Summary of recommendations

The guideline recommendations were approved by the Chief Executive Officer of the National Health and Medical Research Council (NHMRC) on
7 November 2019 under section 14A of the National Health and Medical Research Council Act 1992.

In approving the guideline recommendations, NHMRC considers that they meet the NHMRC standard for clinical practice guidelines. This approval is valid for a period of five years.

NHMRC is satisfied that the guideline recommendations are systematically derived, based on the identification and synthesis of the best available scientific evidence, and developed for health professionals practising in an Australian health care setting.

This publication reflects the views of the authors and not necessarily the views of the Australian Government.

Summary of recommendations

This is a summary of all recommendations in these guidelines, please note that some chapters do not have associated recommendations.

Recommendations and practice points were developed by working party members and subcommittee members. See NHMRC approved recommendation types and definitions table at the end of this page.

Each EBR was assigned a grade by the expert working group, taking into account the volume, consistency, generalisability, applicability and clinical impact of the body of evidence according to NHMRC Level and Grades for Recommendations for Guidelines Developers.

Jump to:

• 7. Surgical treatment*
• 8. Radiotherapy*
• 12. Metastatic disease and systemic therapies*
• 2. Prevention
• 3. Early detection
• 4. Clinical features
• 5. Pathology
• 6. Prognosis
• 9. Cryotherapy and electrodessication and curettage
• 10. Topical treatments and photodynamic therapy
• 11. Organ transplantation and conditions associated with immunosuppression
• 13. Follow-up
• 14. The role of primary care
• NHMRC approved recommendation types and definitions
• Evidence-based recommendation grades

*Note: this section is not in sequential order, those sections that were systematically reviewed (see the Technical report) and have EBRs are at the top, all other sections follow the order of the table of contents.

7. Surgical treatment

7.1 Considerations before selecting a surgical treatment modality

Evidence-based recommendation	Grade
EBR 7.1.1. Both surgical and nonsurgical treatment modalities can be considered for superficial and nodular basal cell carcinomas in favourable sites.	C

• Clinical question:What factors need to be considered when determining if surgical treatment modalities are optimal over non-surgical modalities for the management and/or treatment of BCC or SCC?#Recommendation_1
• EBR 7.1.1. Both surgical and nonsurgical treatment modalities can be considered for superficial and nodular basal cell carcinomas in favourable sites.
• Recommendation

7.3 Optimal surgical technique for the treatment of basal cell carcinoma

Evidence-based recommendation	Grade
EBR 7.3.1. Patients with high-risk recurrent facial basal cell carcinomas should be offered wide surgical excision or Mohs micrographic surgery. Regular follow-up should be provided.	C

• Clinical question:Factors to consider to determine optimal BCC treatment#Recommendation_1
• EBR 7.3.1. Patients with high-risk recurrent facial basal cell carcinomas should be offered wide surgical excision or Mohs micrographic surgery. Regular follow-up should be provided.
• Recommendation

Evidence-based recommendation	Grade
EBR 7.3.2. Non-surgical treatment modalities can be considered for patients with basal cell carcinomas assessed to have a low risk of recurrence based on favourable histological type (e.g. superficial or nodular types) and favourable anatomic locations (away from unique structures).	C

• Clinical question:Factors to consider to determine optimal BCC treatment#Recommendation_2
• EBR 7.3.2. Non-surgical treatment modalities can be considered for patients with basal cell carcinomas assessed to have a low risk of recurrence based on favourable histological type (e.g. superficial or nodular types) and favourable anatomic locations (away from unique structures).
• Recommendation

7.4 Considerations when planning surgical treatment for cutaneous squamous cell carcinoma

Practice point
PP 7.4.1. Referral to a multidisciplinary team or to a specialist for assessment and treatment should be considered for patients with cutaneous squamous cell carcinomas with poor prognostic features (e.g. poorly differentiated, fibrosing or ≥20mm).

• Clinical question:Factors to consider to determine optimal SCC treatment#Practice_point_1
• PP 7.4.1. Referral to a multidisciplinary team or to a specialist for assessment and treatment should be considered for patients with cutaneous squamous cell carcinomas with poor prognostic features (e.g. poorly differentiated, fibrosing or ≥20mm).
• Good practice point

7.5 Post-surgical care and interpretation of the pathology report

Practice point
PP 7.5.1. When perineural invasion is reported by the pathologist, the clinician should discuss this finding with the pathologist to ascertain its likely clinical significance.

• Guidelines:Keratinocyte carcinoma/Post-surgical care follow-up#Practice_point_1
• PP 7.5.1. When perineural invasion is reported by the pathologist, the clinician should discuss this finding with the pathologist to ascertain its likely clinical significance.
• Good practice point

Practice point
PP 7.5.2. Preoperative magnetic resonance imaging should be considered for patients with clinical evidence of perineural involvement.

