Non-Melanoma Skin Cancer (NMSC)
Read more clinical background about NMSC treatment, including treatment type, treatment description, advantages, and risks.
Curative treatment of NMSC is broadly divided into surgical excision (which accounts for most cases), radiation therapy, and other treatments.
Choice of treatment depends on:
- Tumor factors – histological diagnosis, stage, location of lesion, and number of lesions
- Patient factors – comorbidities, previous treatments, condition of surrounding skin, and patient choice
- Treatment factors – cure rate, side effects, cosmetic, and functional effects
- Availability of treatment modalities
X-ray therapy is also used for the treatment of pre-cancerous lesions (e.g., carcinoma in situ, actinic keratosis, and lentigo maligna), where radiation therapy is deemed to provide more favorable treatment outcome than other treatment options.
The patient population tends to be mainly adults. The major risk factor for NMSC (and pre-cancerous lesions) is chronic ultraviolet sun exposure, and lesions are most commonly found on sun-exposed areas such as the head and neck.
Basal Cell Carcinoma (BCC)
BCC’s can grow and cause significant local damage but do not tend to metastasize to other areas and do not tend to cause mortality.
Squamous Cell Carcinoma (SCC)
SCCs grow and cause local damage but can also spread (metastasize) to regional lymph nodes and to distant sites, and therefore they can ultimately be fatal.
All Treatment options (including X-ray therapy) for BCC and SCC are detailed and compared in the following table, with advantages and disadvantages.
| Treatment Type | Treatment Description | Advantages | Disadvantages / Risks |
|---|---|---|---|
| Surgical excision (National and international guidelines list surgical excision as the most common treatment for BCC and SCC [NCCN[1]and Australian[2]guidelines]) | Standard surgical excision - The majority of NMSC can be excised under local anesthetic on an outpatient basis. Moh’s micrographic surgery - a highly specialized technique using fresh frozen tissue for histological examination. Required for only a very small number of tumors. | Simple and quick technique, generally acceptable cosmetic/functional result with rapid healing, histological confirmation of completeness of excision. Excellent overall cure rate, comprehensive examination of the excised tissue compared with standard excision. | Hemorrhage, infection, wound rupture, hypertrophic scarring. Contraindications: Where excision is likely to cause cosmetic/functional deformity, comorbidities including anticoagulation, caution with widespread lesions or field cancerization. Hemorrhage, infection, wound rupture, hypertrophic scarring. Time consuming and expensive, requires specific training and expertise, limited patient access, interpretation is difficult for some tumors. |
| Curettage and cautery | A combination of scraping of the tissue and destruction; e.g., with an electric needle. | Rapid to perform, tissue conserving, for lesions on low-risk areas (neck, trunk and limbs), BCCs on the legs of older patients, not contraindicated in anticoagulated patients. | Specialist training required, not appropriate for all tumors - e.g., where penetrates the dermis, clinically morphoeic lesions, high-risk areas and recurrent tumors; unpredictable cosmetic results. |
| Cryotherapy | Removal of lesions by freezing; e.g., with liquid nitrogen. | Rapid and simple to perform, treats benign and pre-cancerous lesions, and some BCCs. | Acute side effects – pain, swelling and redness, blistering, infection; Chronic side-effects – scarring, dyspigmentation, numbness; not indicated for SCC or more advanced lesions. |
| Photodynamic therapy | Use of a photosensitizing cream with the application of red light or daylight to kill the abnormal cells. | Effective in the treatment of pre-cancerous lesions and low-risk BCCs. | Acute side-effects: Common - Pain, inflammation, uncommon - blistering and ulceration bruising, changes in hair growth, dermatitis and contact allergy, infection; Chronic side-effects: scarring, dyspigmentation. |
| Topical treatments | Application of creams to the affected area; e.g., Imiquimod, Effudix. | Can be effective for pre-cancerous change and for superficial BCCs. | Acute inflammatory side-effects, flu-like symptoms, allergic reactions, wound infection, scarring, hair loss; Not for more advanced BCC or for SCC. |
| Radiotherapy (including X-ray Therapy) | Treatment of benign, pre-cancerous and cancerous lesions with X-rays and other forms of ionizing radiation (e.g., electrons). For example, NCCN guidelines state that “considerations of function, cosmesis, and patient preference may lead to choosing RT as primary treatment in order to achieve overall optimal results”. | a. Can be used where surgery is not feasible; e.g., due to patient comorbidities (e.g., anticoagulation). No need for anesthetic. b. Good cosmetic outcome where surgery would cause unacceptable cosmetic or functional morbidity; e.g., around the nose, lips or eyes c. Can treat large areas of tissue where there are large or multiple lesions, where surgery would cause a large tissue deficit d. Outpatient procedure, painless, short sessions e. Good rates of local control. | a. Tends to be given over several sessions, so requires multiple attendances b. Does not give information about margin status c. Acute and chronic side effects. |
| Systemic therapies (BCC) | Hedgehog pathway inhibitors; e.g., Vismodegib, used to treat: a. Locally advanced disease that cannot be treated with curative treatments. b. Metastatic disease. | Shrink the disease and relieve symptoms, although they have not demonstrated an increase in overall survival. | Not curative. Side-effects include nausea, muscle spasms, hair loss, loss of taste, tiredness. |
| Systemic therapies (SCC) (note: treatments are not curative) | Chemotherapy; e.g., cisplatin-based. Immunotherapy; e.g., cemiplimab. | Can produce tumors and symptomatic responses. Increases progression-free survival. | Side-effects include tiredness, kidney damage, nerve damage, deafness, neutropenic sepsis. Side effects include joint pain, tiredness, colitis, liver disorders, thyroid dysfunction, infusion related reactions, muscle pain, pneumonitis, skin reactions. |
Pre-Invasive NMSC lesions
Pre-invasive NMSC lesions include actinic keratosis and Bowen’s disease (squamous cell carcinoma in situ). They can progress to invasive cancers and cause morbidity due to their appearance and associated symptoms, such as itching. They can present as single lesions, but more often present as wide areas of field change. Therapies can be directed towards individual lesions or towards wide fields of cancerization. All treatment options for pre-invasive NMSC lesions are listed below with detailed descriptions provided in the previous table.
- Surgical excision and curettage – These are effective ways of removing or destroying single lesions but may not be possible or desirable due to comorbidities (including anticoagulation). Risks include infection, bleeding, wound rupture, and poor cosmetic outcome.
- Topical creams including Effudix and Imiquimod – these can be effective in some patients, but do not clear all lesions, need to be repeated, and have inflammatory side-effects.
- Photodynamic therapy – This can be effective in the treatment of single lesions, but its utility for wider fields is limited by pain.
- Radiation therapy is effective at clearing single lesions and areas of field change, including pre-cancerous change and admixed invasive NMSC. Advantages, disadvantages, and side effects are detailed above.
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