Interventions for Basal Cell Carcinoma

Abridged Cochrane Systematic Review and Grade Assessments

J. Thomson; S. Hogan; J. Leonardi-Bee; H. C. Williams; F. J. Bath-Hextall


The British Journal of Dermatology. 2021;185(3):499-511. 

In This Article

Abstract and Introduction


Background: Basal cell carcinoma (BCC) is the most common cancer affecting white-skinned individuals, and the worldwide incidence is increasing. Although rarely fatal, BCC is associated with significant morbidity and costs.

Objectives: To assess the effects of interventions for primary BCC in immunocompetent adults.

Methods: We updated our searches of the following databases to November 2019: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and LILACS. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation method. We used standard methodological procedures expected by Cochrane.

Results: We included 52 randomized controlled trials with 6990 participants (median age 65 years; range 20–95). Mean study duration was 13 months (range 6 weeks–10 years). Ninety-two per cent (n = 48/52) of studies exclusively included histologically low-risk BCC (nodular and superficial subtypes). The certainty of evidence was predominantly low or moderate for the outcomes of interest. Overall, surgical interventions have the lowest recurrence rates, and there may be slightly fewer recurrences with Mohs micrographic surgery over surgical excision for primary, facial BCC (high-risk histological subtype or located in the 'H-zone' or both) (low-certainty evidence). Nonsurgical treatments, when used for low-risk BCC, are less effective than surgical treatments, but recurrence rates are acceptable and cosmetic outcomes are probably superior.

Conclusions: Surgical interventions have lower recurrence rates and remain the gold standard for high-risk BCC. Of the nonsurgical treatments, topical imiquimod has the best evidence to support its efficacy for low-risk BCC. Priorities for future research include agreement on core outcome measures and studies with longer follow-up.


Basal cell carcinoma (BCC) is the most common skin cancer and the most common cancer found in white-skinned individuals.[1–3] BCCs are slow-growing, locally invasive, malignant (but not life-threatening), epidermal skin tumours.[4,5] BCCs affect the head and neck region around 70% of the time, and the trunk and extremities around 30% of the time.[6] A systematic review identified that the incidence of BCC is increasing in Europe by 5·5% annually.[3] Between 2013 and 2015 there was a mean annual percentage increase of 5% in BCC incidence across the UK.[6]

Clinicopathological features are used to differentiate BCCs into high- and low-risk subtypes, which has implications on management. High-risk BCCs include morphoeic, infiltrative and micronodular histological subtypes; the presence of perineural or perivascular invasion; size > 5 cm; a recurrent lesion; a centrofacial location, including periocular areas and the ears; and host immunosuppression.[2] Low-risk BCCs include superficial and nodular histological subtypes when they are located at a low-risk site (e.g. not centrofacial location).

Numerous interventions are available for treating BCC, with the primary aim of treatment being to remove or destroy the lesion completely, resulting in cure with minimal risk of recurrence. Tumour removal should also be balanced against the patient's requirement for a good/acceptable cosmetic result. The first-line treatment of BCC is often surgical excision (SE) with Mohs micrographic surgery (MMS) reserved for high-risk sites. Numerous alternatives are available and include surgery under frozen section margin control; radiotherapy; photodynamic therapy (PDT); curettage and cautery ('electrodesiccation'); cryosurgery ('cryotherapy'); laser; electrochemotherapy; immunomodulators; topical chemotherapy; intralesional chemotherapy; systemic chemotherapy; and targeted molecular therapy (hedgehog pathway inhibitors).

This article is a summary of a Cochrane review that evaluated the effects of interventions for BCC,[7] providing the best available evidence to healthcare providers and patients so that they can weigh up the risks and benefits of treatments, and to allow and promote shared decision-making.