Guideline sources The following summarized guidelines for the evaluation and management of basal cell carcinoma (BCC) are prepared by our editorial team based on guidelines from the U.S. Preventive Services Task Force (USPSTF 2023; 2018), the American Society of Plastic Surgeons (ASPS 2021), the British Association of Dermatologists (BAD 2021), the American Society for Radiation Oncology (ASTRO 2020), the European Association of Dermato-Oncology (EADO/EDF/EORTC 2019), and the American Academy of Dermatology (AAD 2018). 1 2 3 4 5 6 7 Calculator Calculator Calculator Eastern Cooperative Oncology G Karnofsky performance status s TNM class https://web.pathway.md/diseases/recwv4t9NOosmhAmc 1/8 6/29/23, 3:16 AM Basal cell carcinoma Pathway Guidelines 1. Screening and diagnosis Indications for screening: As per USPSTF 2023 guidelines, insufficient evidence to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adolescents and adults. I As per USPSTF 2018 guidelines, insufficient evidence to assess the balance of benefits and harms of counseling adult persons about skin self-examination to prevent skin cancer. I Diagnosis: Confirm the diagnosis of BCC histopathologically in patients with ambiguous lesions, large tumors and tumors located in high-risk areas. B Avoid obtaining histological confirmation in patients with superficial and small nodular (< 1 cm) BCCs in low-risk areas, if clearly diagnosed clinically and/or with noninvasive techniques. D 2. Diagnostic investigations Noninvasive evaluation: consider obtaining dermatoscopy, reflectance confocal microscopy and/or optical coherence tomography to improve the diagnostic accuracy in patients with difficult- to-recognize BCCs. B 3. Diagnostic procedures Biopsy: perform a punch, shave, or excisional biopsy, depending on the characteristics of the suspected malignancy (including morphology and location) and the physician's judgment, for the diagnosis of BCC. B Show 4 more 4. Medical management General principles: As per BAD 2021 guidelines, refer all adult patients with high-risk BCC and all adult patients with low-risk BCC to a local skin multidisciplinary team or a specialized skin cancer multidisciplinary team member in the absence of an accredited general practitioner with an enhanced role or if the primary care facility is not suitable for surgery. A As per EDF 2019 guidelines: Decide on potential suitability, indication and technique for difficult-to-treat BCC in a multidisciplinary team. B https://web.pathway.md/diseases/recwv4t9NOosmhAmc 2/8 6/29/23, 3:16 AM Basal cell carcinoma Pathway Avoid using topical or destructive (blind) treatments in patients with BCC at risk of recurrences. D As per AAD 2018 guidelines, provide a treatment plan taking into account recurrence rate, preservation of function, patient expectations, and potential adverse effects. B Topical agents: As per BAD 2021 guidelines, offer topical imiquimod and 5-fluorouracil as treatment options in adult patients with low-risk BCC unsuitable for or declining standard surgical excision. A Show 2 more As per EDF 2019 guidelines, offer topical imiquimod (5%) in patients with primary superficial BCC. B Show 2 more As per AAD 2018 guidelines, consider offering topical therapy with imiquimod B or 5- fluorouracil C in patients with low-risk tumors if surgical therapy is not feasible or preferred. Adjust topical therapy dosing regimen based on side effect tolerance. B Hedgehog pathway inhibitors: As per BAD 2021 guidelines, offer vismodegib as a treatment option in adult patients with advanced BCC unsuitable for Mohs micrographic surgery, standard surgical excision, or radiotherapy, including patients with Gorlin syndrome, following discussion at a multidisciplinary team. A As per EDF 2019 guidelines, offer Hedgehog pathway inhibitors in patients with locally advanced or metastatic BCC. B As per AAD 2018 guidelines: Offer multidisciplinary consultation and smoothened inhibitors in patients with metastatic BCC. B Consider offering systemic therapy