• Guidelines:Keratinocyte carcinoma/Post-surgical care follow-up#Practice_point_2
• PP 7.5.2. Preoperative magnetic resonance imaging should be considered for patients with clinical evidence of perineural involvement.
• Good practice point

7.6 Protocol to manage incompletely resected basal cell carcinoma

Evidence-based recommendation	Grade
EBR 7.6.1. Incompletely excised basal cell carcinomas should be assessed and treatment selected on a case-by-case basis.	C

• Clinical question:Management protocol for incomplete resected BCC#Recommendation_1
• EBR 7.6.1. Incompletely excised basal cell carcinomas should be assessed and treatment selected on a case-by-case basis.
• Recommendation

Evidence-based recommendation	Grade
EBR 7.6.2. Incompletely excised basal cell carcinomas that have high-risk features, or occur in high-risk anatomical sites, should be re-excised, where possible.	C

• Clinical question:Management protocol for incomplete resected BCC#Recommendation_2
• EBR 7.6.2. Incompletely excised basal cell carcinomas that have high-risk features, or occur in high-risk anatomical sites, should be re-excised, where possible.
• Recommendation

7.7 Protocol to manage rapidly growing tumours

Evidence-based recommendation	Grade
EBR 7.7.1. For patients with cutaneous squamous cell carcinomas with features associated with poor prognosis, wider surgical margin should be planned, adjuvant radiotherapy should be considered, and regular follow-up for locoregional or distant recurrence should be provided.	C

• Clinical question:Management protocol for rapidly growing tumours#Recommendation_1
• EBR 7.7.1. For patients with cutaneous squamous cell carcinomas with features associated with poor prognosis, wider surgical margin should be planned, adjuvant radiotherapy should be considered, and regular follow-up for locoregional or distant recurrence should be provided.
• Recommendation

Evidence-based recommendation	Grade
EBR 7.7.2. For tumours with perineural invasion, the combination of surgery and radiotherapy is recommended when a nerve with diameter >0.1mm is involved.	C

• Clinical question:Management protocol for rapidly growing tumours#Recommendation_2
• EBR 7.7.2. For tumours with perineural invasion, the combination of surgery and radiotherapy is recommended when a nerve with diameter >0.1mm is involved.
• Recommendation

Evidence-based recommendation	Grade
EBR 7.7.3. Cutaneous squamous cell carcinomas with high-risk features should be managed with wider surgical margins, adjuvant radiotherapy, and regular follow-up for locoregional or distant recurrence.	C

• Clinical question:Management protocol for rapidly growing tumours#Recommendation_3
• EBR 7.7.3. Cutaneous squamous cell carcinomas with high-risk features should be managed with wider surgical margins, adjuvant radiotherapy, and regular follow-up for locoregional or distant recurrence.
• Recommendation

Practice point
PP 7.7.1. For patients with cutaneous squamous cell carcinoma, consider referral to a specialist or multidisciplinary team if there are any risk factors for poor prognosis, such as: size >2 cm in diameter tumour depth > 4 mm recurrent lesion high-risk anatomic location perineural invasion or lymphovascular invasion poorly differentiated subtype immunosuppression.

• Clinical question:Management protocol for rapidly growing tumours#Practice_point_1
• PP 7.7.1. For patients with cutaneous squamous cell carcinoma, consider referral to a specialist or multidisciplinary team if there are any risk factors for poor prognosis, such as:
• size >2 cm in diameter
• tumour depth > 4 mm
• recurrent lesion
• high-risk anatomic location
• perineural invasion or lymphovascular invasion
• poorly differentiated subtype
• immunosuppression.
• Good practice point

Practice point
PP 7.7.2. Patients with rapidly growing squamous cell carcinomas should be referred timely for assessment for specialised therapies or combination therapies.

• Clinical question:Management protocol for rapidly growing tumours#Practice_point_2
• PP 7.7.2. Patients with rapidly growing squamous cell carcinomas should be referred timely for assessment for specialised therapies or combination therapies.
• Good practice point

7.8 Criteria for choosing Mohs micrographic surgery in preference to other surgical techniques

Practice point

PP 7.8.1. Mohs micrographic surgery may also be considered as an alternative to wide surgical excision in the following types of basal cell carcinoma: poorly defined clinical border infiltrating, micronodular, sclerosing, and other aggressive histological subtypes residual following previous treatment located in the H‐zone of the face large >10mm in diameter on the face if utilising MMS compared to wide excision the defect size reduction would be of clinical value.

