From the Guidelines
Basal cell carcinoma in a 60-year-old male requires prompt evaluation by a dermatologist or surgical oncologist for definitive treatment, with the primary treatment being complete surgical removal, typically through excision with appropriate margins or Mohs micrographic surgery, as recommended by the NCCN guidelines 1. The goal of primary treatment is to cure the tumor while maximizing preservation of function and cosmesis, with surgical approaches often offering the most effective and efficient means of accomplishing this, as stated in the NCCN guidelines 1.
- The treatment options for basal cell carcinoma include:
- Surgical excision with appropriate margins
- Mohs micrographic surgery
- Radiation therapy, which is often reserved for patients over 60 years due to concerns about long-term sequelae, as mentioned in the NCCN guidelines 1
- Topical treatments like 5-fluorouracil or imiquimod for small, superficial lesions
- Following treatment, the patient should undergo regular skin examinations every 6-12 months, as having one basal cell carcinoma increases the risk of developing additional skin cancers, and prevention measures are essential, including daily application of broad-spectrum sunscreen (SPF 30+), wearing protective clothing and wide-brimmed hats, avoiding peak sun hours (10 AM to 4 PM), and performing monthly self-skin examinations, as recommended by the NCCN guidelines 1.
- The NCCN guidelines also recommend considering multidisciplinary tumor board consultation for complicated cases or when surgery and radiation therapy are contraindicated, and the use of hedgehog pathway inhibitors, such as vismodegib and sonidegib, for advanced and metastatic basal cell carcinoma, as stated in the NCCN guidelines 1.
From the FDA Drug Label
ERIVEDGE is indicated for the treatment of adults with metastatic basal cell carcinoma, or with locally advanced basal cell carcinoma that has recurred following surgery or who are not candidates for surgery and who are not candidates for radiation.
In two double-blind, vehicle-controlled clinical studies, 364 subjects with primary sBCC were treated with imiquimod cream or vehicle cream 5 times per week for 6 weeks.
Of imiquimod-treated subjects, 6% (11/178) who had both clinical and histological assessments post-treatment, and who appeared to be clinically clear had evidence of tumor on excision of the clinically-clear treatment area.
Data on composite clearance (defined as both clinical and histological clearance) are shown in the table below
Table 12: Composite Clearance Rates at 12 Weeks Post-Treatment for Superficial Basal Cell Carcinoma
Study Imiquimod Cream Vehicle Cream
Study sBCC1 70% (66/94) 2% (2/89)
Study sBCC2 80% (73/91) 1% (1/90)
Total 75% (139/185) 2% (3/179)
The treatment options for a 60-year-old male with basal cell carcinoma are:
- Vismodegib (PO): indicated for the treatment of adults with metastatic basal cell carcinoma, or with locally advanced basal cell carcinoma that has recurred following surgery or who are not candidates for surgery and who are not candidates for radiation 2.
- Imiquimod (TOP): for the treatment of superficial basal cell carcinoma, with a composite clearance rate of 75% (139/185) at 12 weeks post-treatment 3. Key points to consider:
- The patient's age and type of basal cell carcinoma should be taken into account when choosing a treatment option.
- Imiquimod (TOP) has been shown to be effective in treating superficial basal cell carcinoma, but may not be suitable for more advanced cases.
- Vismodegib (PO) is indicated for more advanced cases of basal cell carcinoma, but may have different side effects and considerations compared to imiquimod (TOP).
From the Research
Treatment Options for Basal Cell Carcinoma
- Surgical excision is considered the standard treatment for basal cell carcinoma (BCC) 4, 5
- Mohs micrographic surgery is a highly effective treatment option, especially for high-risk lesions, with the highest cure rates and minimal invasiveness 5, 6, 7
- Other treatment options include radiotherapy, cryotherapy, photodynamic therapy, topical imiquimod, and topical 5-fluorouracil (5-FU) 4, 5, 8
- Hedgehog pathway inhibitors, such as vismodegib and sonidegib, have emerged as an important treatment option for advanced BCC 4, 5
Considerations for Elderly Patients
- Treatment decisions for BCC in elderly patients should be tailored to achieve patients' goals of care within their anticipated life expectancy 8
- Radiotherapy is a suitable alternate treatment option for surgical methods in older patient populations 5
- Other treatment options, such as electrodessication and curettage, cryosurgery, imiquimod, photodynamic therapy, and 5-fluorouracil, may also be considered based on tumor characteristics and patient preferences 8
Efficacy of Treatment Options
- Mohs micrographic surgery has been shown to have a lower recurrence rate compared to surgical excision, especially for high-risk facial BCC 7
- The 10-year cumulative probabilities of recurrence were 4.4% after Mohs micrographic surgery and 12.2% after surgical excision for primary BCC 7
- A substantial proportion of recurrences occurred after more than 5 years post-treatment, stressing the need for long-term follow-up in patients with high-risk facial BCC 7