with a smoothened inhibitor if surgery and radiation therapy are contraindicated or inappropriate for the treatment of locally advanced BCC, or if residual tumor persists following surgery and/or radiotherapy and further surgery and radiotherapy are contraindicated or inappropriate. B Chemotherapy: As per EDF 2019 guidelines, consider offering chemotherapy in patients with BCC if Hedgehog pathway inhibitors are contraindicated and no clinical trials are available. C As per AAD 2018 guidelines: Offer platinum-based chemotherapy or best supportive care if treatment of metastatic BCC with smoothened inhibitors is not feasible. B Provide with or refer for best supportive and palliative care to optimize symptom management and maximize the quality of life in patients with advanced disease. B Combination therapy: Insufficient evidence to recommend any of the following combinations in patients with BCC: topical diclofenac and calcitriol https://web.pathway.md/diseases/recwv4t9NOosmhAmc 3/8 6/29/23, 3:16 AM Basal cell carcinoma Pathway topical imiquimod and Mohs micrographic surgery intralesional interferon-alpha and standard surgical excision topical photodynamic therapy and Mohs micrographic surgery laser therapy and topical photodynamic therapy. I 5. Therapeutic procedures Curettage and electrodessication: As per BAD 2021 guidelines, do not perform curettage and cautery in adult patients with high- risk BCC unsuitable for or declining Mohs micrographic surgery or standard surgical excision. D As per EDF 2019 guidelines, consider performing curettage and electrodessication as an alternative treatment in patients with small, low-risk BCC on the trunk and extremities. C As per AAD 2018 guidelines, consider performing curettage and electrodessication in patients with low-risk tumors in non-terminal hair-bearing locations. C Cryotherapy: As per BAD 2021 guidelines, offer cryosurgery as a treatment option in adult patients with low- risk BCC unsuitable for or declining standard surgical excision. A Show 2 more As per EDF 2019 guidelines, consider offering cryotherapy as an alternative treatment in patients with small, low-risk BCC on the trunk and extremities. C As per AAD 2018 guidelines, consider offering cryosurgery in patients with low-risk BCC when more effective therapies are contraindicated or impractical. B Definitive radiotherapy, indications: As per BAD 2021 guidelines, offer radiotherapy as a treatment option in adult patients (suggested age 60 years) with low-risk and high-risk BCC unsuitable for or declining Mohs micrographic surgery or standard surgical excision and expressing a preference for radiotherapy, and if the lesion is: a nodular BCC an infiltrative subtype of BCC provided a sufficient planning margin is used an excised BCC with involved margins. A Show 3 more As per ASTRO 2020 guidelines, offer definitive radiotherapy as a curative treatment modality in patients with BCC unable to undergo or declining surgical resection. B Show 4 more As per EORTC/EADO/EDF 2019 guidelines, offer radiotherapy as an alternative to surgery for BCC on the face, including periorbital regions and other anatomical regions, in elderly patients and in patients not suitable for surgery. A As per AAD 2018 guidelines: https://web.pathway.md/diseases/recwv4t9NOosmhAmc 4/8 6/29/23, 3:16 AM Basal cell carcinoma Pathway Consider offering radiotherapy (such as superficial radiation therapy, brachytherapy, external electron beam, or other traditional radiotherapy forms for BCC) in patients with low-risk tumors if surgical therapy is not feasible or preferred. C Insufficient evidence to recommend the routine use of electronic surface brachytherapy in patients with BCC. I Definitive radiotherapy (dosing): use conventional fractionation (180-200 cGy/fraction) for a total of 6,000-6,600 cGy for adjuvant radiotherapy after therapeutic lymphadenectomy. B Show 2 more Postoperative radiotherapy: offer postoperative radiotherapy in patients with clinically or radiologically apparent