• Guidelines:Keratinocyte carcinoma/Criteria for Mohs surgery#Practice_point_1
• PP 7.8.1. Mohs micrographic surgery may also be considered as an alternative to wide surgical excision in the following types of basal cell carcinoma:
• poorly defined clinical border
• infiltrating, micronodular, sclerosing, and other aggressive histological subtypes
• residual following previous treatment
• located in the H‐zone of the face
• large >10mm in diameter on the face
• if utilising MMS compared to wide excision the defect size reduction would be of clinical value.
• Good practice point

7.9 Surgical management of advanced cutaneous squamous cell carcinoma

Practice point
PP 7.9.1. Dermal lymphatic spread (in-transit metastasis) should be managed by wide surgical excision followed by adjuvant radiotherapy.

• Guidelines:Keratinocyte carcinoma/Surgical management advanced SCC#Practice_point_1
• PP 7.9.1. Dermal lymphatic spread (in-transit metastasis) should be managed by wide surgical excision followed by adjuvant radiotherapy.
• Good practice point

Practice point
PP 7.9.2. For patients with cutaneous squamous cell carcinoma, consider referral to a specialist or multidisciplinary team if there are any risk factors for poor prognosis, such as: size >2 cm in diameter tumour depth > 4 mm recurrent lesion high-risk anatomic location perineural invasion or lymphovascular invasion poorly differentiated subtype immunosuppression.

• Guidelines:Keratinocyte carcinoma/Surgical management advanced SCC#Practice_point_2
• PP 7.9.2. For patients with cutaneous squamous cell carcinoma, consider referral to a specialist or multidisciplinary team if there are any risk factors for poor prognosis, such as:
• size >2 cm in diameter
• tumour depth > 4 mm
• recurrent lesion
• high-risk anatomic location
• perineural invasion or lymphovascular invasion
• poorly differentiated subtype
• immunosuppression.
• Good practice point

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8. Radiotherapy

8.1 Radiotherapy with or without surgical treatment for keratinocyte cancer

Evidence-based recommendation	Grade
EBR 8.1.1. Radiotherapy can be used alone in the treatment of keratinocyte cancers when surgery is not possible or the patient declines surgery.	D

• Clinical question:RT with or without surgery for KC treatment#Recommendation_1
• EBR 8.1.1. Radiotherapy can be used alone in the treatment of keratinocyte cancers when surgery is not possible or the patient declines surgery.
• Recommendation

Evidence-based recommendation	Grade
EBR 8.1.2. Radiotherapy may be used in combination with surgical excision with the aim of improving locoregional control.	D

• Clinical question:RT with or without surgery for KC treatment#Recommendation_2
• EBR 8.1.2. Radiotherapy may be used in combination with surgical excision with the aim of improving locoregional control.
• Recommendation

Practice point
PP 8.1.1. Radiotherapy should begin within 6 weeks following surgery, as macroscopic recurrence at the start of radiotherapy will necessitate a higher dose, which is associated with a higher risk of poor cosmetic and functional outcomes.

• Clinical question:RT with or without surgery for KC treatment#Practice_point_1
• PP 8.1.1. Radiotherapy should begin within 6 weeks following surgery, as macroscopic recurrence at the start of radiotherapy will necessitate a higher dose, which is associated with a higher risk of poor cosmetic and functional outcomes.
• Good practice point

8.2 Radiotherapy for basal cell carcinoma

Evidence-based recommendation	Grade
EBR 8.2.1. Radiotherapy using curative doses can be considered as an alternative to surgical excision in the definitive treatment of basal cell carcinoma if surgery is either declined by the patient or surgery is inappropriate.	D

• Clinical question:Patient outcomes of RT modality vs conventional surgery for BCC#Recommendation_1
• EBR 8.2.1. Radiotherapy using curative doses can be considered as an alternative to surgical excision in the definitive treatment of basal cell carcinoma if surgery is either declined by the patient or surgery is inappropriate.
• Recommendation

Consensus-based recommendation
CBR 8.2.1. For patients with T3/T4 primary persistent or recurrent basal cell carcinoma, consideration should be given to obtaining an opinion from a radiation oncologist as part of multidisciplinary care.

• Clinical question:Patient outcomes of RT modality vs conventional surgery for BCC#Practice_point_1
• CBR 8.2.1. For patients with T3/T4 primary persistent or recurrent basal cell carcinoma, consideration should be given to obtaining an opinion from a radiation oncologist as part of multidisciplinary care.
• Consensus based recommendation

Practice point
PP 8.2.1. Clinical persistence or progression of a basal cell carcinoma after a standard curative dose of radiotherapy should be confirmed in consultation with the treating radiation oncologist. The lesion should be biopsied and managed with salvage excisional surgery.

