What are the National Comprehensive Cancer Network (NCCN) treatment guidelines for basal cell carcinoma (BCC)?

Updated: Mar 23, 2021
  • Author: Robert S Bader, MD; Chief Editor: William D James, MD  more...
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According to the National Comprehensive Cancer Network (NCCN) guidelines, the goal of treatment of basal cell carcinomas (BCCs) is elimination of the tumor with maximal preservation of function and physical appearance. As such, treatment decisions should be individualized according to the patient's particular risk factors and preferences. In nearly all cases, the recommended treatment modality is surgery, but patient preference may lead to choosing radiation therapy in order to achieve optimal results. [7]

Treatments vary according to cancer size, depth, and location. In select patients at high risk for multiple primary tumors, increased surveillance and prophylactic measures may be appropriate. [7]

In low-risk lesions, several options are recommended by the NCCN. Curettage and electrodessication in non–hair-bearing areas is appropriate. If lesions extend to adipose tissue, surgical excision is necessary.

A standard excision with 4 mm margins with postoperative margin assessment is also appropriate, reportedly with a higher 5-year cure rate, and should be followed by second-intention healing, linear repair, or skin grafting. Closures with significant tissue rearrangement and adjacent tissue transfer are best performed after clear margins are verified.

Radiotherapy is another potential treatment, especially for nonsurgical candidates over 60 years of age. In low-risk, superficial cancers or in cases where surgery and radiation is contraindicated or impractical, topical therapies such as 5-fluorouracil, imiquimod, photodynamic therapy (eg, aminolevulinicacid [ALA], porfimer sodium), or vigorous cryotherapy may be considered, even though the cure rate may be lower. If margins are positive, Mohs micrographic surgery (MMS) or standard re-excision of the L-area with complete circumferential, peripheral, and deep margin assessment is indicated. [7]

More aggressive treatments should be pursued for basal cell skin cancer with any high-risk feature. Comprehensive intraoperative margin control is the NCCN’s preferred treatment modality; if standard excision with postoperative margin assessment is chosen, wider surgical margins and increased recurrence rates should be expected. Radiotherapy may also be used in high-risk tumors in non-surgical candidates, but may also be used if residual disease, extensive perineural involvement, or large-nerve involvement is present. [7]

In complicated lesions where radiation and surgery have been exhausted or are impractical, the NCCN guidelines recommend multidisciplinary tumor board consultation with consideration of vismodegib or clinical trial enrollment. [7]    

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