Summary of recommendations

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Summary of recommendations

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

This guideline includes evidence-based recommendations (EBR), consensus-based recommendations (CBR) and practice points (PP) as defined in the table below. Recommendations and practice points were developed by working party members and subcommittee members.

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]

Note: some PPs may be repeated and appear in more than one section if they were relevant to both BCC and SCC.

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 recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process
Source: National Health and Medical Research Council. Procedures and requirements for meeting the NHMRC standard for clinical practice guidelines. Melbourne: National Health and Medical Research Council, 2011


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. NHMRC levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC; 2009. (https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf)

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Summary of recommendations

Epidemiology

Epidemiology of basal cell carcinoma

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Sun protection from childhood onwards should be promoted and encouraged to reduce the risk of basal cell carcinoma.

  • Guidelines:Keratinocyte carcinoma/Epidemiology BCC#Practice_point_1
  • Sun protection from childhood onwards should be promoted and encouraged to reduce the risk of basal cell carcinoma.
  • Good practice point

Epidemiology of cutaneous squamous cell carcinoma

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Ongoing protection from incremental sun exposure throughout adulthood should be promoted and encouraged, especially in those with sun-sensitive skin, to reduce the risk of cutaneous squamous cell carcinoma.

  • Guidelines:Keratinocyte carcinoma/Epidemiology SCC#Practice_point_1
  • Ongoing protection from incremental sun exposure throughout adulthood should be promoted and encouraged, especially in those with sun-sensitive skin, to reduce the risk of cutaneous squamous cell carcinoma.
  • Good practice point

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Prevention of keratinocyte cancer (UV avoidance strategies, chemoprevention and vitamin D)

Strategies for protection from excessive exposure to ultraviolet radiation

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To encourage patients to seek medical attention for any suspicious skin lesions without delay and to reduce high out-of-pocket medical expenses, clinicians should consider whether cost is a barrier to treatment for individuals and consider strategies for minimising out-of-pocket costs to the patient needing keratinocyte cancer services and especially those patients returning for multiple skin cancer treatments.

  • Guidelines:Keratinocyte carcinoma/UV protection strategies#Practice_point_1
  • To encourage patients to seek medical attention for any suspicious skin lesions without delay and to reduce high out-of-pocket medical expenses, clinicians should consider whether cost is a barrier to treatment for individuals and consider strategies for minimising out-of-pocket costs to the patient needing keratinocyte cancer services and especially those patients returning for multiple skin cancer treatments.
  • Good practice point
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Clinicians should strongly encourage patients to engage in sun protection behaviours during the time of high UV readings (e.g. ≥3) and advise that prevention measures will save the patient health care expenses in the future.

  • Guidelines:Keratinocyte carcinoma/UV protection strategies#Practice_point_2
  • Clinicians should strongly encourage patients to engage in sun protection behaviours during the time of high UV readings (e.g. ≥3) and advise that prevention measures will save the patient health care expenses in the future.
  • Good practice point
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Clinicians should strongly counsel patients against personal home use of sunbeds or sunlamps for cosmetic tanning purposes if these behaviours are suspected or revealed during consultations.

  • Guidelines:Keratinocyte carcinoma/UV protection strategies#Practice_point_3
  • Clinicians should strongly counsel patients against personal home use of sunbeds or sunlamps for cosmetic tanning purposes if these behaviours are suspected or revealed during consultations.
  • Good practice point

Chemoprevention

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Nicotinamide may be a useful chemopreventive adjunct to sun protection and sunscreen use in high risk, immune-competent individuals with a history of multiple keratinocyte cancers. It should not be recommended for lower-risk individuals without a history of skin cancer.

  • Guidelines:Keratinocyte carcinoma/Chemoprevention#Practice_point_1
  • Nicotinamide may be a useful chemopreventive adjunct to sun protection and sunscreen use in high risk, immune-competent individuals with a history of multiple keratinocyte cancers. It should not be recommended for lower-risk individuals without a history of skin cancer.
  • Good practice point

Vitamin D

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Most Australian adults will maintain adequate vitamin D levels from incidental sun exposure during typical day-to-day outdoor activities and therefore vitamin D testing of healthy individuals is generally not required.

  • Guidelines:Keratinocyte carcinoma/Vitamin D#Practice_point_1
  • Most Australian adults will maintain adequate vitamin D levels from incidental sun exposure during typical day-to-day outdoor activities and therefore vitamin D testing of healthy individuals is generally not required.
  • Good practice point
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People who wear concealing clothing for religious or cultural reasons (especially those with naturally very dark skin), who are pregnant or planning pregnancy should be assessed to determine whether their vitamin D levels are adequate.

