Interventions for basal cell carcinoma: abridged Cochrane systematic review and GRADE assessments

BACKGROUND

Basal cell carcinoma (BCC) is the most common cancer affecting white-skinned individuals, and the worldwide incidence is increasing. Although rarely fatal, BCC is associated with significant morbidity and costs.

OBJECTIVES

To assess the effects of interventions for primary BCC in immunocompetent adults.

METHODS

We updated our searches of the following databases to November 2019: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and LILACS. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation method. We used standard methodological procedures expected by Cochrane.

RESULTS

We included 52 randomized controlled trials with 6990 participants (median age 65 years; range 20-95). Mean study duration was 13 months (range 6 weeks-10 years). Ninety-two per cent (n = 48/52) of studies exclusively included histologically low-risk BCC (nodular and superficial subtypes). The certainty of evidence was predominantly low or moderate for the outcomes of interest. Overall, surgical interventions have the lowest recurrence rates, and there may be slightly fewer recurrences with Mohs micrographic surgery over surgical excision for primary, facial BCC (high-risk histological subtype or located in the 'H-zone' or both) (low-certainty evidence). Nonsurgical treatments, when used for low-risk BCC, are less effective than surgical treatments, but recurrence rates are acceptable and cosmetic outcomes are probably superior.

CONCLUSIONS

Surgical interventions have lower recurrence rates and remain the gold standard for high-risk BCC. Of the nonsurgical treatments, topical imiquimod has the best evidence to support its efficacy for low-risk BCC. Priorities for future research include agreement on core outcome measures and studies with longer follow-up.

Probiotics for the treatment of eczema: a systematic review

BACKGROUND

Probiotics have been proposed as a treatment for eczema, but the results of intervention trials have been mixed.

OBJECTIVE

To evaluate the efficacy of probiotics for treating eczema by performing a systematic review of randomized-controlled trials (RCTs).

DESIGN

We searched the Cochrane Skin Group Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO, AMED, LILACS, ISI Web of Science, the reference lists of articles, ongoing clinical trial registers and conference proceedings. RCTs of live orally ingested microorganisms for the treatment of eczema were eligible for inclusion.

RESULTS

Twelve trials (781 participants) were identified. Meta-analysis of data from five of these trials showed that there was no significant reduction in eczema symptoms with probiotic treatment compared with placebo (mean difference -0.90 points on a 20-point visual analogue scale; 95% confidence interval -2.84, 1.04). Meta-analysis of data from seven trials showed no significant difference in investigator rated eczema severity between probiotic and placebo treatments. Subgroup analysis by eczema severity or presence of atopy did not identify a specific population in which probiotic treatment was effective. There was significant heterogeneity between studies; however, the results of three studies that used the same probiotic strain were concordant. The adverse events search identified case reports of sepsis and bowel ischaemia caused by probiotics.

CONCLUSIONS

Currently, probiotics cannot be recommended for treating eczema. The heterogeneity between studies may be attributable to probiotic strain-specific effects, which means that novel probiotic strains may still have a role in eczema management.

Interventions for basal cell carcinoma of the skin

BACKGROUND

Basal cell carcinoma (BCC) is the commonest skin cancer. BCCs are slow-growing, locally invasive, epidermal skin tumours which mainly affect white skinned people. The first line treatment is usually surgical excision, but numerous alternatives are available.

OBJECTIVES

To assess the effects of treatments for basal cell carcinoma.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (January 2006), the Cochrane Central Register of Controlled Trials (The Cochrane LIbrary Issue 1, 2006), the Cochrane Database of Systematic Reviews (The Cochrane Library Issue 1, 2006), MEDLINE (2004 to January 2006), EMBASE (2005 to January 2006), the metaRegister of Controlled Trials (February 2006). Cited references of all trials identified and key review articles were searched. Pharmaceutical companies were contacted where appropriate for reviews or unpublished trials.

