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Viewpoint
June 14, 2021

Active Surveillance as a Management Option for Low-risk Basal Cell Carcinoma

Author Affiliations
  • 1Department of Dermatology, Stanford University, Stanford, California
  • 2Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
JAMA Intern Med. 2021;181(8):1032-1033. doi:10.1001/jamainternmed.2021.2643

Active surveillance—defined as close monitoring without initial treatment—is an established management option for several low-risk, slow-growing cancers. The rationale is that some patients may experience the risks of unnecessary treatment even if the cancer would not progress and become harmful if left untreated. One example is prostate cancer: active surveillance is a frequent management option for localized, low-risk prostate cancer. The proportion of patients choosing this approach in the US increased from 14.5% in 2010 to 42.1% in 2015.1 Another example is low-risk papillary thyroid carcinoma; a recent meta-analysis showed that active surveillance was not associated with an increased risk of recurrence or death.2 Active surveillance for breast ductal carcinoma in situ is being evaluated in clinical trials.3 In this Viewpoint, we propose that active surveillance be evaluated as a management option for select patients with low-risk and asymptomatic basal cell carcinoma. A basal cell carcinoma can be considered low risk if it is smaller than 1 cm in diameter and located on the trunk or extremities and the patient is immunocompetent.

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    1 Comment for this article
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    Active surveillance for low-risk basal cell carcinoma: is there an alternative?
    Cristian Navarrete-Dechent, MD | Department of Dermatology, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
    We read with interest Linos and Chren article.1 We agree that low-risk basal cell carcinoma (BCC) is a significant public health issue. In the United States, the standard of care is to diagnose BCC through histopathological examination of a skin biopsy. The authors propose active surveillance rather than treatment for low-risk BCCs (i.e., asymptomatic lesion, immunocompetent individual, trunk/extremity, <1cm size, low-risk histopathological subtype). For patients with these lesions, physician follow-up every 3 months was suggested and if no “change” is documented after 2–4 evaluations, follow-up frequency could be extended to every 6 months. However, it is often difficult to differentiate scar from residual/recurrent BCC via visual inspection, making monitoring these biopsy sites challenging.2

    Instead of conducting a partial biopsy for suspected low-risk BCCs, we routinely perform a shave removal or excisional procedure with 2-3mm clinical margins. The intent is therefore to both diagnose and treat the lesion. This approach has advantages. First, by sampling the entire clinical tumor, the risk of missing high-risk histopathological features is reduced.3 Second, in the uncommon scenario where positive histopathological margins are encountered, it often suggests greater sub-clinical tumor extent than appreciated by clinical examination and allows one to incorporate this factor into shared medical decision-making. Third, amelanotic melanoma is occasionally identified among pink lesions clinically suspected to be BCC; an excisional procedure aids correct diagnostic interpretation, complete tumor microstaging, and appropriate treatment.4 Finally, BCCs confirmed to have low-risk histopathology and negative pathologic margins can be safely monitored on a routine follow-up schedule without the need for high-frequency physician examinations. This streamlined approach has the potential to reduce patient anxiety as well as healthcare costs.5

    In a single-institution retrospective analysis of this approach, of 204 lesions suspected to be low-risk BCCs, 202 were confirmed to be BCC (>99% diagnostic accuracy). Of these 202 BCCs, 179 (88%) had a low-risk histopathological subtype and 175 (86%) were successfully removed with clear pathological margins. One recurrence was reported after an average of 3-years of follow-up. A decision analytical model suggested that this strategy would reduce expenditures compared to usual care.5

    We applaud efforts to mitigate harms resulting from overdiagnosis and overtreatment of low-risk BCCs, which affects millions of patients worldwide. We hope this discussion motivates future, high-quality studies evaluating the validity, utility, and cost-effectiveness of novel diagnostic (including potential non-invasive tests, like reflectance confocal microscopy or molecular tape-stripping assays) and therapeutic approaches to these cancers.

    References:

    1. Linos E, Chren MM. JAMA Intern Med. 2021.
    2. Navarrete-Dechent C et al. J Am Acad Dermatol. 2019;81(2):417-426.
    3. Singh B, et al. Dermatol Surg. 2017;43(8):1003-1011.
    4. McClain SE, et al. Int J Dermatol. 2012;51(4):420-426.
    5. Wu X, et al. J Am Acad Dermatol. 2015;73(5):791-798

    Cristian Navarrete-Dechent, MD;1 Ashfaq A. Marghoob, MD;2 Michael A. Marchetti, MD.2
    1Department of Dermatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
    2 Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
    CONFLICT OF INTEREST: None Reported
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