• Clinical question:Patient outcomes of RT modality vs conventional surgery for BCC#Practice_point_2
• PP 8.2.1. Clinical persistence or progression of a basal cell carcinoma after a standard curative dose of radiotherapy should be confirmed in consultation with the treating radiation oncologist. The lesion should be biopsied and managed with salvage excisional surgery.
• Good practice point

Practice point

PP 8.2.2. Patients who have undergone complete excision of basal cell carcinomas should be offered referral to a specialist skin cancer clinic (or head and neck clinic) for individual assessment and consideration of postoperative radiotherapy or additional treatment if any of the following are present: bone invasion rapidly growing tumour tumour recurrence (including multifocal recurrence or multiple recurrences) inadequate margins on excision when further surgery is problematic perineural invasion (major and minor nerves) lymphovascular invasion in-transit metastases regional nodal involvement histological subtype associated with poor prognosis (micronodular, infiltrative or metatypical).

• Clinical question:Patient outcomes of RT modality vs conventional surgery for BCC#Practice_point_3
• PP 8.2.2. Patients who have undergone complete excision of basal cell carcinomas should be offered referral to a specialist skin cancer clinic (or head and neck clinic) for individual assessment and consideration of postoperative radiotherapy or additional treatment if any of the following are present:
• bone invasion
• rapidly growing tumour
• tumour recurrence (including multifocal recurrence or multiple recurrences)
• inadequate margins on excision when further surgery is problematic
• perineural invasion (major and minor nerves)
• lymphovascular invasion
• in-transit metastases
• regional nodal involvement
• histological subtype associated with poor prognosis (micronodular, infiltrative or metatypical).
• Good practice point

8.3 Radiotherapy for cutaneous squamous cell carcinoma

Evidence-based recommendation	Grade
EBR 8.3.1 Radiotherapy using curative doses can be considered as an alternative to surgery for cutaneous squamous cell carcinomas if surgery is either declined by the patient or surgery is inappropriate.	B

• Clinical question:Patient outcomes of RT modality vs conventional surgery for SCC#Recommendation_1
• EBR 8.3.1 Radiotherapy using curative doses can be considered as an alternative to surgery for cutaneous squamous cell carcinomas if surgery is either declined by the patient or surgery is inappropriate.
• Recommendation

Practice point
PP 8.3.1 If surgical excision of a cutaneous squamous cell carcinoma is not possible, referral for a radiotherapy opinion should be considered.

• Clinical question:Patient outcomes of RT modality vs conventional surgery for SCC#Practice_point_1
• PP 8.3.1 If surgical excision of a cutaneous squamous cell carcinoma is not possible, referral for a radiotherapy opinion should be considered.
• Good practice point

Practice point
PP 8.3.2 For patients with T3/T4 primary, persistent and recurrent cutaneous squamous cell carcinomas, a consideration should be given to obtaining an opinion from a radiation oncologist as part of multidisciplinary care.

• Clinical question:Patient outcomes of RT modality vs conventional surgery for SCC#Practice_point_2
• PP 8.3.2 For patients with T3/T4 primary, persistent and recurrent cutaneous squamous cell carcinomas, a consideration should be given to obtaining an opinion from a radiation oncologist as part of multidisciplinary care.
• Good practice point

Practice point

PP 8.3.3 Postoperative radiotherapy should be considered after complete excision for high-risk cutaneous squamous cell carcinomas, including when any of the following are present: T3/T4 tumours extradermal invasion beyond subcutaneous fat, bone >6mm depth of invasion rapidly growing tumour recurrent disease inadequate margins on excision when further surgery is problematic poorly differentiated tumour perineural invasion (major and minor nerves) lymphovascular invasion in-transit metastases regional nodal involvement.

• Clinical question:Patient outcomes of RT modality vs conventional surgery for SCC#Practice_point_3
• PP 8.3.3 Postoperative radiotherapy should be considered after complete excision for high-risk cutaneous squamous cell carcinomas, including when any of the following are present:
• T3/T4 tumours
• extradermal invasion beyond subcutaneous fat, bone
• >6mm depth of invasion
• rapidly growing tumour
• recurrent disease
• inadequate margins on excision when further surgery is problematic
• poorly differentiated tumour
• perineural invasion (major and minor nerves)
• lymphovascular invasion
• in-transit metastases
• regional nodal involvement.
• Good practice point

Practice point
PP 8.3.4 Following incomplete surgical excision of a cutaneous squamous cell carcinoma, radiotherapy can be considered as an alternative to re-excision if further treatment is deemed advisable and re-excision is disadvantageous or not feasible.

• Clinical question:Patient outcomes of RT modality vs conventional surgery for SCC#Practice_point_4
• PP 8.3.4 Following incomplete surgical excision of a cutaneous squamous cell carcinoma, radiotherapy can be considered as an alternative to re-excision if further treatment is deemed advisable and re-excision is disadvantageous or not feasible.
• Good practice point

Practice point
PP 8.3.5 For recurrent and/or locally advanced cutaneous squamous cell carcinomas, the draining regional nodes must be examined (even after treatment of the primary site), because of the relatively higher propensity of cutaneous squamous cell carcinoma to metastasise, compared with basal cell carcinoma.