SELECTION CRITERIA

Inclusion criteria were adults with one or more histologically proven, primary basal cell carcinoma. The primary outcome measure was recurrence at three to five years, measured clinically. The secondary outcome included early treatment failure within six months, measured histologically. Adverse treatment effects included aesthetic appearance and pain during and after treatment.

DATA COLLECTION AND ANALYSIS

Two authors independantly carried out study selection and assessment of methodological quality.

MAIN RESULTS

Twenty seven studies were identified. Only one RCT of surgery versus radiotherapy had primary outcome data at four years, showing significantly more persistent tumours and recurrences in the radiotherapy group as compared to the surgery group, (RR 0.09, 95%CI, 0.01 to 0.69). One study found no significant difference for recurrence at 30 months when Moh's micrographic surgery was compared to surgery for high risk facial BCCs, (RR 0.64, 95%CI 0.16,2.64). One study of methylaminolevulinate photodynamic therapy (MAL PDT) versus cryotherapy found no significant difference in recurrences in the MAL PDT group when compared to cryotherapy at one year (RR 0.50, 95% CI 0.22,1.12). Cryotherapy showed no significant difference in recurrences at one year when compared to surgery on one small study. When radiotherapy was compared to cryotherapy there were significantly fewer recurrences at one year in the radiotherapy group compared to the cryotherapy group.Short-term studies suggest a success rate of 87 to 88% for imiquimod in the treatment of superficial BCC using a once-daily regimen for 6 weeks and a 76% treatment response when treating nodular BCC for 12 weeks, when measured histologically.

AUTHORS' CONCLUSIONS

Overall there has been very little good quality research on treatments for BCC. Most trials have only evaluated BCCs in low risk locations. Surgery and radiotherapy appear to be the most effective treatments with surgery showing the lowest failure rates. Although cosmetic outcomes appear good with PDT, long term follow up data are needed. Other treatments might have some use but few have been compared to surgery. An ongoing study comparing imiquimod to surgery should clarify whether imiquimod is a useful option.

Pentoxifylline, propentofylline and pentifylline for acute ischaemic stroke

BACKGROUND

Methylxanthine derivatives are vasodilators. They also inhibit platelet aggregation and thromboxane A2 synthesis, decrease the release of free radicals and may be neuroprotective. NOTE: This review covers an area where no active research is taking place. It will be updated if relevant information becomes available, e.g. on completion of an appropriate study.

OBJECTIVES

To assess the effect of intravenous or oral methylxanthines (pentoxifylline, propentofylline, or pentifylline) in patients with acute ischaemic stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (last searched November 2003). For the first version, we also searched EMBASE (1980 to 1999), MEDLINE (1966 to 1999), Science Citation Index (1981 to 1999) and the Ottawa Stroke Trials Registry. We also contacted the manufacturers of methylxanthines and the principal investigators of the identified trials.

SELECTION CRITERIA

Randomised trials comparing pentoxifylline, propentofylline or pentifylline with placebo or control in patients with definite or presumed acute ischaemic stroke. Trials were included if treatment was started within one week of stroke onset.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied the inclusion criteria. Trial quality was assessed.

MAIN RESULTS

Five trials were included. Four trials tested pentoxifylline in 763 people, and one tested propentofylline in 30 people. No trials of pentifylline were found. The odds of early death (within four weeks) was non-significantly reduced in patients given a methylxanthine drug as compared with those given placebo (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.41 to 1.02). This non-significant trend to less deaths was due mainly to one pentoxifylline trial that found a highly significant reduction in early deaths. Two trials reported early death or disability and found a non-significant reduction (OR 0.49, 95% CI 0.20 to 1.20). There was no significant difference in late death (beyond four weeks), as reported in the propentofylline trial involving 30 patients, although the confidence interval was wide (OR 0.70, 95% CI 0.13 to 3.68). Data for neurological impairment and disability were not in a form suitable for analysis. Data on quality of life, stroke recurrence, thromboembolism and bleeding were not reported.

REVIEWERS' CONCLUSIONS

There is not enough evidence to assess adequately the effectiveness and safety of methylxanthines after acute ischaemic stroke.