Watchful Waiting in BCC: Which Patients Can Benefit?

M. Alexander Otto, MMS, PA

September 20, 2021

Basal cell carcinomas (BCCs), the most common form of skin cancer, are generally slow-growing tumors that occur in older patients.

Given the low rates of metastasis and mortality associated with BCC, some patients do not require treatment. However, there have had no evidence-based recommendations on who may benefit from a watch-and-wait approach.

Now, a study published in JAMA Dermatology sheds light on which patients with BCC may be appropriate candidates for watchful waiting.

The investigators found that for older people with low-grade BCCs and limited life expectancy, the risks associated with surgery — bleeding, infection, and wound dehiscence — appeared to outweigh the advantages. According to the authors, these patients "might not live long enough to benefit from treatment."

This finding mirrors oncologists' observations regarding low-risk prostate cancer, for which watchful waiting is now the standard of care.

"At present, however, procedure rates [for patients with BCC] increase with age, and many basal cell carcinomas are treated surgically regardless of a patient's life expectancy," Eleni Linos, MD, PhD, professor of dermatology at Stanford University, in Stanford, California, and Mary-Margaret Chren, MD, chair of dermatology at Vanderbilt University, Nashville, Tennessee, write in a viewpoint article published in JAMA Internal Medicine.

Considering the current treatment patterns for BCC, patients would "benefit from the existence of an evidence-based standard of care that includes active surveillance," Mackenzie Wehner, MD, assistant professor at MD Anderson Cancer Center, Houston, Texas, writes in an editorial that accompanies the article in JAMA Dermatology.

Insights From the Dutch Study

The article in JAMA Dermatology presents a cohort study conducted at Radboud University Medical Center, in Nijmegen, the Netherlands. The study included 89 patients who were managed with watchful waiting. The patients received no treatment for at least 3 months following their diagnoses.

The median age of the patients was 83 years. The patients had a total of 280 BCCs. The median initial diameter of the BCCs was 9.5 mm. Just over half of the patients were men, and about half of the BCCs were in the head and neck region.

The median follow-up was 9 months; the maximum follow-up was 6.5 years. Remarkably, the investigators say, more than half the tumors (53.2%) did not grow, and some even shrank. The majority of patients were asymptomatic at presentation, and fewer than 10% developed new symptoms, such as bleeding and itching, during follow-up.

Among the tumors that did grow, 70% were low-risk superficial/nodular tumors, which only increased in size by an estimated 1.06 mm over a year. Thirty percent were higher-risk micronodular/infiltrative tumors, which grew an estimated 4.46 mm over a 12-month period.

About two thirds of patients eventually chose to have at least one of their BCCs removed after a median of about 7 months. Only three BCCs (2.8%) needed more extensive surgery — reconstructive surgery, rather than primary closure, for instance — than would have been necessary with an earlier excision.

No deaths from BCC were reported in the study.

The investigators tracked the reasons patients opted for watchful waiting. Many understood that their tumors likely would not cause problems in their remaining years. Others prioritized dealing with more pressing health or family problems. Logistics came into play for some, such as not having reliable transportation for hospital visits.

"In patients with [limited life expectancy] and asymptomatic low-risk tumors, [watchful waiting] should be discussed as a potentially appropriate approach," the investigators, led by Marieke E. C. van Winden, MD, a dermatology resident at Radboud University, conclude.

For patients who wish to pursue a watchful waiting approach, the Dutch team recommends conducting follow-up visits every 3 to 6 months to see whether patients wish to continue with watchful waiting and to determine whether the risk-to-benefit ratio has shifted.

These recommendations are in line with criteria Linos and Chren propose in their viewpoint article in JAMA Internal Medicine. They characterize low-risk BCCs as asymptomatic, smaller than 1 cm in diameter, and located on the trunk or extremities in immunocompetent patients. They note that details regarding active survillance for BCCs need to be worked out.

"Active surveillance should be studied as a management option because it is supported by the available evidence, congruent with the care of other low-risk cancers, and in accord with principles of shared decision-making," Linos and Chren write.

No funding source was reported. Wehner, Winden, Linos, and Chren have disclosed no relevant financial relationships. Two of Winden's co-authors report ties to several companies, including Sanofi Genzyme, AbbVie, Novartis, and Janssen.

JAMA Intern Med. Published online June 14, 2021. Abstract

JAMA Dermatol. Published online September 8, 2021, Abstract, Editorial

M. Alexander Otto is a physician assistant with a master's degree in medical science. He is an award-winning medical journalist who worked for several major news outlets before joining Medscape. He is an MIT Knight Science Journalism fellow. Email: aotto@mdedge.com.

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