• Clinical question:Patient outcomes of RT modality vs conventional surgery for SCC#Practice_point_5
• PP 8.3.5 For recurrent and/or locally advanced cutaneous squamous cell carcinomas, the draining regional nodes must be examined (even after treatment of the primary site), because of the relatively higher propensity of cutaneous squamous cell carcinoma to metastasise, compared with basal cell carcinoma.
• Good practice point

8.4 Radiotherapy for regional (nodal) metastatic disease (non-distant)

Practice point

PP 8.4.1. For patients with extensive disease, such as those with very large nodes, multiple nodes, bilateral nodes and involvement of overlying skin or fixation of nodes, perineural invasion, multimodal treatment is indicated. In these instances, or if any doubt exists on the extent or integration of treatment, preoperative assessment and opinion from a multidisciplinary team is recommended. Involvement of a head and neck surgeon, reconstructive surgeon, dental oncologist, surgical oncologist, radiation oncologist and medical oncologist may be necessary for complex cases.

• Guidelines:Keratinocyte carcinoma/Radiotherapy for regional metastatic disease#Practice_point_1
• PP 8.4.1. For patients with extensive disease, such as those with very large nodes, multiple nodes, bilateral nodes and involvement of overlying skin or fixation of nodes, perineural invasion, multimodal treatment is indicated. In these instances, or if any doubt exists on the extent or integration of treatment, preoperative assessment and opinion from a multidisciplinary team is recommended. Involvement of a head and neck surgeon, reconstructive surgeon, dental oncologist, surgical oncologist, radiation oncologist and medical oncologist may be necessary for complex cases.
• Good practice point

Practice point
PP 8.4.2. Modern radiotherapy techniques should be considered as the modality of choice for treating the regional lymph node basin, to limit rates of significant adverse events.

• Guidelines:Keratinocyte carcinoma/Radiotherapy for regional metastatic disease#Practice_point_2
• PP 8.4.2. Modern radiotherapy techniques should be considered as the modality of choice for treating the regional lymph node basin, to limit rates of significant adverse events.
• Good practice point

8.8 Management of radiotherapy side effects

Practice point
PP 8.8.1. When treating a patient who has undergone previous radiotherapy, the clinician (e.g. general practitioner or skin cancer specialist) should consult the radiation oncologist on the patient’s history to ascertain the dose and location of prior radiation.

• Guidelines:Keratinocyte carcinoma/Management of radiotherapy side effects#Practice_point_1
• PP 8.8.1. When treating a patient who has undergone previous radiotherapy, the clinician (e.g. general practitioner or skin cancer specialist) should consult the radiation oncologist on the patient’s history to ascertain the dose and location of prior radiation.
• Good practice point

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12. Metastatic disease and systemic therapies

12.1 Systemic therapies for advanced and metastatic basal cell carcinoma

Practice point
PP 12.1.1. Patients with locoregional metastases of basal cell carcinoma should be offered surgical excision or radiotherapy if possible. It is appropriate to check for the presence of distant metastatic disease.

• Guidelines:Keratinocyte carcinoma/Metastatic disease systemic therapies BCC#Practice_point_1
• PP 12.1.1. Patients with locoregional metastases of basal cell carcinoma should be offered surgical excision or radiotherapy if possible. It is appropriate to check for the presence of distant metastatic disease.
• Good practice point

Practice point
PP 12.1.2. Patients with distant metastatic basal cell carcinoma should be referred to a medical oncologist or multidisciplinary team for consideration of hedgehog signalling pathway inhibitor treatment.

• Guidelines:Keratinocyte carcinoma/Metastatic disease systemic therapies BCC#Practice_point_2
• PP 12.1.2. Patients with distant metastatic basal cell carcinoma should be referred to a medical oncologist or multidisciplinary team for consideration of hedgehog signalling pathway inhibitor treatment.
• Good practice point

12.2 Systemic therapies for metastatic cutaneous squamous cell carcinoma

Evidence-based recommendation	Grade
EBR 12.2.1. For patients with resected high-risk cutaneous squamous cell carcinoma, adjuvant radiotherapy to reduce the risk of locoregional recurrence should be considered.	D

• Clinical question:Protocol to treat local regional SCC#Recommendation_1
• EBR 12.2.1. For patients with resected high-risk cutaneous squamous cell carcinoma, adjuvant radiotherapy to reduce the risk of locoregional recurrence should be considered.
• Recommendation

Evidence-based recommendation	Grade
EBR 12.2.2. For patients with cutaneous squamous cell carcinoma metastatic to cervical lymph node(s) who have adverse factors such as multiple node involvement, extra-nodal extension or involved margin, neck dissection followed by adjuvant radiotherapy is recommended.	D

