Who determines whether a patient with a large squamous‑cell carcinoma or basal‑cell carcinoma is a surgical candidate?

Who Determines Surgical Candidacy for Large Squamous Cell or Basal Cell Carcinoma

The ultimate judgment regarding surgical candidacy must be made by the physician and the patient together in light of all circumstances presented by the individual patient, though patients with high-risk tumors should ideally be reviewed by a multiprofessional oncology team. 1

Primary Decision-Making Framework

Initial Assessment by Treating Physician

• The treating dermatologist or surgeon makes the initial determination of whether a patient can undergo surgical excision based on tumor characteristics, patient comorbidities, and functional considerations 1
• For large tumors, the physician must assess whether the tumor can be excised with adequate margins while preserving function and achieving acceptable cosmesis 1

Multiprofessional Team Review for High-Risk Cases

Patients with high-risk squamous cell carcinoma and those presenting with clinically involved lymph nodes should ideally be reviewed by a multiprofessional oncology team that includes: 1

• Dermatologist
• Pathologist
• Trained surgeon (usually plastic or maxillofacial surgeon)
• Clinical oncologist
• Clinical nurse specialist in skin cancer
• Appropriately trained oncology nurses 1

For basal cell carcinoma, the American Academy of Dermatology recommends consultation with a physician or multidisciplinary group with specific expertise in BCC (surgical, medical, or radiation oncologist, head and neck surgeon, plastic surgeon, or dermatologist specializing in BCC) for advanced tumors 1

Factors That Define Non-Surgical Candidacy

Medical Contraindications

• Patients for whom surgery is not feasible due to medical comorbidities should be offered alternative treatments such as radiation therapy 1
• Advanced tumors that are not surgically resectable require multiprofessional setting management to consider other therapeutic options 1

Tumor-Related Factors

• Some advanced tumors where surgical morbidity would be unacceptably high may be best treated by radiotherapy 1
• Negative margins unachievable by Mohs surgery or more extensive surgical procedures may necessitate non-surgical approaches 1
• Extensive perineural or large-nerve involvement may require adjuvant radiation therapy even after surgery 1

Patient Preference

• Patients who refuse surgery should be offered radiation therapy or other alternatives 2
• The decision-making process explicitly requires patient participation in determining the propriety of any specific therapy 1

Alternative Treatment Pathways for Non-Surgical Candidates

For Basal Cell Carcinoma

• Radiation therapy is often reserved for patients over 60 years due to concerns about long-term sequelae 1
• If surgery and radiation are contraindicated, consider multidisciplinary tumor board consultation and hedgehog pathway inhibitors (vismodegib or sonidegib) 1

For Squamous Cell Carcinoma

• Radiation therapy alone offers cure rates comparable with other treatments and may give the best cosmetic/functional result for certain locations (lip, nasal vestibule, ear) 1
• For stage IV disease, EGFR inhibitors such as cetuximab or erlotinib should be discussed as second-line treatments 3

Critical Pitfalls to Avoid

• Failing to involve a multiprofessional team for high-risk tumors or those with lymph node involvement, which can lead to suboptimal treatment planning 1
• Making unilateral decisions without patient input, as the guidelines explicitly state that both physician and patient must participate in the decision 1
• Assuming all elderly patients are non-surgical candidates without proper assessment, as age alone (particularly over 60) is primarily a consideration for radiation therapy sequelae rather than surgical eligibility 1
• Delaying multidisciplinary consultation for complicated cases, which can impact treatment outcomes 1