White GM, Zhou HC, Burchette RJ. Biopsy Followed by Immediate Curettage and Electrodesiccation of Suspected Basal Cell Carcinomas at the First Visit. JAMA Dermatol. 2013;149(8):980-981. doi:10.1001/jamadermatol.2013.727
The diagnosis and treatment of basal cell carcinoma (BCC) represents a significant portion of the work for many dermatologists. Any efficiency in this endeavor is welcome. This study assesses the value of both biopsying and treating a suspected BCC on the first visit.
The purpose of this study was to determine both the positive predictive value (PPV) and the success rate (SR) for the biopsy and treatment at the same (first) visit of a lesion suspected of being a BCC. The PPV was the proportion of cases that our algorithm identified as positive for BCC that actually were BCC on histologic analysis. The SR was defined as the proportion of lesions that were treated appropriately (BCC, squamous cell carcinoma [SCC], Bowen disease, or actinic keratosis) out of the total treated with curettage and electrodesiccation (C & D) on the first visit. The entrance criteria were as follows: (1) The lesion was biopsied by a dermatologist in the department of dermatology; (2) the lesion was thought to be a BCC and BCC only (eg, lesions that the medical chart noted as “rule out BCC vs SCC” were excluded); and (3) the lesion was biopsied and treated with C & D at that same (first) visit.
A retrospective medical chart analysis was performed over approximately 1 year from July 2011 to July 2012. Fifteen dermatologists worked in the department during that time. For any given physician, the 3 most recent months of patient data were analyzed in an attempt to fill the study. The goal was to have at least 500 data points (individual biopsies). After 1 cycle through all 15 dermatologists, the study had not been filled, so an additional 3 months of patient data were analyzed for some of the physicians (chosen at random). The total number of data points was 524.
For all lesions that met these entrance criteria, the results of the biopsy were recorded. The positive predictive value for all lesions was determined twice: first, for all lesions for which the pathologic finding was found to be BCC (PPV), and second for all lesions found to be either a BCC, SCC, Bowen disease, or actinic keratosis (SR)—diagnoses for which C & D is appropriate.
This study was approved by the Kaiser Permanente Southern California institutional review board.
A total of 524 individual biopsies by 15 dermatologists were studied. Many patients had multiple lesions. The positive predicted proportion of BCC was 84.0% (95% CI, 80.5%-87.0%) (Table 1). The positive predicted proportion for BCC, SCC, Bowen disease, or actinic keratosis (SR) was 95.8% (95% CI, 93.7%-97.4%) (Table 2). The individual SR for each of the 15 dermatologists was also calculated (data not shown). These individual SRs varied from 86.84% to 100% showing no outliers. No melanomas or Merkel cell cancers were inadvertently treated with C & D in this study. Benign lesions that were inadvertently treated with C & D were as follows: scar, syringoma, inflammation, purpura, inverted follicular keratosis, epidermal inclusion cyst, seborrheic keratosis, fungal folliculitis, acanthosis, comedone, benign nevus, digital mucous cyst, and sebaceous hyperplasia.
Basal cell carcinoma is the most common cancer. The cost of its diagnosis and treatment represents a large percentage of the budget for departments of dermatology. The biopsy and immediate C & D at the first visit of a lesion suspected to be a BCC has the potential for improving efficiency. There is a risk, however, that nonmalignant lesions will inadvertently be overtreated or that amelanotic melanomas will be treated and prognostic information (eg, depth of melanoma) will be lost. This study did not address histologic patterns (eg, sclerosing BCC, perineural invasion). If a histologic pattern is found that conveys a high risk of recurrence, surgery at the treatment site can always be performed.
In our pilot study, 84% of lesions thought initially to be BCC turned out to be BCC histologically. Furthermore, 95.8% of the time, C & D was the appropriate treatment for the pathologic diagnosis. Note that all health care providers in this study were board-certified dermatologists. These results cannot be generalized to nondermatologists.
In conclusion, this study supports the notion that performing C & D at the first visit of a lesion suspected of being a BCC by a board-certified dermatologist can be an efficient approach, with a high success rate and a low risk of negative outcomes.
Corresponding Author: Gary M. White, MD, Department of Dermatology, Kaiser Permanente, 7060 Clairemont Mesa Blvd, San Diego, CA 92110 (Gary.M.White@kp.org).
Published Online: June 12, 2013. doi:10.1001/jamadermatol.2013.727.
Author Contributions: Dr White had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: White.
Acquisition of data: White.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: White.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Zhou, Burchette.
Administrative, technical, and material support: White.
Study supervision: White.
Conflict of Interest Disclosures: None reported.