Basal Cell Carcinoma: The Treatment Choice is Personal

Why do doctors say surgery is the first “treatment of choice” for basal cell carcinoma (BCC), the most common cancer among fair-skinned people worldwide? And why, given the proven efficacy of photodynamic therapy, or PDT, isn’t it considered a superior treatment option?

After all, PDT involves no cutting or damage to normal tissue, and many studies have shown that overall treatment efficacy is about the same—and even better in the case of superficial BCC, which occurs mostly on the upper trunk or shoulders—when compared to surgery. PDT is also more cost-effective than surgery. So why isn’t PDT the first treatment option listed, and surgery second?

The reason doctors regard PDT as second best to surgery can be summarized simply as follows: PDT takes more time. In PDT, a photosensitizing cream is applied on top of the skin cancer lesion, and one must then wait a few hours before performing the light treatment. Many doctors consider this a time-consuming inconvenience. Most would rather just cut out the cancerous lesion and be done with it.

But this situation could be changing very soon, thanks to a new approach called daylight PDT or daylight-mediated PDT. This approach involves being outside for a short period of time instead of sitting or laying indoors under the treatment lights. Daylight PDT is now widely viewed as an excellent alternative to conventional PDT.

In a recent clinical study in Copenhagen (Denmark), daylight-PDT proved to be as effective as conventional PDT in the treatment of BCC lesions. The daylight approach was pain free and of course far more convenient for both clinicians and patients. The cosmetic outcome was rated as good to excellent, certainly far better than surgery.

This last point is why so many people, when faced with BCC, are beginning to ask their physicians for PDT in lieu of surgery. The time factor is less of a concern, and the patient’s concerns about cosmetic outcomes may often eclipse or at least rival concerns about efficacy or recurrences. Like other skin cancers, treatment of a BCC lesion can leave a mark on the skin

Dr. Isabelle Martin and colleagues at the University Medical Center Mannheim in Mannheim, Germany, recently assessed the patient’s preference for different outcomes in a study of 124 BCC patients. Overall, the patients reported that their greatest concern was the recurrence rate, and this was followed concerns for the cosmetic outcome and finally for the cure rate (ability to get rid of the lesion).

Nevertheless, the location of the BCC lesion affected the outcome. Patients with BCC on the head or neck were mainly interested in cosmetic outcome. In fact, those who had already experienced a recurrence were willing to trade risk of a future recurrence, treatment location and duration of wound healing for a better cosmetic result—and logically that meant preferring PDT or immunotherapy to surgery. These findings were reported online ahead-of-print in the 5 November 2015 issue of Acta Dermato-Venereologica.

As just mentioned, the Mannheim study found that patients with recurrent BCC were willing to trade a higher risk of recurrence in favor of a better cosmetic outcome. Though this finding may seem surprising, the scientists suggest it’s “highly conceivable that patients with recurrent BCC are less afraid of relapse than those with a primary BCC because they have already had the experience that their BCC was not life-threatening and did not metastasize.” Because BCC is not immediately life-threatening, and bacause most cases take a relatively benign course, it is understandable that PDT would be a preferred treatment for many of these patients.

Paola Savoia and colleagues from the University of Turin in Torino, Italy, recently sought to clarify PDT’s role as a possible alternative to surgery in the treatment of BCC. They conclude that the “high cure rate and excellent cosmetic outcome requires considering this possibility for the management of patients with both sporadic and hereditary BCC,” as reported in the 28 September 2015 International Journal of Molecular Science.

Clearly increasing the chances of a favorable appearance is a top priority for many BCC patients, though of course this needs to be balanced with the desire for a cure and for keeping the recurrence rate down. Most studies in the past have shown that participants preferred Mohs micrographic surgery (because it helps preserve normal tissue) over standard surgery, and moreover preferred PDT or immunotherapy (using imiquimod cream) over any type of surgery.

PDT and immunotherapy are also being combined in some studies, and this strategy can further reduce the recurrence rate while at the same time honoring the patient’s desire for a normal or pleasant appearance after the treatment. In the next Discoveries article, we’ll take a look at how this is being done, and what the most recent research is telling us about the perfect marriage between PDT and immunotherapy.

Sources

Savoia P, Deboli T, Previgliano A, Broganelli P. Usefulness of Photodynamic Therapy as a Possible Therapeutic Alternative in the Treatment of Basal Cell Carcinoma. Int J Mol Sci. 2015 Sep 28;16(10):23300-17.

Fargnoli MC, Peris K. Photodynamic therapy for basal cell carcinoma. Future Oncol. 2015 Nov;11(22):2991-6.

Wiegell SR, Skødt V, Wulf HC. Daylight-mediated photodynamic therapy of basal cell carcinomas – an explorative study. J Eur Acad Dermatol Venereol. 2014 Feb;28(2):169-75.

Martin I1, Schaarschmidt ML, Glocker A, Herr R, Schmieder A, Goerdt S, Peitsch WK. Patient Preferences for Treatment of Basal Cell Carcinoma: Importance of Cure and Cosmetic Outcome. Acta Derm Venereol. 2015 Nov 5. doi: 10.2340/00015555-2273. [Epub ahead of print]