  • Guidelines:Keratinocyte carcinoma/Vitamin D#Practice_point_2
  • People who wear concealing clothing for religious or cultural reasons (especially those with naturally very dark skin), who are pregnant or planning pregnancy should be assessed to determine whether their vitamin D levels are adequate.
  • Good practice point

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Early detection

Early detection of keratinocyte cancers and opportunistic screening

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People in the general population who are at high risk for developing keratinocyte cancers should be identified using risk prediction tools and offered regular skin examinations to minimise future morbidity.

  • Guidelines:Keratinocyte carcinoma/Early detection and screening#Practice_point_1
  • People in the general population who are at high risk for developing keratinocyte cancers should be identified using risk prediction tools and offered regular skin examinations to minimise future morbidity.
  • Good practice point
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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_2
  • 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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Clinical features

Clinical features of keratinocyte cancer

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When assessing a skin lesion, always ask whether it has changed over time and whether there are any symptoms (e.g. irritation, discomfort). Lesions that are growing rapidly or associated with irritation or pain should be examined closely.

  • Guidelines:Keratinocyte carcinoma/Clinical features#Practice_point_1
  • When assessing a skin lesion, always ask whether it has changed over time and whether there are any symptoms (e.g. irritation, discomfort). Lesions that are growing rapidly or associated with irritation or pain should be examined closely.
  • Good practice point
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Local pain and induration and non-healing should trigger suspicion of keratinocyte cancer.

  • Guidelines:Keratinocyte carcinoma/Clinical features#Practice_point_2
  • Local pain and induration and non-healing should trigger suspicion of keratinocyte cancer.
  • Good practice point
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Examination for skin cancer should be considered during physical examination for all patients over the age of 40, particularly for the elderly.

  • Guidelines:Keratinocyte carcinoma/Clinical features#Practice_point_3
  • Examination for skin cancer should be considered during physical examination for all patients over the age of 40, particularly for the elderly.
  • Good practice point

Clinical features of basal cell carcinoma

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Consider dermoscopy in the examination of all skin lesions in order to better identify changes in blood vessels and pigmentation.

  • Guidelines:Keratinocyte carcinoma/Clinical features BCC#Practice_point_1
  • Consider dermoscopy in the examination of all skin lesions in order to better identify changes in blood vessels and pigmentation.
  • Good practice point
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Biopsy should precede treatment for a single localised erythematous scaling lesion.

  • Guidelines:Keratinocyte carcinoma/Clinical features BCC#Practice_point_2
  • Biopsy should precede treatment for a single localised erythematous scaling lesion.
  • Good practice point
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Superficial basal cell carcinoma should be considered in the differential diagnosis when reviewing a bright pink, shiny erythematous macular lesion, particularly if well defined.

  • Guidelines:Keratinocyte carcinoma/Clinical features BCC#Practice_point_3
  • Superficial basal cell carcinoma should be considered in the differential diagnosis when reviewing a bright pink, shiny erythematous macular lesion, particularly if well defined.
  • Good practice point
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Nodular basal cell carcinoma should be considered when assessing in any lesion that is shiny, translucent (pearly), telangiectatic and has papules or nodules.

  • Guidelines:Keratinocyte carcinoma/Clinical features BCC#Practice_point_4
  • Nodular basal cell carcinoma should be considered when assessing in any lesion that is shiny, translucent (pearly), telangiectatic and has papules or nodules.
  • Good practice point
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Consider the possibility of sclerosingscar-like (morphoeic) (morphoeic) basal cell carcinoma when assessing scar-like lesions.

  • Guidelines:Keratinocyte carcinoma/Clinical features BCC#Practice_point_5
  • Consider the possibility of sclerosingscar-like (morphoeic) (morphoeic) basal cell carcinoma when assessing scar-like lesions.
  • Good practice point
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Stretching the skin accentuates features in basal cell carcinoma subtypes (eg. nodular subtypes and sclerosingscar-like (morphoeic) subtype).

  • Guidelines:Keratinocyte carcinoma/Clinical features BCC#Practice_point_6
  • Stretching the skin accentuates features in basal cell carcinoma subtypes (eg. nodular subtypes and sclerosingscar-like (morphoeic) subtype).
  • Good practice point

Clinical features of cutaneous squamous cell carcinoma and related keratinocyte tumours

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If a skin lesions 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.

  • Guidelines:Keratinocyte carcinoma/Clinical features SCC and other related tumours#Practice_point_1
  • If a skin lesions 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.
  • Good practice point
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All patients with actinic keratoses should be offered regular follow-up, with the aim of early detection of cutaneous squamous cell carcinoma, should it occur.

