Treatment of most common skin cancer can sometimes wait

Basal cell cancer, the most common form of skin cancer, does not always need to be removed immediately. The so-called watchful waiting, in which a doctor does not treat the tumor but does monitor it regularly, can be a good option for some patients. This is evident from a publication in JAMA Dermatology by researchers Satish Lubeek and Marieke van Winden and their team of the Radboudumc.

Basal cell carcinoma occurs mainly in older patients with a light skin tone. It usually occurs on parts of the body that get a lot of sun exposure, such as the head and neck, but also on the torso, for example. Per year many tens of thousands of patients in the Netherlands get a basal cell carcinoma. This skin cancer grows slowly, rarely spreads and is almost never life threatening. The treatment is relatively simple: removing the tumor. This is inexpensive and carries little risk. So why would you want to wait to treat?

"People have different reasons for not planning surgery right away," answers Marieke van Winden, dermatologist in training at Radboudumc and first author of the article. "For example, because of a short life expectancy, or poor health. Also, sometimes a tumor gives few symptoms and grows very slowly. Or people are afraid of the burden and the aftermath of treatment. But until now, little was known about the consequences of waiting, making it difficult for dermatologists to give advice. We have now investigated this."

Deciding together

For the study, the research team followed 280 tumors spread across 89 patients. Every three months the patients came for a check-up. Sometimes the doctor and the patient decided together whether the tumor should still be removed. This generally took place after seven months. In almost all cases, this could be done in exactly the same way as at the start of the course, even if the tumor had grown slightly. Especially for a certain subtype of basal cell carcinoma, namely nodular and superficial basal cell tumors, doctors may consider waiting or abandoning treatment more often. In this study, these tumors were found to grow an average of only 1 millimeter per year. This makes them seem like a good candidate for watchful waiting.

According to Van Winden, the choice of whether or not to treat immediately is a good example of personalized care. "A doctor makes the consideration: what are the consequences of 1 to 2 millimeters of growth per year? It matters where the tumor is located. In the eye, 1 millimeter of growth can be a lot, while in the back it makes little difference. Also, a doctor always decides together with the patient. Some people want you to remove a tumor as quickly as possible. Others say, "Should all that still be done at my age?" and would rather wait. That's how we arrive at affordable and meaningful care together."

Wise considerations

Watchful waiting is already listed as a strategy in guidelines and recommendations for prostate cancer. Watchful waiting is also emerging for other types of cancer, but not yet for basal cell cancer. Van Winden: "While this cancer lends itself very well to easy monitoring because of its location on the skin. This study is hopefully a starting point for watchful waiting as a strategy. We still need to do a larger follow-up study and the development of guidelines takes a lot of time. But for these types of tumors, I see a future where we can sometimes forgo treatment based on sensible considerations."

About the publication

This article was published in JAMA Dermatology: Evaluation of Watchful Waiting and Tumor Behavior in Patients With Basal Cell Carcinoma. An Observational Cohort Study of 280 Basal Cell Carcinomas in 89 Patients. Marieke E. C. van Winden, Charlotte R. M. Hetterschijt, Ewald M. Bronkhorst, Peter C. M. van de Kerkhof, Elke M. G. J. de Jong, Satish F. K. Lubeek.

An editorial on this publication also appeared: Clinical Evidence on “Watchful Waiting” in Basal Cell Carcinoma. Mackenzie R. Wehner, MD, MPhil.

Thesis defense

On November 1 at 14.30 Marieke van Winden will defend her dissertation titled ‘A patient-centered approach in geriatric dermatology’. The live stream can be followed via this link.

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