What are the treatment options for skin cancer?

Treatment Options for Skin Cancer

The primary treatment for skin cancer is surgical removal of the tumor, with the specific approach determined by cancer type, location, and risk factors. 1

Types of Skin Cancer

Skin cancers are broadly categorized into:

1. Melanoma - Most dangerous form, accounts for 1% of skin cancers but causes most skin cancer deaths 1
2. Keratinocyte carcinomas (previously called nonmelanoma skin cancers):
   • Basal Cell Carcinoma (BCC) - Most common skin cancer
   • Squamous Cell Carcinoma (SCC) - Second most common skin cancer

Treatment Options by Cancer Type

Basal Cell Carcinoma Treatment

Low-Risk BCC:

• Curettage and electrodesiccation - For small, well-defined tumors in non-hair-bearing areas 1
• Standard surgical excision - With 4mm clinical margins 1
• Mohs micrographic surgery - For certain anatomical locations (face, genitals) 1
• Radiation therapy - For non-surgical candidates over 60 years 1
• Topical therapies (for superficial BCC only):
  • 5-fluorouracil 1, 2
  • Imiquimod 1, 3
  • Photodynamic therapy 1

High-Risk BCC:

• Mohs micrographic surgery - Preferred for high-risk tumors 1
• Surgical excision with complete margin assessment - Alternative to Mohs 1
• Adjuvant radiation therapy - For extensive perineural or large nerve involvement 1
• Hedgehog pathway inhibitors (vismodegib, sonidegib) - For advanced cases where surgery and radiation are contraindicated 1

Squamous Cell Carcinoma Treatment

• Surgical excision - Primary treatment of choice 1, 4
  • 4mm margins for low-risk tumors <2cm
  • 6mm or greater margins for high-risk or larger tumors
• Mohs micrographic surgery - For high-risk tumors or sensitive anatomic locations 1
• Radiation therapy - For non-surgical candidates or certain anatomic locations 1, 4
• Systemic therapy for advanced/metastatic SCC:
  • EGFR inhibitors (cetuximab) 4
  • Pembrolizumab (for PD-L1 positive tumors) 4, 5

Melanoma Treatment

• Surgical excision - Primary treatment with wider margins based on depth 1
• Sentinel lymph node biopsy - For staging 1
• Immunotherapy - For advanced melanoma 1
• Targeted therapy - For advanced melanoma 1

Treatment Selection Algorithm

1. Determine cancer type (BCC, SCC, or melanoma) through biopsy
2. Assess risk factors:
   • Tumor size (>2cm = higher risk)
   • Location (head/neck, genitals, hands/feet = higher risk)
   • Depth/invasion
   • Histologic features
   • Patient immune status
3. Select treatment based on risk assessment:
   • Low-risk tumors: Standard excision, curettage and electrodesiccation
   • High-risk tumors: Mohs surgery, wide excision with margin control
   • Non-surgical candidates: Radiation therapy, topical treatments, or systemic therapy

Special Considerations

• Elderly patients: Consider quality of life and comorbidities when selecting treatment 1
• Immunosuppressed patients: More aggressive treatment approach due to higher recurrence risk 1
• Cosmetically sensitive areas: Consider Mohs surgery or radiation therapy 4

Follow-up and Surveillance

• High-risk patients should be monitored for at least 5 years 4
• 95% of recurrences occur within 5 years 4
• Patient education on self-examination is essential 4

Common Pitfalls to Avoid

• Inadequate margins: Ensure appropriate margins based on tumor type and risk factors
• Overlooking perineural invasion: May require adjuvant radiation therapy
• Neglecting immunosuppressed patients: They require closer follow-up and may need more aggressive treatment
• Delaying treatment: Early intervention improves outcomes, particularly for melanoma where 5-year survival drops from 99.5% for localized disease to 31.9% for distant disease 1