gross perineural spread. B Show 3 more Photodynamic therapy: As per BAD 2021 guidelines, offer topical photodynamic therapy as a treatment option in adult patients with low-risk BCC unsuitable for or declining standard surgical excision. A Show 2 more As per EDF 2019 guidelines, offer 5-ALA or methyl-5-amino-4-oxopentanoate in combination with red light in patients with superficial and thin nodular BCC. A As per AAD 2018 guidelines, consider offering methyl aminolevulinate- or ALA-photodynamic therapy in patients with low-risk tumors if surgical therapy is not feasible or preferred. B Laser therapy: As per BAD 2021 guidelines, insufficient evidence to recommend CO or pulsed-dye laser therapy in patients with BCC. I As per EDF 2019 guidelines, do not offer laser ablation in patients with BCC. D As per AAD 2018 guidelines, insufficient evidence to recommend laser therapy in patients with BCC. I 6. Surgical interventions Surgical excision: As per BAD 2021 guidelines, perform standard surgical excision as a first-line treatment option in adult patients with low-risk BCC. A Show 12 more As per EDF 2019 guidelines, perform surgical removal for the treatment and histological confirmation in patients with BCC. B Show 5 more As per AAD 2018 guidelines, perform surgical excision with 4-mm clinical margins and histologic margin assessment in patients with low-risk primary BCC. A Show 2 more https://web.pathway.md/diseases/recwv4t9NOosmhAmc 5/8 6/29/23, 3:16 AM Basal cell carcinoma Pathway 7. Specific circumstances Patients with nevoid basal cell carcinoma syndrome: As per BAD 2021 guidelines, offer vismodegib as a treatment option in adult patients with advanced BCC unsuitable for Mohs micrographic surgery, standard surgical excision or radiotherapy, including patients with nevoid BCC syndrome, following discussion at a multidisciplinary team. A As per EDF 2019 guidelines, establish the diagnosis of nevoid BCC syndrome based on clinical criteria. Consider offering genetic testing for germline mutations in the Hedgehog pathway in selected patients. B Show 2 more 8. Patient education General counseling: Provide verbal and written information about BCC in all adult patients with BCC, including the nature and prognosis of BCC, available treatment options and the ongoing need for sun protection and self-surveillance of their skin as part of prevention or early detection of future skin tumors. A Inform all adult patients with BCC declining all treatments that the risk of significant progression of the tumor is at least 25% over 2-5 years. A 9. Preventative measures Primary prevention: Counsel persons with fair skin types aged 6 months to 24 years and parents of young children about minimizing exposure to UV radiation to reduce the risk of skin cancer. B Offer counseling selectively in adults > 24 years with fair skin types about minimizing exposure to UV radiation to reduce the risk of skin cancer, taking into consideration the presence of risk factors for skin cancer. B Secondary prevention: counsel patients with a history of BCC on skin self-examination and sun protection. B Show 3 more 10. Follow-up and surveillance Postoperative evaluation: Do not offer routine follow-up in patients with adequately treated isolated BCC, unless for a postoperative review. D Offer a postoperative review in adult patients with adequately treated BCC by an appropriate healthcare professional, in either secondary or primary care, if possible. E https://web.pathway.md/diseases/recwv4t9NOosmhAmc 6/8 6/29/23, 3:16 AM Basal cell carcinoma Pathway Skin reconstruction after tumor resection (timing): consider performing reconstructive surgery in a delayed (asynchronous) fashion in adult patients after skin cancer resection. C Skin reconstruction after tumor resection (perioperative antibiotics): consider discussing the management of antibiotics with adult patients undergoing reconstruction after skin cancer resection when relevant. C Show 3 more Skin reconstruction after tumor resection (perioperative antithrombotics): consider discussing the management of anticlotting agents with adult patients undergoing reconstruction after skin cancer resection when relevant. C Show 2 more Skin reconstruction after tumor resection (perioperative analgesics): consider discussing the management of pain with adult patients undergoing reconstruction after skin cancer resection when relevant. C Show 2 more Skin reconstruction after tumor resection (follow-up): consider obtaining postoperative follow- up assessment in adult patients undergoing reconstruction after skin cancer resection. C Surveillance for future malignancies: As per BAD 2021 guidelines, offer at least yearly follow-up, if possible, in adult patients with a history of multiple BCC likely to develop further tumors or recurrence within 12 months. E As per EDF 2019 guidelines, follow-up patients with BCC in 3, 6 or 12 monthly intervals according to the risk category. B As per AAD 2018 guidelines, obtain skin cancer screening for new keratinocyte cancers (BCC or cutaneous SCC) and for melanoma on at least an annual basis after diagnosis of first BCC. A Clinical findings Patient demographics Symptoms Elderly Itching Skin growth Past medical history Social history Exposure to radiation therapy Xeroderma pigmentosum Exposure to excessive sun Integument exam Fitzpatrick skin type 1 Nonhealing skin lesion Skin nodule Skin plaque https://web.pathway.md/diseases/recwv4t9NOosmhAmc 7/8 6/29/23, 3:16 AM Basal cell carcinoma Pathway References 1. Work Group, Invited Reviewers, John Y S Kim et al. Guidelines of care for the management of basal cell carcinoma. J Am Acad Dermatol. 2018 Mar;78 3 540 559. Open 2. US Preventive Services Task Force, Grossman DC, Curry SJ et al. Behavioral Counseling to Prevent Skin Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Mar 20;319 11 1134 1142. Open 3. Anna Likhacheva, Musaddiq Awan, Christopher A Barker et al. Definitive and Postoperative Radiation Therapy for Basal and Squamous Cell Cancers of the Skin: Executive Summary of an American Society for Radiation Oncology Clinical Practice Guideline. Pract Radiat Oncol. Jan-Feb 2020;10 1 8 20. Open 4. Peris K, Fargnoli MC, Garbe C et al. Diagnosis and treatment of basal cell carcinoma: European consensus-based interdisciplinary guidelines. Eur J Cancer. 2019 Sep;118 10 34. Open 5. Andrew Chen, John G Albertini, Jeremy S Bordeaux et al. Evidence-Based Clinical Practice Guideline: Reconstruction after Skin Cancer Resection. Plast Reconstr Surg. 2021 May 1;147 5 812e-829e. Open 6. US Preventive Services Task Force, Carol M Mangione, Michael J Barry et al. Screening for Skin Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2023 Apr 18;329 15 1290 1295. Open 7. I Nasr, E J McGrath, C A Harwood et al. British Association of Dermatologists guidelines for the management of adults with basal cell carcinoma 2021. Br J Dermatol. 2021 Nov;185 5 899 920. Open 8. Lang BM, Balermpas P, Bauer A et al. S2k Guidelines for Cutaneous Basal Cell Carcinoma Part 1 Epidemiology, Genetics and Diagnosis. J Dtsch Dermatol Ges. 2019 Jan;17 1 94 103. Open 9. Lang BM, Balermpas P, Bauer A et al. S2k Guidelines for Cutaneous Basal Cell Carcinoma Part 1 Epidemiology, Genetics and Diagnosis. J Dtsch Dermatol Ges. 2019 Jan;17 1 94 103. Open 10. Alexander G Marzuka, Samuel E Book. Basal cell carcinoma: pathogenesis, epidemiology, clinical features, diagnosis, histopathology, and management. Yale J Biol Med. 2015 Jun 1;88 2 167 79. eCollection 2015 Jun. Open 11. Emi Dika, Federica Scarf , Manuela Ferracin et al. Basal Cell Carcinoma: A Comprehensive Review. Int J Mol Sci. 2020 Aug 4;21 15 5572. Open 12. C A Morton, R M Szeimies, N Basset-Seguin et al. European Dermatology Forum guidelines on topical photodynamic therapy 2019 Part 1 treatment delivery and established indications - actinic keratoses, Bowen's disease and basal cell carcinomas. J Eur Acad Dermatol Venereol. 2019 Dec;33 12 2225 2238. Open https://web.pathway.md/diseases/recwv4t9NOosmhAmc 8/8