More Research Needed to Address Discordance in Skin Cancer Treatment Guidelines

The current guidelines for the management of cutaneous squamous cell carcinoma (cSCC) and cutaneous basal cell carcinoma (cBCC) are useful; however, due to lingering disagreements about treatment recommendations and a lack of data, there is room for growth in this research area, according to a recent study published in Journal of Skin Cancer.

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In the US, skin cancer constitutes the most prevalent malignancy, with cSCC and cBCC being the most prevalent skin malignancies. Managing skin cancer and associated tumors is accomplished through a wide variety of approaches. Although the authors of the present study note that patient survival rates and local control of their skin cancer are considered relatively superb, data that compare the different available treatment methods are insufficient. To address gaps in knowledge in US literature, the researchers conducted an analysis to compare the published US guidelines for managing cSCC and cBCC.

The used keywords such as cutaneous, squamous, basal, carcinoma, cancer, guidelines, and additional search terms such as diagnosis, management, squamous cell carcinoma, and basal cell carcinoma, limiting their data to studies published between June 1, 2016, and December 1, 2022, on PubMed. They proceeded to analyze areas concerning staging and risk stratification, methodology of guideline development, and tumor management.

Their final analysis focused on 4 articles: 2 from the American Academy of Dermatology (AAD), 1 from the National Comprehensive Cancer Network (NCCN), and 1 from the American Society for Radiation Oncology (ASTRO).

Each of these organizations recommend surgery as a preferable treatment. For patients who are unable to undergo surgery or who decline, there was also a unanimous recommendation for radiotherapeutics across the guidelines. As for postoperative radiation therapy (PORT), each organization recommended this approach for patients with nerve invasion, but the authors noted a significant variation in definitions, extent of nerve invasion, and standards, options, and recommendations (SOR) between the guidelines. PORT had a universal recommendation in patients with positive margins that were unable to be corrected through surgery; ASTRO strongly recommended this method for those who had T3 and T4 tumors, recurrent disease, and infiltrative and desmoplastic tumors; NCCN recommended PORT in high-risk and very-high-risk cases; and AAD did not indicate other risk factors to inform their recommendation of PORT.

Additionally, in terms of modalities such as 5-fluorouracil, cryosurgery, imiquimod, and photodynamic therapy, the NCCN and AAD posited that these interventions do not have a role in the treatment of SCC. AAD, however, did advocate for cryotherapy in cases of low-risk SCC when more effective modalities are contraindicated. The authors noted that discussions of these approaches were outside the scope of ASTRO guidelines.

In the management of cBCC, the NCCN and AAD each recommended surgical routes with or without PORT, as well as hedgehog indicators. In regard to cSCC, the NCCN and AAD recommended surgery with or without PORT in cases with regional lymph node metastases. The NCCN, however, altered this recommendation depending on the number and size of nodes, as well as the presence of extracapsular extension (ECE). ASTRO guidelines were similar to the NCCN but they additionally advised elective nodal radiation in cases with high risk for regional nodal metastases.

For managing distant metastases and advanced disease with palliative intent, each set of guidelines advised multidisciplinary consultation, supportive care, and clinical trial participation. Additionally, all uniformly recommended combinations of radiation, surgery, platinum-based chemotherapy, immunomodulators, and epidermal growth factor receptor inhibitors depending on the clinical context. Furthermore, in cases of cBCC, there was a consensus recommending hedgehog inhibitors for patients to manage their disease.

As the authors conclude, they reflect on the few disagreements they came across in their analysis that presented opportunities for future research; for example, in cases of patients with perineural invasion, where the guidelines were unable to come to an agreement on risk categories in these cases. Addressing discordances such as these, the authors add, could be assuaged by the creation of a national task force of stakeholders to help create uniform guidelines.

Reference

Mittal A, Mittal BB. Comparative analysis of US guidelines for the management of cutaneous squamous cell and basal cell carcinoma. J Skin Cancer. Published online February 9, 2024. doi:10.1155/2024/3859066