Key points

• Despite the enormous amount of work involved in the treatment of BCC, there has been very little good-quality research on the efficacy of the treatment modalities used.

• Surgery and radiotherapy appear to be the most effective treatments. Other treatments might have some use, but none has been compared with surgery.

• The majority studies have been performed on low-risk BCCs, the results of which are probably not applicable to tumours of the morphoeic type shown in Figure 26.3. Specific trials or subgroup analyses are required for morphoeic tumours.

• Cryotherapy, although convenient and less expensive than surgery or radiotherapy, does not have better cure rates than surgery or radiotherapy (especially for lesions >2 cm). Cosmetic effect is better for surgery and comparable for radiotherapy.

• If cryosurgery is to be used, two freeze-thaw cycles are recommended for nodular and superficial facial lesions (Figures 26.1 and 26.2) if cure rates approaching equivalence to that of formal excision or radiotherapy are to be achieved.

• An RCT of PDT versus surgery is needed.

• Further studies for all of the interferon treatments and PDT that demonstrate greater efficacy are needed before they can be recommended.

• Broadband halogen light source may give cure rates and cosmetic outcome similar to laser light PDT with possible benefits of reduced costs, increased safety and ease of use.

• The efficacy of interferon alfa has not been directly compared with standard surgical treatment; inteferons are associated with significant side-effects, which may overshadow their usefulness, especially in the elderly. Interferon therapy requires several clinic visits.

• Increased short-term eradication of BCC using 5-FU in a phosphatidyl choline based vehicle to increase penetration should be compared with surgery, with long-term follow up.

• Preliminary studies suggest a high success rate (87-88%) for imiquimod in the treatment of superficial BCC using a once-daily regimen for 6 weeks and a useful (76%) treatment response when treating nodular BCC for 12 weeks. These results need to be confirmed in a long-term study (3-5 years) with excision surgery as a comparator.

• Studies comparing excision with predetermined margins versus Mohs' micrographic surgery in high-risk tumours would be useful.

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