine, were invited to critically review the current guidelines.”


The guidelines do not cover the management of actinic keratosis and cSCC in situ, he said. “The work group acknowledges the importance of appropriate management of premalignant and in situ lesions in the prevention of their potential progression to cSCC. However, additional data to provide comprehensive evidence-based recommendations were deemed too extensive to include in the current guidelines and will need to addressed separately.”

In an interview, David J. Leffell, MD, who was not an author of the guidelines, said that the new guidelines do an effective job of “highlighting where valid outcomes data exist and areas where they do not” for a wide range of therapies. They also “attempt to standardize approaches to diagnosis and care of nonmelanoma skin cancer and in general are consistent with established practice patterns,” he added. “Those contemporary approaches have developed in largely empirical fashion over many decades, but bear clarification and reinforcement,” said Dr. Leffell, professor of dermatology and surgery and chief of the section of dermatologic surgery and cutaneous oncology at Yale University, New Haven, Conn.

The guidelines “thoroughly summarize evidence-based recommendations for the entire spectrum of disease management,” Daniel D. Bennett, MD, of the department of dermatology at the University of Wisconsin – Madison, said in an interview. “While surgery remains the mainstay of treatment for BCC and cutaneous SCC, these guidelines include excellent reviews of nonsurgical management options,” he said.

Dr. Bichakjian, who is also chief of the division of cutaneous surgery and oncology at the University of Michigan, had no relevant financial disclosures to report. Dr. Alam, who is also chief of cutaneous and aesthetic surgery in the department of dermatology at Northwestern, disclosed relationships with Amway, OptMed, and 3M. Dr. Bennett and Dr. Leffell had no relevant disclosures.

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