INTRODUCTION
Basal cell carcinoma (BCC) is the most common cancer
worldwide.1-3 Based on National Cancer Institute estimates
of nonmelanoma skin cancer, more than 1.5 million
new cases of BCC were diagnosed in the United States in
2012.4 The incidence of BCC has been rising in the United States
and other countries in recent decades,5-8 particularly in younger
women.8 Rising incidence combined with the costs of BCC management6,9
makes BCC a significant health problem both in terms
of patient well-being and overall healthcare expenditures.10
BCCs are generally slow-growing tumors without significant
extension.2,11 With early intervention, most low-to-moderate
risk BCCs can be treated surgically with 5-year cure rates above
95%.12-14 However, either because the patient postpones medical
care or for other reasons, some BCCs become locally aggressive
or, more rarely, metastasize distally. A significant percentage of
these tumors are not amenable to surgical treatment options.
Nonsurgical management approaches are sometimes chosen
for less aggressive, low-risk BCCs as well.
This third in a series of 3 CME articles examines nonsurgical approaches
to BCC, with particular focus on the management of
advanced BCCs. The first installment (published in the October
2013 issue) examined new agents for BCC and their mechanism
of action. The second installment (published in the November
2013 issue) reviewed risk factors for recurrent or advanced BCC,
and management choices based on lowor high-risk tumors.
Overview of BCC Management and Nonsurgical Options
The aim of BCC treatment is complete tumor eradication that
prevents or reduces recurrence while providing optimal cosmesis
and quality of life.15-17 Treatment is largely based on risk of
BCC recurrence or progression to advanced disease.15,17 Factors
associated with higher recurrence risk include histological type
(morpheaform, infiltrative, micronodular, or basosquamous),
tumor size and depth, tumor location (midface, nose, ears, or
scalp), poorly defined tumor borders, perineural or vascular
involvement, recurrence despite optimal treatment, prior radiation
treatment/exposure, older age, male gender, and (for
patients undergoing surgery) positive excision margins.18-25
Risk factors for metastasis appear to be similar to those for recurrence,
23,25-31 although neglect (persistent BCC of many years
duration without treatment) should be added as the strongest
risk factor for metastatic BCC (mBCC).23,25,28,29 Considerations
besides risk of recurrence or advanced disease that may affect
treatment choice in particular cases include likelihood of
disfigurement or reduced quality of life with one as opposed
to another treatment option, patient preference or suitability,
treatment costs, and availability of local services.16,21,24
According to the most recent National Clinical Practice Network
(NCCN) guidelines for BCC, suitable primary treatment for lowrisk
BCCs most often includes a surgical approach, although
radiotherapy or (less often) photodynamic therapy may be a
better option in some patients.15 Since surgical options were