• Clinical question:Protocol to treat local regional SCC#Recommendation_2
• EBR 12.2.2. For patients with cutaneous squamous cell carcinoma metastatic to cervical lymph node(s) who have adverse factors such as multiple node involvement, extra-nodal extension or involved margin, neck dissection followed by adjuvant radiotherapy is recommended.
• Recommendation

Evidence-based recommendation	Grade
EBR 12.2.3. For patients with cutaneous squamous cell carcinoma metastatic to the parotid, surgery or radiotherapy of the ipsilateral neck is recommended, even if clinically uninvolved.	D

• Clinical question:Protocol to treat local regional SCC#Recommendation_3
• EBR 12.2.3. For patients with cutaneous squamous cell carcinoma metastatic to the parotid, surgery or radiotherapy of the ipsilateral neck is recommended, even if clinically uninvolved.
• Recommendation

Evidence-based recommendation	Grade
EBR 12.2.4. Patients with resected primary cutaneous squamous cell carcinoma should be assessed for high-risk features and referred for consideration of adjuvant treatment, if appropriate.	D

• Clinical question:Protocol to treat local regional SCC#Recommendation_4
• EBR 12.2.4. Patients with resected primary cutaneous squamous cell carcinoma should be assessed for high-risk features and referred for consideration of adjuvant treatment, if appropriate.
• Recommendation

Evidence-based recommendation	Grade
EBR 12.2.5. Do not routinely offer carboplatin chemotherapy in addition to adjuvant radiotherapy for patients who have undergone excision of high-risk head and neck cutaneous squamous cell carcinoma.	B

• Clinical question:Protocol to treat local regional SCC#Recommendation_5
• EBR 12.2.5. Do not routinely offer carboplatin chemotherapy in addition to adjuvant radiotherapy for patients who have undergone excision of high-risk head and neck cutaneous squamous cell carcinoma.
• Recommendation

Consensus-based recommendation
CBR 12.2.1. Patients with cutaneous squamous cell carcinoma involving the parotid or cervical lymph nodes should be offered adjuvant radiotherapy after surgery.

• Clinical question:Protocol to treat local regional SCC#Practice_point_1
• CBR 12.2.1. Patients with cutaneous squamous cell carcinoma involving the parotid or cervical lymph nodes should be offered adjuvant radiotherapy after surgery.
• Consensus based recommendation

Practice point
PP 12.2.1. Recurrences of cutaneous squamous cell carcinoma in the axillary, epitrochlear or inguinal lymph nodes should be treated with surgery and adjuvant radiotherapy.

• Clinical question:Protocol to treat local regional SCC#Practice_point_2
• PP 12.2.1. Recurrences of cutaneous squamous cell carcinoma in the axillary, epitrochlear or inguinal lymph nodes should be treated with surgery and adjuvant radiotherapy.
• Good practice point

Practice point
PP 12.2.2. Patients with resected lymph node metastases of cutaneous squamous cell carcinoma should be followed 3-monthly for the first 2 years after surgery.

• Clinical question:Protocol to treat local regional SCC#Practice_point_3
• PP 12.2.2. Patients with resected lymph node metastases of cutaneous squamous cell carcinoma should be followed 3-monthly for the first 2 years after surgery.
• Good practice point

Practice point
PP 12.2.3. Patients with unresectable local cutaneous squamous cell carcinoma can be considered for radiotherapy and, if fit for chemotherapy, platinum-based chemoradiation

• Clinical question:Protocol to treat local regional SCC#Practice_point_4
• PP 12.2.3. Patients with unresectable local cutaneous squamous cell carcinoma can be considered for radiotherapy and, if fit for chemotherapy, platinum-based chemoradiation
• Good practice point

Practice point
PP 12.2.4. Cemiplimab treatment should be considered for patients with unresectable locoregionally advanced cutaneous squamous cell carcinoma not suitable for surgery or radiotherapy.

• Clinical question:Protocol to treat local regional SCC#Practice_point_5
• PP 12.2.4. Cemiplimab treatment should be considered for patients with unresectable locoregionally advanced cutaneous squamous cell carcinoma not suitable for surgery or radiotherapy.
• Good practice point

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3. Early detection

3. Early detection of keratinocyte cancers

Practice point
PP 3.1.1. Patients at very high risk of keratinocyte cancers (e.g. organ transplant recipients) should be monitored in specialist clinics at least annually.

• Guidelines:Keratinocyte carcinoma/Early detection and screening#Practice_point_1
• PP 3.1.1. Patients at very high risk of keratinocyte cancers (e.g. organ transplant recipients) should be monitored in specialist clinics at least annually.
• Good practice point

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4. Clinical features

4.2 Clinical features of cutaneous squamous cell carcinoma and related keratinocyte tumours

Practice point
PP 4.2.1. If a skin lesion is initially considered to be an actinic keratosis, but it persists following cryotherapy, enlarges or becomes tender, it should be biopsied to investigate the possibility of cutaneous squamous cell carcinoma or other dysplastic lesions.

