What's the best treatment approach for a high-risk basal cell carcinoma (BCC) in a frail patient with dementia?

From the Guidelines

The best treatment approach for high-risk basal cell carcinoma (BCC) in a frail patient with dementia is typically a conservative, minimally invasive approach that balances cancer control with the patient's overall well-being and quality of life. For such patients, the following treatment options may be considered:

• Topical therapy with 5% imiquimod cream applied once daily, five days per week for 6-12 weeks may be appropriate for superficial BCCs, as it has been shown to be effective with minimal side effects 1.
• Photodynamic therapy involving application of aminolevulinic acid followed by light activation can be effective with minimal side effects, and may be preferred in patients who are unable to tolerate the downtime associated with weeks to months of local skin irritation 1.
• For more invasive BCCs, consider simple surgical excision under local anesthesia rather than Mohs surgery, as it requires less time and cooperation from the patient 1.
• If surgery is contraindicated, radiation therapy delivered in fewer, larger fractions (hypofractionation) such as 5-7 treatments over 1-2 weeks might be suitable, as it can provide effective treatment with minimal side effects 1.
• Hedgehog pathway inhibitors like vismodegib (150mg daily orally) can be considered for advanced cases, though side effects must be carefully monitored, as they have been shown to be effective in treating metastatic and locally advanced BCC 1. Treatment decisions should involve a multidisciplinary approach including the patient's caregivers, considering the patient's life expectancy, tumor characteristics, and potential treatment burden, as patient-specific factors such as general fitness, coexisting serious medical conditions, and the use of antiplatelet or anticoagulant medication may influence the choice of treatment 1.

From the FDA Drug Label

The diagnosis should be established prior to treatment, since this method has not been proven effective in other types of basal cell carcinomas. With isolated, easily accessible basal cell carcinomas, surgery is preferred since success with such lesions is almost 100%. In the 5% strength, it is also useful in the treatment of superficial basal cell carcinomas when conventional methods are impractical, such as with multiple lesions or difficult treatment sites.

The best treatment approach for a high-risk basal cell carcinoma (BCC) in a frail patient with dementia is not explicitly stated in the provided drug labels. However, considering the patient's frailty and dementia, surgery may not be the most suitable option due to potential risks and complications.

• Topical treatment with 5-fluorouracil (5% strength) may be considered for superficial basal cell carcinomas, especially when conventional methods are impractical.
• Sonidegib is another option, but its use may be limited by its potential adverse reactions, such as musculoskeletal adverse reactions, which may be a concern in frail patients. Given the lack of direct information on treating high-risk BCC in frail patients with dementia, a conservative approach would be to consult with a specialist, such as a dermatologist or oncologist, to determine the best course of treatment for this specific patient population 2 3.

From the Research

Treatment Approaches for High-Risk BCC in Frail Patients with Dementia

• The treatment of high-risk basal cell carcinoma (BCC) in frail patients with dementia requires a multidisciplinary approach, considering the patient's overall health and potential tolerability of different treatments 4.
• For high-risk BCC, microscopically controlled surgery is recommended, but this may not be suitable for all frail patients with dementia 4.
• In such cases, alternative treatments like topical therapies (e.g., 5% imiquimod, 5% fluorouracil) or destructive approaches (e.g., curettage, electrocautery, cryotherapy, laser ablation) may be considered 4.
• Photodynamic therapy is also an effective treatment for superficial BCC and thin nodular BCC, and may be a viable option for frail patients with dementia 4.
• Radiotherapy represents a valid alternative to surgery for BCC on the face, especially in elderly patients, and may be considered for frail patients with dementia 4.

Hedgehog Inhibitors and Other Systemic Therapies

• Hedgehog inhibitors, such as vismodegib and sonidegib, are approved for the treatment of advanced BCC and may be considered for high-risk BCC in frail patients with dementia 5, 6.
• These therapies have shown efficacy in clinical trials, but their use in frail patients with dementia requires careful consideration of potential side effects and tolerability 5, 6.
• Immunotherapy with anti-programmed cell death 1 (PD-1) antibodies is a promising therapeutic option, currently being investigated in clinical trials, but its use in frail patients with dementia is not yet established 4.

Topical Therapies and Their Efficacy

• Topical therapies like imiquimod 5% and fluorouracil 1% creams have shown efficacy in the treatment of complex eyelid BCC, including in elderly patients with co-morbidities 7.
• These therapies may be considered for high-risk BCC in frail patients with dementia, but their use requires careful monitoring of side effects and treatment response 7.
• Dermoscopy can be a useful tool in monitoring treatment response and detecting residual disease after incomplete surgical excision or topical therapy 8.