Watchful waiting an appropriate strategy for basal cell carcinoma
Basal cell carcinoma ( BCC ) is the most common form of nonmelanoma skin cancer and is the fifth most common cancer in men and women , with figures for 2018 showing that there were over 1 million diagnoses worldwide . 1 BCCs are slow-growing tumours that occur mainly on sun-exposed areas of the body such as the face and head , with the median age of diagnosis being 68 years . While BCCs are rarely fatal or undergo metastases , the cancer can be highly destructive locally and can result in disfigurement . Treatment involves surgical removal such as excision , curettage , Mohs micrographic surgery and liquid nitrogen cryosurgery . 2
Given that BCCs are slow-growing , rarely fatal and do not have an appreciable negative impact on quality of life , older patients with limited life expectancy ( LLE ) may not live to experience any bothersome symptoms . An alternative management approach is therefore ‘ watchful waiting ’ ( WW ), which involves monitoring of the condition but without actually treating it . Such a strategy avoids any potential treatment adverse effects but a downside to this approach is the risk of further tumour growth and the need for more intensive therapy .
Researchers from the Radboud Institute for Health Sciences , Department of Dermatology , Radboud University , Nijmegen , the Netherlands , recently undertook an observational cohort study to evaluate the reasons for WW among patients diagnosed
with a BCC but also to document the natural course of the tumour and the reasons to subsequently initiate treatment . 3 They enrolled patients diagnosed with BCC who decided to adopt a WW approach after a thorough consideration , irrespective of the tumour location , subtype or patient age . For the study , WW was defined as no active treatment for at least three months after the initial presentation and the cohort included patients even if they were advised against WW . The main outcome of the study were patient ’ s reasons for WW ( as documented in the medical notes ) and these were categorised as patient-related ( that is , prioritisation of co-morbidities , severe frailty or LLE ), tumour-related ( that is , asymptomatic ), treatment-related ( due to expected treatment burden ) or circumstantial reasons ( that is , too many other current stresses , planning or logistic reasons etc ). These reasons together with any subsequent treatment initiation were collected from the patient ’ s medical records .
Findings A total of 89 patients with a mean age of 79.5 years ( 53 % male ) and 227 BBCs chose WW after a consultation on their tumour and the median followup time for tumours was nine months . Patients chose more than one reason , but the majority chose WW because of patient-related factors ( 83 %); for example , prioritising other health problems , frailty or LLE . Tumourrelated reasons were chosen by 55 % and treatment-related factors by 35 % and circumstantial reasons by 46 %.
Over the follow-up period , only 46.8 % of tumours showed an increase in size and this was more likely in a high-risk BBC ( odds ratio , OR = 3.35 , 95 % CI 1.47 – 7.97 , p = 0.005 ). After the initial WW , 38.2 % of BCCs in 54 patients were treated a median of seven months later with excision being the most common treatment modality ( 73.6 %). The most common reason for treatment initiation ( 59.1 %) was potential tumour burden followed by resolution of circumstantial reasons ( 34.5 %) and a re-evaluation of patientrelated factors ( 27.3 %).
The authors concluded that while WW might be an appropriate strategy in those with LLE or if tumours are asymptomatic , patients required regular follow-up to assess whether this approach remains a suitable option . They added that given the sparsity of data on this topic , future studies are needed to provide the necessary evidence base for this patient group .
References 1 Skin Cancer Statistics . World Cancer Research Fund . www . wcrf . org / dietandcancer / skin-cancerstatistics / ( accessed Sept 2021 ). 2 McDaniel B et al . Basal Cell Carcinoma . [ updated 2020 ]. In : StatPearls [ Internet ]. www . ncbi . nlm . nih . gov / books / NBK482439 / ( accessed Sept 2021 ). 3 Van Winden MEC et al . Evaluation of watchful waiting and tumor behaviour in patients with Basal Cell Carcinoma . An observational cohort study of 280 basal cell carcinomas in 89 patients . JAMA Dermatol 2021 . doi : 10.1001 / jamadermatol . 2021.3020
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