• Guidelines:Keratinocyte carcinoma/Clinical features SCC and other related tumours#Practice_point_1
• PP 4.2.1. If a skin lesion is initially considered to be an actinic keratosis, but it persists following cryotherapy, enlarges or becomes tender, it should be biopsied to investigate the possibility of cutaneous squamous cell carcinoma or other dysplastic lesions.
• Good practice point

Practice point
PP 4.2.2. Keratoacanthomas should be managed by early excision rather than relying on correct clinical diagnosis and waiting for spontaneous resolution.

• Guidelines:Keratinocyte carcinoma/Clinical features SCC and other related tumours#Practice_point_2
• PP 4.2.2. Keratoacanthomas should be managed by early excision rather than relying on correct clinical diagnosis and waiting for spontaneous resolution.
• Good practice point

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5. Pathology of keratinocyte cancer

5.4 Pathology of rare tumours

Practice point
PP 5.4.1 When a diagnosis is made on histopathology in the following conditions referral to a specialist for assessment and treatment should be undertaken: Merkel cell carcinoma extramammary Paget’s disease mammary Paget’s disease (refer to a breast surgeon) atypical fibroxanthoma or pleomorphic dermal sarcoma not otherwise (consider referral).

• Guidelines:Keratinocyte carcinoma/Pathology rare tumours#Practice_point_1
• PP 5.4.1 When a diagnosis is made on histopathology in the following conditions referral to a specialist for assessment and treatment should be undertaken:
• Merkel cell carcinoma
• extramammary Paget’s disease
• mammary Paget’s disease (refer to a breast surgeon)
• atypical fibroxanthoma or pleomorphic dermal sarcoma not otherwise (consider referral).
• Good practice point

5.5 Biopsy considerations and the biopsy report

Practice point
PP 5.5.1. Excision biopsy should be performed when appropriate. If complete excision is not possible, punch biopsies, shave biopsy or curettage can be considered, as appropriate to the size and depth of the lesion.

• Guidelines:Keratinocyte carcinoma/Pathology biopsy report#Practice_point_1
• PP 5.5.1. Excision biopsy should be performed when appropriate. If complete excision is not possible, punch biopsies, shave biopsy or curettage can be considered, as appropriate to the size and depth of the lesion.
• Good practice point

Practice point
PP 5.5.2. A suture should be placed in the specimen and a diagram should be provided to enable the pathologist to orient the specimen within the anatomical site and/or lesion.

• Guidelines:Keratinocyte carcinoma/Pathology biopsy report#Practice_point_2
• PP 5.5.2. A suture should be placed in the specimen and a diagram should be provided to enable the pathologist to orient the specimen within the anatomical site and/or lesion.
• Good practice point

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6. Prognosis

6.2 Prognosis of cutaneous squamous cell carcinoma

Practice point
PP 6.2.1. Incompletely excised cutaneous squamous cell carcinomas should be prophylactically re-excised or treated with radiotherapy.

• Guidelines:Keratinocyte carcinoma/Prognosis SCC#Practice_point_1
• PP 6.2.1. Incompletely excised cutaneous squamous cell carcinomas should be prophylactically re-excised or treated with radiotherapy.
• Good practice point

Practice point
PP 6.2.2. If a cutaneous squamous cell carcinoma recurs in a nodal basin after standard lymphadenectomy, the patient should be offered referral to a specialist advanced skin cancer clinic that can provide access to a multidisciplinary team (including surgeons, radiation oncologists, medical oncologists and allied health professionals) and the opportunity to participate in clinical trials.

• Guidelines:Keratinocyte carcinoma/Prognosis SCC#Practice_point_2
• PP 6.2.2. If a cutaneous squamous cell carcinoma recurs in a nodal basin after standard lymphadenectomy, the patient should be offered referral to a specialist advanced skin cancer clinic that can provide access to a multidisciplinary team (including surgeons, radiation oncologists, medical oncologists and allied health professionals) and the opportunity to participate in clinical trials.
• Good practice point

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9. Cryotherapy and electrodessication and curettage

9.1 Cryotherapy and electrodessication and curettage for basal cell carcinoma

Practice point
PP 9.1.1. Long-term follow-up is essential after treatment of basal cell carcinoma with cryotherapy, as late recurrences may occur.

• Guidelines:Keratinocyte carcinoma/Cryotherapy curettage diathermy BCC#Practice_point_1
• PP 9.1.1. Long-term follow-up is essential after treatment of basal cell carcinoma with cryotherapy, as late recurrences may occur.
• Good practice point

9.2 Cryotherapy and electrodessication and curettage for cutaneous squamous cell carcinoma

Practice point
PP 9.2.1. Cryotherapy is contraindicated for recurrent cutaneous squamous cell carcinoma.

