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Traffic light skin cancer management sheet 2015 version

Basal and squamous cell carcinoma – a short guide to treatment **

Treatment

Invasive SCC & keratoacanthoma

Superficial BCCs & SCC in situ (Bowen’s)

Nodular & other BCCs

Actinic keratoses

Surgical excision

(Most cases will be amenable to simple excision and direct primary closure)

Treatment of choice for almost all SCCs.  Minimum clinical margin of 4mm.  Greater margin for higher risk tumours.

Benchmark treatment but often non excisional treatments are appropriate. Often simpler treatments preferable.  See options below

Treatment of choice except for tumours to be considered for margin control approach.  Minimum 3mm (nodular) but usually 4mm clinical margin.

Not a treatment of choice unless there is doubt over diagnosis and invasive SCC to be excluded.

Margin control surgery including Mohs surgery and “Slow Mohs”

Strongly suggested for high risk tumours on difficult sites on face. Consider also for less aggressive SCC tumours on “H zone” ##.

Not applicable - excessive

Mohs is benchmark approach for recurrent, poorly defined or > 1 cm on H zone ## or on the rest of face when both poorly defined and > 1 cm in diameter.

Not applicable - excessive

Delineating curettage followed by surgical excision

As an alternative when Mohs surgery is contemplated.  Supervised training in this specialised technique is essential.

Not applicable - excessive

As an alternative when Mohs surgery is contemplated.  Contraindicated on nose.  Supervised training is essential.

Not applicable – excessive

Cryotherapy

(Requires histologic confirmation and follow up except when used for Actinic keratoses)

Contraindicated

Efficacy inadequate

Prolonged 30 sec freeze with 3mm margin or freeze / thaw / freeze with 3mm margin.  Better combined with curettage prior to cryotherapy. 

Avoid prolonged usage on face (hypopigmentation)

Contraindicated

Efficacy inadequate

Benchmark approach for individual lesions.  6 -10 second freeze cycle directly to the lesion.  Unsuitable for field change.

Curettage

(Training essential.

Always send curettings for histology.

Follow up essential)

Contraindicated

Efficacy inadequate

Serial curette often appropriate.  Recommended to use supplementary ablation of further tissue layer with cryotherapy or diathermy. Caution on thick hair bearing areas: scalp, beard, pubic regions

Efficacy poor.

Consider only for very small well defined nodular BCCs on trunk or elsewhere when excisional surgery not appropriate

Not a treatment of choice – consider when hyperkeratotic or diagnosis in doubt.

Caution with keratoacanthoma.  Technique difficult.

**     This guide is a short ready reference guide only and should not be considered comprehensive.

##    “H zone” refers to the skin on or immediately adjacent to the ears, lips, nose and mouth.

∞∞     Only prescribe for TGA approved indications and consult product information on dosage schedules.

Professor Anthony Dixon – Australasian College of Cutaneous Oncology - 2015

Non surgical management options

Treatment

Invasive SCC & keratoacanthoma

Superficial BCCs & SCC in situ (Bowen’s)

Nodular & other BCCs

Actinic keratoses

Imiquimod

(Aldara ®) ∞∞

TGA Approved

(Follow up essential)

Not TGA approved

Efficacy inadequate based on clinical trials

Not TGA approved for Bowen’s

Not TGA approved

Efficacy inadequate based on clinical trials

Suitable for field change on face & scalp, treating ¼ of face at a time.  Minimum 3 times per week for 4 weeks.

Consider for biopsy proven superficial BCCs when not on H zone ## & when surgery inappropriate

Ingenol

Mebutate

(TGA approved)

Contraindicated

Efficacy inadequate

Not TGA Approved

Contraindicated

Trials pending

Not TGA approved

Contraindicated

Efficacy inadequate

Not TGA Approved

Suitable for face and scalp (3 daily applications) or limbs and trunk (2)

5 fluorouracil

(Efudix ®) ∞∞

TGA Approved

(Follow up essential)

Not TGA approved and efficacy inadequate based on clinical trials

Not TGA approved for superficial BCC

Not TGA approved

Efficacy inadequate based on clinical trials

Suitable for field change.  Twice daily for 2 to 4 weeks.  Regular reviews needed.

Suitable for Bowen’s when localised & biopsy proven when surgery inappropriate

Diclofenac

(Solaraze ®) ∞∞

TGA Approved

Not TGA approved and efficacy inadequate based on clinical trials

Not TGA approved and efficacy inadequate based on clinical trials

Not TGA approved

Efficacy inadequate based on clinical trials

Suitable for field change but efficacy limited.  Twice daily for 90 days.

Photodynamic therapy ∞∞

TGA Approved

MAL -  Metvix (Galderma)

Contraindicated

Not TGA approved

Efficacy inadequate

When localised biopsy proven, not on H zone ## & surgery considered inappropriate. Warning re high recurrence rates

high recurrence rates mean this approach only when others inappropriate. Consider rarely for very thin nodular BCCs not on H zone ##

Suitable for field change to face and scalp ∞∞

Do not expect reduced future cancers

Photodynamic therapy ∞∞

ALA – inc:

Tru PDT (Allmedic)

Photodynamix therapy

ACP – 5 ALA

Photocure

Contraindicated

Not TGA approved

Safety & efficacy concerns

Contraindicated

Not TGA approved

Safety & efficacy concerns

Contraindicated

Not TGA approved

Safety & efficacy concerns

Contraindicated

Not TGA approved

Safety & efficacy concerns

Superficial X Ray therapy

(Largely when patient declines surgery)

Consider when biopsy proven and surgery inappropriate in older patients in difficult locations

Contraindicated – excessive

Consider when biopsy proven and tumour well defined only when surgery inappropriate in older patients

Contraindicated – excessive

Radium

weed (Euphorbia

peplis), Milk vetch, Alovera

Contraindicated

Efficacy inadequate

Not TGA approved

Contraindicated

Efficacy inadequate

Not TGA Approved

Contraindicated

Efficacy inadequate

Not TGA Approved

Contraindicated

Efficacy inadequate

Not TGA Approved