Summary of recommendations
Summary of recommendations[edit source]
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.[1]
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 |
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EBR 7.1.1. Both surgical and nonsurgical treatment modalities can be considered for superficial and nodular basal cell carcinomas in favourable sites. | C |
7.3 Optimal surgical technique for the treatment of basal cell carcinoma
7.4 Considerations when planning surgical treatment for cutaneous squamous cell carcinoma
7.5 Post-surgical care and interpretation of the pathology report
Practice point![]() |
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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. |
Practice point![]() |
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PP 7.5.2. Preoperative magnetic resonance imaging should be considered for patients with clinical evidence of perineural involvement. |
7.6 Protocol to manage incompletely resected basal cell carcinoma
Evidence-based recommendation![]() |
Grade |
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EBR 7.6.1. Incompletely excised basal cell carcinomas should be assessed and treatment selected on a case-by-case basis. | C |
Evidence-based recommendation![]() |
Grade |
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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 |
7.7 Protocol to manage rapidly growing tumours
Evidence-based recommendation![]() |
Grade |
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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 |
Practice point![]() |
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PP 7.7.2. Patients with rapidly growing squamous cell carcinomas should be referred timely for assessment for specialised therapies or combination therapies. |
7.8 Criteria for choosing Mohs micrographic surgery in preference to other surgical techniques
7.9 Surgical management of advanced cutaneous squamous cell carcinoma
Practice point![]() |
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PP 7.9.1. Dermal lymphatic spread (in-transit metastasis) should be managed by wide surgical excision followed by adjuvant radiotherapy. |
8. Radiotherapy
8.1 Radiotherapy with or without surgical treatment for keratinocyte cancer
Evidence-based recommendation![]() |
Grade |
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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 |
Evidence-based recommendation![]() |
Grade |
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EBR 8.1.2. Radiotherapy may be used in combination with surgical excision with the aim of improving locoregional control. | D |
8.2 Radiotherapy for basal cell carcinoma
8.3 Radiotherapy for cutaneous squamous cell carcinoma
Practice point![]() |
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PP 8.3.1 If surgical excision of a cutaneous squamous cell carcinoma is not possible, referral for a radiotherapy opinion should be considered. |
8.4 Radiotherapy for regional (nodal) metastatic disease (non-distant)
Practice point![]() |
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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. |
8.8 Management of radiotherapy side effects
12. Metastatic disease and systemic therapies
12.1 Systemic therapies for advanced and metastatic basal cell carcinoma
12.2 Systemic therapies for metastatic cutaneous squamous cell carcinoma
Consensus-based recommendation![]() |
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CBR 12.2.1. Patients with cutaneous squamous cell carcinoma involving the parotid or cervical lymph nodes should be offered adjuvant radiotherapy after surgery. |
Practice point![]() |
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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. |
Practice point![]() |
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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. |
Practice point![]() |
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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 |
Practice point![]() |
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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. |
3. Early detection
3. Early detection of keratinocyte cancers
Practice point![]() |
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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. |
4. Clinical features
Practice point![]() |
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PP 4.2.2. Keratoacanthomas should be managed by early excision rather than relying on correct clinical diagnosis and waiting for spontaneous resolution. |
5. Pathology of keratinocyte cancer
5.4 Pathology of rare tumours
5.5 Biopsy considerations and the biopsy report
Practice point![]() |
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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. |
6. Prognosis
6.2 Prognosis of cutaneous squamous cell carcinoma
Practice point![]() |
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PP 6.2.1. Incompletely excised cutaneous squamous cell carcinomas should be prophylactically re-excised or treated with radiotherapy. |
9. Cryotherapy and electrodessication and curettage
9.1 Cryotherapy and electrodessication and curettage for basal cell carcinoma
Practice point![]() |
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PP 9.1.1. Long-term follow-up is essential after treatment of basal cell carcinoma with cryotherapy, as late recurrences may occur. |
9.2 Cryotherapy and electrodessication and curettage for cutaneous squamous cell carcinoma
Practice point![]() |
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PP 9.2.1. Cryotherapy is contraindicated for recurrent cutaneous squamous cell carcinoma. |
10. Topical treatments and photodynamic therapy
10.1 The role of topical treatments in the treatment of keratinocyte cancer
Practice point![]() |
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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). |
11. Organ transplantation and conditions associated with immunosuppression
11.3 Strategies to manage keratinocyte cancer in organ transplant recipients
Practice point![]() |
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PP 11.3.1. Chemoprophylaxis with systemic acitretin should be considered for reducing tumour burden in patients who develop multiple keratinocyte cancers. |
Practice point![]() |
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PP 11.3.2.Reduction of immunosuppression should be considered in organ transplant recipients who develop multiple keratinocyte cancers. |
13. Follow-up
13. Follow-up after treatment for keratinocyte cancer
14. The role of primary care
14. The role of primary care in the prevention and management of keratinocyte cancer
Practice point![]() |
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PP 14.1.1. Uncomplicated small tumours should be removed by an elliptical excision and direct closure. |
NHMRC approved recommendation types and definitions[edit source]
Definition | |
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A recommendation formulated after a systematic review of the evidence, indicating supporting references | |
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 | |
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.[2]
Evidence-based recommendation grades[edit source]
Description | |
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Body of evidence can be trusted to guide practice | |
Body of evidence can be trusted to guide practice in most situations | |
Body of evidence provides some support for recommendation(s) but care should be taken in its application | |
Body of evidence is weak and recommendation must be applied with caution |
Source: National Health and Medical Research Council.[3]
References[edit source]
- ↑ National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for guideline developers. Canberra: National Health and Medical Research Council; 2009 Available from: https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf.
- ↑ National Health and Medical Research Council. 2016 NHMRC Standards for Guidelines. [homepage on the internet] Canberra: NHMRC Australian Government; [cited 2019 Aug 22]. Available from: https://www.nhmrc.gov.au/guidelinesforguidelines/standards.
- ↑ National Health and Medical Research Council. NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. Canberra; 2009 Available from: www.mja.com.au/sites/default/files/NHMRC.levels.of.evidence.2008-09.pdf.