• Guidelines:Keratinocyte carcinoma/Cryotherapy curettage diathermy SCC#Practice_point_1
• PP 9.2.1. Cryotherapy is contraindicated for recurrent cutaneous squamous cell carcinoma.
• Good practice point

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10. Topical treatments and photodynamic therapy

10.1 The role of topical treatments in the treatment of keratinocyte cancer

Practice point
PP 10.1.1. Skin biopsy is highly recommended before treatment of superficial basal cell carcinoma with imiquimod 5% cream (and is required for PBS-reimbursed prescription).

• Clinical question:Topical treatments#Practice_point_1
• PP 10.1.1. Skin biopsy is highly recommended before treatment of superficial basal cell carcinoma with imiquimod 5% cream (and is required for PBS-reimbursed prescription).
• Good practice point

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11. Organ transplantation and conditions associated with immunosuppression

11.3 Strategies to manage keratinocyte cancer in organ transplant recipients

Practice point
PP 11.3.1. Chemoprophylaxis with systemic acitretin should be considered for reducing tumour burden in patients who develop multiple keratinocyte cancers.

• Guidelines:Keratinocyte carcinoma/Organ transplant keratinocyte cancer strategies#Practice_point_1
• PP 11.3.1. Chemoprophylaxis with systemic acitretin should be considered for reducing tumour burden in patients who develop multiple keratinocyte cancers.
• Good practice point

Practice point
PP 11.3.2.Reduction of immunosuppression should be considered in organ transplant recipients who develop multiple keratinocyte cancers.

• Guidelines:Keratinocyte carcinoma/Organ transplant keratinocyte cancer strategies#Practice_point_2
• PP 11.3.2.Reduction of immunosuppression should be considered in organ transplant recipients who develop multiple keratinocyte cancers.
• Good practice point

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13. Follow-up

13. Follow-up after treatment for keratinocyte cancer

Practice point
PP 13.1.1. For patients who have undergone non-surgical treatments, where histological evidence of clearance is not available, planned regular follow-up (not just reassessment prompted by clinical need) should be provided for up to 3 years. Examination includes a full skin check for new lesions as well as inspection of the site of the original lesion.

• Guidelines:Keratinocyte carcinoma/Follow-up#Practice_point_1
• PP 13.1.1. For patients who have undergone non-surgical treatments, where histological evidence of clearance is not available, planned regular follow-up (not just reassessment prompted by clinical need) should be provided for up to 3 years. Examination includes a full skin check for new lesions as well as inspection of the site of the original lesion.
• Good practice point

Practice point
PP 13.1.2. For patients with cutaneous squamous cell carcinoma that is moderately to poorly differentiated or occurs on the lip or ear, initial follow-up should be conducted at 3 months and then every 6 months. It should always include examination of the draining lymph node basin.

• Guidelines:Keratinocyte carcinoma/Follow-up#Practice_point_2
• PP 13.1.2. For patients with cutaneous squamous cell carcinoma that is moderately to poorly differentiated or occurs on the lip or ear, initial follow-up should be conducted at 3 months and then every 6 months. It should always include examination of the draining lymph node basin.
• Good practice point

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14. The role of primary care

14. The role of primary care in the prevention and management of keratinocyte cancer

Practice point
PP 14.1.1. Uncomplicated small tumours should be removed by an elliptical excision and direct closure.

• Guidelines:Keratinocyte carcinoma/Problems to refer#Practice_point_1
• PP 14.1.1. Uncomplicated small tumours should be removed by an elliptical excision and direct closure.
• Good practice point

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NHMRC approved recommendation types and definitions

Type of recommendation	Definition
Evidence-based recommendation*	A recommendation formulated after a systematic review of the evidence, indicating supporting references
Consensus-based recommendation*	A recommendation formulated in the absence of quality evidence, after a systematic review of the evidence was conducted and failed to identify admissible evidence on the clinical question
Practice point	A point of guidance on a subject that is outside the scope of the search strategy for the systematic review, or guidance on topic not subject to a systematic review, formulated by a consensus process and based on a general literature review, clinical experience and expert opinion

*NHMRC recommendation. Note: The definition for Practice Points has been adapted from the original NHMRC definition.
Source: National Health and Medical Research Council.

Evidence-based recommendation grades

Grade of recommendation	Description
A	Body of evidence can be trusted to guide practice
B	Body of evidence can be trusted to guide practice in most situations
C	Body of evidence provides some support for recommendation(s) but care should be taken in its application
D	Body of evidence is weak and recommendation must be applied with caution

Source: National Health and Medical Research Council.

References

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Medical practitioners who through training, experience and peer opinion specialise in the management of keratinocyte cancers

scar-like (morphoeic)

showing evidence of squamatisation (descriptor applicable to basaloid tumours and indicating aggressive subtype)