Cost-effectiveness of treatment of superficial basal cell carcinoma: surgical excision vs. imiquimod 5% cream

Diagnosis and Treatment of Basal Cell Carcinoma in Specialized Dermatology Units: A Clinical Practice Guideline

BACKGROUND AND OBJECTIVE

Basal cell carcinoma (BCC) is the most common skin cancer in the general population. BCC is managed in a variety of ways, and available international guidelines are difficult to put into practice in Spain. This guideline aims to improve the management of BCC based on current evidence and provide a point of reference for Spanish dermatologists.

MATERIAL AND METHODS

Members of the Spanish Oncologic Dermatology and Surgery Group (GEDOC) with experience treating BCC were invited to participate in drafting this guideline. The drafters used the ADAPTE collaboration process to develop the new guideline based on existing ones, first summarizing the care pathway and posing relevant clinical questions. They then searched for guidelines, assessed them with the AGREEII (Appraisal of Guidelines for Research and Evaluation) tool, and searched the selected guidelines for answers to the clinical questions. Finally, the recommendations were drafted and submitted for external review.

RESULTS

The highest-scoring guidelines were from the Association of Dermatologists, the National Comprehensive Cancer Network, the European Dermatology Forum, and the European Academy of Dermatology and Venereology. A total of 11 clinical questions were answered.

CONCLUSIONS

This new guideline answers the working group's clinical questions about the routine management of BCC in Spain. It provides dermatologists with a tool they can use for decision-making while taking into consideration the resources available and patient preferences.

Is early detection of basal cell carcinoma worthwhile? Systematic review based on the WHO criteria for screening

The incidence of basal cell carcinoma (BCC) has risen three- to fourfold over the last 30 years and is expected to continue to increase with ageing of the population. Although BCC has a good prognosis, it causes significant morbidity and has an important impact on the public health budget due to direct treatment costs. Based on the existing evidence, a systematic evaluation of the World Health Organization criteria was performed to determine whether earlier detection of BCC could reduce morbidity and cost. BCC slowly increases in size, with a median increase in diameter of 0·5 mm over 10 weeks. There is an important delay in diagnosis ranging from 19 to 25 months. In several studies BCC size was the main determinant of treatment cost, surgical complexity, reconstruction technique and the specific surgical procedure performed, such as Mohs micrographic surgery or surgical excision. One study showed that size also seems to affect the cost per treatment for other nonsurgical options. The use of vismodegib, an inhibitor of the hedgehog pathway, is confined to locally advanced or metastatic BCC. Delays in diagnosis and appropriate treatment are the most important underlying causes in the occurrence of giant BCC and/or BCC with metastasis. Although the latter represent only a very small fraction of all BCCs, the majority of them are located in the facial region. The available data point to a slow increase in the size of BCCs over time. Size is one of the major determinants in choice of treatment and the associated cost, especially for facial BCC. Therefore we conclude that current data support early detection and adequate management of BCCs on the face.

Traditional versus streamlined management of basal cell carcinoma (BCC): A cost analysis

BACKGROUND

Facing rising incidence of basal cell carcinoma (BCC) and increasing pressure to contain health care spending, physicians need to contemplate cost-effective paradigms for managing BCC.

OBJECTIVE

We sought to perform a cost analysis comparing the traditional BCC management scheme with a simplified detect-and-treat scheme that eliminates the biopsy before initiating definitive treatment.

METHODS

A decision analytic model was developed to compare the costs of traditional BCC management with the detect-and-treat scheme, under which qualifying lesions diagnosed clinically were either treated with shave removal or referred to Mohs micrographic surgery for on-site histologic check. Values for model parameters were based on literature and our institutional data analysis. Costs were based on 2014 Medicare fee schedule.

RESULTS

The average cost per lesion with detect-and-treat scheme was $449 for non-Mohs micrographic surgery-indicated lesions (vs $566 with traditional management, $117 in savings) and $819 for Mohs micrographic surgery-indicated lesions (vs $864 with traditional management, $45 in savings). The combined weighted average savings per case was $95 (15% of total average cost). Conclusions were similar under various plausible scenarios.

LIMITATIONS

Model parameter values may vary based on individual practices.

CONCLUSIONS

A simplified management strategy eliminating routine pretreatment biopsy can reduce BCC treatment cost without compromising quality of care.

Treatment of various types of basal cell carcinoma with topical 5% imiquimod in the elderly who refused surgical intervention: a case series

Basal cell carcinoma (BCC) is the most common non-melanoma skin cancer in the elderly population, causing significant local destruction and image deformities. Although surgical excision is the primary treatment modality, preservation of functions, cosmetic concerns and patient's age, as well as tumor prognostic factors, aid in treatment selection. Topical imiquimod provides immunomodulatory effects by increasing the release of proinflammatory cytokines, and is currently approved and funded for pathologically diagnosed superficial BCC. We report herein the successful results of topical imiquimod in four cases of BCC, nodular and large superficial types, all of whom refused surgical intervention. The lesions regressed in all except one in whom more than one BCC of superficial type was present. She is still on follow-up for intermittent cryotherapy sessions. Imiquimod is a good alternative to surgery in elderly patients who have unwillingness to surgery and are often poor candidates for surgery.

