Most dermatologists were comfortable monitoring nodular and/or superficial/multifocal BCCs less than 1 cm in diameter on low- or medium-risk sites (trunk, extremities, neck or scalp) while less than 50% were comfortable monitoring larger tumors.
Clinical Pearls
The objectives of this study were to determine dermatologists’ comfort level with active surveillance of BCCs, and understand which factors and concerns influence their decisions to monitor rather than to treat BCCs
Most dermatologists were comfortable monitoring nodular and/or superficial/multifocal BCCs less than 1 cm in diameter on low- or medium-risk sites (trunk, extremities, neck or scalp) while less than 50% were comfortable monitoring larger tumors
The most common concerns with active surveillance were larger surgical-site defects (84%), bleeding (83%), ulceration (80%), local destruction to adjacent vital organs (64%) and pain (51%)
Discussion:
Basal cell carcinoma (BCC) is the most common form of skin cancer and over 2-5 million individuals are diagnosed with this malignancy in the United States. As BCCs are most often treated regardless of life expectancy, there is concern we may be over diagnosing and overtreating BCC cases, especially in older adults with limited life expectancy (LLE) and low-risk asymptomatic lesions. The objectives of this study were to determine dermatologists’ comfort level with active surveillance of BCCs, and understand which factors and concerns influence their decisions to monitor rather than to treat BCCs.
A cross sectional survey was completed of dermatologist members of the US Association of Professors of Dermatology in August and September of 2019 to evaluate dermatologists’ attitudes regarding active surveillance of BCCs. The main outcomes were percentage of dermatologists comfortable with the concept of active surveillance for BCCs, factors influencing their decision to monitor BCCs rather than treat, and feared complications.
The response rate was 13% with 70/528 members completing the survey. Eighty-three per cent of respondents felt comfortable monitoring nodular and/or superficial/multifocal BCCs. The factors that dermatologists considered when determining comfort with monitoring a BCC included medical comorbidities (90%), functional status (84%), age (83%), anatomical location (77%), size (71%) and histological subtype (66%). The most common concerns with active surveillance were larger surgical-site defects (84%), bleeding (83%), ulceration (80%), local destruction to adjacent vital organs (64%) and pain (51%). Of note, metastasis (6%) and death (6%) were not common concerns.
Overall, the authors found most dermatologists are comfortable with active surveillance of low-risk BCCs (defined by NCCN and BAD BCC guidelines) in patients with LLE. The major factors clinicians considered in monitoring BCCs included medical comorbidities, functional status, age, anatomical location, size, and histological subtype. Limitations include a low response rate, small sample size, and participation limited to academic dermatologists.
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