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Treatment options

What are the treatment options for skin cancer?

There are several options available to treat non melanoma skin cancer. These include:

  • Surgery
  • Simple excision - surgical removal
  • Mohs surgery surgical removal in multiple steps. While the patient waits, the removed tissue is examined immediately under a microscope by the Mohs surgeon to look for cancer cells in the excision edges. If cancer cells are found, the surgeon will remove another layer of skin only in the area where the skin cancer was found until all excision edges are clean.
  • Electrodessication and Curettage–Scraping the tumor with a curette (a surgical instrument shaped like a long spoon) and then using an electric needle to gently cauterize (burn) the remaining cancer cells and some normal-looking tissue.
  • Radiation therapy

    • External beam radiation therapy, radiation from outside in
    • Brachytherapy; bringing the source of radiation close to the tumor

      • Isotope based brachytherapy
      • Electronic brachytherapy

  • Topical therapies

    • Topical chemotherapy – given as a cream that is applied to the skin
    • Topical immunotherapy – given as cream that is applied to the skin
    • Photodynamic therapy
    • Cryotherapy (freezing of the lesion with liquid nitrogen)

The most common modality used for treating skin cancer is surgical excision, there is however a subgroup of patients which will be better off when treated with radiation therapy. Considerations of cosmetic and/or functional outcome and considerations of risks of surgical procedures might lead to the selection of radiation therapy as treatment of choice.1

Based on existing clinical evidence the National Comprehensive Cancer Network, an alliance of the world's leading cancer centers, concluded that topical therapies such as creams and photodynamic therapy should only be considered if surgery and radiation therapy are not possible.1

Radiotherapy – an effective alternative to surgery

Radiotherapy is a good alternative to surgery, not only in cases where surgery is not possible but also in cases where expected functional or cosmetic outcome would be better with radiation therapy than with surgery 1. Radiotherapy is highly effective 2, but does not result in the surgery associated wound healing and scarring.

The table below provides a broad overview of which factors can make a physician decide to prescribe radiation therapy 3, 4, 5, 6, 7, 8

Patient related

Tumor related

Anatomical location related

Elderly/fragile, not able to undergo surgery

Perineural invasion

Cosmetically or functionally sensitive areas (e.g. nose, ears, lips eyelids)

Use of blood thinners

Positive margins after surgery

 

High risk of post-operative wound complications

Recurrent tumors after surgical excision

 

Multiple cancerous lesions

Moderately or poorly differentiated tumors*

 

Refusal of surgery  Advanced lesions where complex surgery (graft or local flap) under general anesthesia is required  
Prone to keloid formation    

 

 

Advantages and disadvantages of skin cancer treatments

Each treatment has advantages and disadvantages. These should be considered and discussed with your healthcare professional when planning your treatment.

Treatment

Advantages

Disadvantages

Surgery (such as excision and Mohs surgery)

High efficacy, margin control possible, single day procedure 9

Also healthy tissue is removed, often restriction of activity to allow wound healing, scarring, often need for reconstructive procedures, risk of wound healing complications 9

(Electronic) Brachytherapy

Non-invasive, painless, high efficacy, excellent functional and cosmetic outcome1, allows patient to continue taking prescribed medications.

Not available at all hospitals, multiple (usually 6-8)  fractions10, no margin control11, some pigmentation changes possible

External beam radiotherapy (EBRT)

Non-invasive, painless, high efficacy, excellent functional and cosmetic outcome 1, allows patient to continue taking prescribed medications 

Treatment course can be long (4–6 weeks) 10

Superficial therapies

Non- invasive, cream can be applied by patient.

Only for superficial lesions, lower cure rates when compared to surgery and radiation therapy13, treatment course can be long (spread out 6-10 weeks), irritation usually develops on treated skin –redness, flaking and scabbing14, side effects can be systemic

References

1. Bichakjian, C. K., Alam, M., Andersen, J., Berg, D., Bowen, G., Cheney, R. T., et al. (2014). NCCN Clinical Practice in Oncology (NCCN Guidelines®) Basal Cell and Squamous Cell Skin Cancers. Retrieved April 9, 2014, from NCCN.org: http://www.nccn.org/professionals/physician_gls/pdf/nmsc.pdf
2. Guix, B., Finestres, F., Tello, J.-I., Palma, C., Martinez, A., Guix, J.-R., et al. (2000). Treatment of skin carcinomas of the face by high dose rate brachytherapy and custom made surface molds. Int J Radiation Oncology Biol Phys., 47(1), 95-102
3. Miller, S. J., Alam, M., Andersen, J., Berg, D., Bichakjian, C. K., Bowen, G., et al. (2010). Basal Cell and Squamous cell skin cancers -clinical practice guidelines in Oncology. Journal of comprehensive Cancer network, 8(8), 836-864
4. Veness, M. J. (2008, Jun). The important role of radiotherapy in patients with non-melanoma skin cancer and other cutaneous entities. J Med Imaging Radiat Oncol, 52(3), 278-286
5. Tward, J. D., Anker, C. J., Gaffney, D. K., & Bowen, G. M. (2012). Radiation Therapy and skin cancer. In G. Natanasabapathi (Ed.), Modern practices in Radiation Therapy (pp. 207-246). Rijeka, Croatia: Intech
6. Ying, C. H. (2001, june). Update of radiotherapy for skin cancers. Hong kong dermatology and venerology bulletin, 9(2), 52-59
7. Marder, G. L., & Bock, M. (2012). Radiation therapy offering hope and excellent cosmesis for treatment of nonmelanoma skin cancer of the eyelid. Cosmetic dermatology, 25, 226-229.
8. Cancer Council Australia, & Australian Cancer Network. (2008). Basal cell carcinoma, squamous cell carcinoma (And related lesions) - a guide to clinical management in Australia. Retrieved April 11, 2014, from cancer council australia: http://www.cancer.org.au/content/pdf/HealthProfessionals/ClinicalGuidelines/Basal_cell_carcinoma_Squamous_cell_carcinoma_Guide_Nov_2008-Final_with_Corrigendums.pdf
9. Healthwise Staff. (2010, October 1). emedicinehealth.com. (K. Romito, & R. D. Burr, Editors) Retrieved April 22, 2014, from nonmelanoma_skin_cancer_comparing_treatments-health: http://www.emedicinehealth.com/nonmelanoma_skin_cancer_comparing_treatments-health/article_em.htm
10. Kennedy Fulkerson, R. (2012). Dosimetric characterization of surface applicators for use with high dose rate 192Ir and electronic brachytherapy sources. Retrieved from library wisc edu: http://depot.library.wisc.edu/repository/fedora/1711.dl:IALVVKH25KMDM8L/datastreams/REF/content
11. Singh, M. K., & Brewer, J. D. (2011). Current Approaches to Skin Cancer Management in Organ Transplant Recipients. Semin Cutan Med Surg, 30, 35-47
12. Gauden, R., Pracy, M., Every, A. M., & Gauden, S. (2013). HDR brachytherapy for superficial non-melanoma skin cancers. J Med Imaging Radiat Oncol, 57(2), 212-217
13. Clark, C. M., Furniss, M., & Mackay-Wiggan, J. M. (2014, April 15). Basal Cell Carcinoma: An Evidence-Based treatment update. Am J Clin Dermatol
14. Korman, N., Moy, R., Ling, M., Matheson, R., Smith, S., McKane, S., et al. (2005, April). Dosing With 5% Imiquimod Cream 3 Times per Week for the Treatment of Actinic Keratosis. Arch Dermatol, 467-473