Surgical excision versus imiquimod 5% cream for nodular and superficial basal-cell carcinoma (SINS): a multicentre, non-inferiority, randomised controlled trial

BACKGROUND

Basal-cell carcinoma is the most common form of skin cancer and its incidence is increasing worldwide. We aimed to assess the effectiveness of imiquimod cream versus surgical excision in patients with low-risk basal-cell carcinoma.

METHODS

We did a multicentre, parallel-group, pragmatic, non-inferiority, randomised controlled trial at 12 centres in the UK, in which patients were recruited between June 19, 2003, and Feb 22, 2007, with 3 year follow-up from June 26, 2006, to May 26, 2010. Participants of any age were eligible if they had histologically confirmed primary nodular or superficial basal-cell carcinoma at low-risk sites. We excluded patients with morphoeic or recurrent basal-cell carcinoma and those with Gorlin syndrome. Participants were randomly assigned (1:1) via computer-generated blocked randomisation, stratified by centre and tumour type, to receive either imiquimod 5% cream once daily for 6 weeks (superficial) or 12 weeks (nodular), or surgical excision with a 4 mm margin. The randomisation sequence was concealed from study investigators. Because of the nature of the interventions, masking of participants was not possible and masking of outcome assessors was only partly possible. The trial statistician was masked to allocation until all analyses had been done. The primary outcome was the proportion of participants with clinical success, defined as absence of initial treatment failure or signs of recurrence at 3 years from start of treatment. We used a prespecified non-inferiority margin of a relative risk (RR) of 0.87. Analysis was by a modified intention-to-treat population and per protocol. This study is registered as an International Standard Randomised Controlled Trial (ISRCTN48755084), and with ClinicalTrials.gov, number NCT00066872.

FINDINGS

501 participants were randomly assigned to the imiquimod group (n=254) or the surgical excision group (n=247). At year 3, 401 (80%) patients were included in the modified intention-to-treat group. At 3 years, 178 (84%) of 213 participants in the imiquimod group were treated successfully compared with 185 (98%) of 188 participants in the surgery group (RR 0.84, 98% CI 0.78-0.91; p<0.0001). No clear difference was noted between groups in patient-assessed cosmetic outcomes. The most common adverse events were itching (211 patients in the imiquimod group vs 129 in the surgery group) and weeping (160 vs 81). We recorded serious adverse events in 99 (40%) of 249 participants in the imiquimod group and 97 (42%) of 229 in the surgery group had serious adverse events, but none were regarded as related to treatment. 12 (5%) participants in the imiquimod group withdrew because of adverse events compared with four (2%) in the surgery group.

INTERPRETATION

Imiquimod was inferior to surgery according to our predefined non-inferiority criterion. Although excisional surgery remains the best treatment for low-risk basal-cell carcinoma, imiquimod cream might still be a useful treatment option for small low-risk superficial or nodular basal-cell carcinoma dependent on factors such as patient preference, size and site of the lesion, and whether the patient has more than one lesion.

FUNDING

Cancer Research UK.

Nonsurgical treatment options for Basal cell carcinoma

Basal cell carcinoma (BCC) remains the most common form of nonmelanoma skin cancer (NMSC) in Caucasians, with perhaps as many as 2 million new cases expected to occur in the United States in 2010. Many treatment options, including surgical interventions and nonsurgical alternatives, have been utilized to treat BCC. In this paper, two non-surgical options, imiquimod therapy and photodynamic therapy (PDT), will be discussed. Both modalities have demonstrated acceptable disease control rates, cosmetically superior outcomes, and short-term cost-effectiveness. Further studies evaluating long-term cure rates and long-term cost effectiveness of imiquimod therapy and PDT are needed.

Management of superficial basal cell carcinoma: focus on imiquimod

Superficial basal cell carcinoma comprise up to 25% of all histological sub-types. They are more likely to occur on younger persons and females and although generally more common on the trunk, also occur frequently on the exposed areas of the head and neck especially in areas of high sun exposure. In the last decade, new treatment options such as topical applications that modify the immune response have been trialed for effectiveness in treating these lesions. Imiquimod 5% cream has been shown to stimulate the innate and cell mediated immune system. The short-term success of imiquimod 5% cream in randomized controlled trials comparing different treatment regimes and dosing as a treatment for small superficial basal cell carcinoma (BCC) not on the face or neck is in the range of 82% for 5 times per week application. A high proportion of participants with good response rates to topical treatment (58%–92%) experience local side effects such as itching and burning, less commonly erosion and ulceration, but the proportion of participants ceasing treatment has not been high. To date one long-term study indicates a treatment success rate of 78%–81% and that initial response is a predictor of long-term outcome. Recurrences tend to occur within the first year after treatment. Future research will compare this preparation to the gold standard treatment for superficial BCC – surgical excision.