  • Guidelines:Keratinocyte carcinoma/Clinical features SCC and other related tumours#Practice_point_2
  • All patients with actinic keratoses should be offered regular follow-up, with the aim of early detection of cutaneous squamous cell carcinoma, should it occur.
  • Good practice point
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When induration, thickening or tenderness in the erythematous base of a scaling lesion is identified, the possibility of early cutaneous squamous cell carcinoma should be considered.

  • Guidelines:Keratinocyte carcinoma/Clinical features SCC and other related tumours#Practice_point_3
  • When induration, thickening or tenderness in the erythematous base of a scaling lesion is identified, the possibility of early cutaneous squamous cell carcinoma should be considered.
  • Good practice point
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Dermoscopy is useful in diagnosing and differentiating cutaneous squamous cell carcinoma.

  • Guidelines:Keratinocyte carcinoma/Clinical features SCC and other related tumours#Practice_point_4
  • Dermoscopy is useful in diagnosing and differentiating cutaneous squamous cell carcinoma.
  • Good practice point
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Consider actinic keratoses when assessing lesions that present as erythematous macules with superimposed hyperkeratosis.

  • Guidelines:Keratinocyte carcinoma/Clinical features SCC and other related tumours#Practice_point_5
  • Consider actinic keratoses when assessing lesions that present as erythematous macules with superimposed hyperkeratosis.
  • Good practice point
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Only a small percentage of actinic keratoses evolve into invasive squamous cell carcinoma.

  • Guidelines:Keratinocyte carcinoma/Clinical features SCC and other related tumours#Practice_point_6
  • Only a small percentage of actinic keratoses evolve into invasive squamous cell carcinoma.
  • Good practice point
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Induration (thickening), erythema and tenderness on lateral and vertical palpation are signs that an actinic keratosis may have developed into invasive cutaneous squamous cell carcinoma.

  • Guidelines:Keratinocyte carcinoma/Clinical features SCC and other related tumours#Practice_point_7
  • Induration (thickening), erythema and tenderness on lateral and vertical palpation are signs that an actinic keratosis may have developed into invasive cutaneous squamous cell carcinoma.
  • Good practice point
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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_8
  • 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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Clinical correlation is required to distinguish between keratoacanthoma and invasive cutaneous squamous cell carcinoma in cases where partial biopsy does not enable a definitive diagnosis.

  • Guidelines:Keratinocyte carcinoma/Clinical features SCC and other related tumours#Practice_point_9
  • Clinical correlation is required to distinguish between keratoacanthoma and invasive cutaneous squamous cell carcinoma in cases where partial biopsy does not enable a definitive diagnosis.
  • Good practice point
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Always consider Paget’s disease in the differential diagnosis of a skin lesion with the appearance of Bowen’s diseasecutaneous squamous cell carcinoma in situ (also known as intra-epidermal squamous cell carcinoma) that occurs in an areas of low sun exposure (e.g areola, breast and genitals) where skin appears like Bowen’s diseasecutaneous squamous cell carcinoma in situ (also known as intra-epidermal squamous cell carcinoma).

  • Guidelines:Keratinocyte carcinoma/Clinical features SCC and other related tumours#Practice_point_10
  • Always consider Paget’s disease in the differential diagnosis of a skin lesion with the appearance of Bowen’s diseasecutaneous squamous cell carcinoma in situ (also known as intra-epidermal squamous cell carcinoma) that occurs in an areas of low sun exposure (e.g areola, breast and genitals) where skin appears like Bowen’s diseasecutaneous squamous cell carcinoma in situ (also known as intra-epidermal squamous cell carcinoma).
  • Good practice point

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Pathology of keratinocyte cancer

Pathology of basal cell carcinoma

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The clinical location, the architectural pattern and excision margins should be considered when determining the risk of recurrence.

  • Guidelines:Keratinocyte carcinoma/Pathology BCC#Practice_point_1
  • The clinical location, the architectural pattern and excision margins should be considered when determining the risk of recurrence.
  • Good practice point


Pathology of keratoacanthoma

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Clinical correlation is required to distinguish between keratoacanthoma and invasive cutaneous squamous cell carcinoma in cases where partial biopsy does not enable a definitive diagnosis.

  • Guidelines:Keratinocyte carcinoma/Pathology keratoacanthoma#Practice_point_1
  • Clinical correlation is required to distinguish between keratoacanthoma and invasive cutaneous squamous cell carcinoma in cases where partial biopsy does not enable a definitive diagnosis.
  • Good practice point

Pathology of rare tumours

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When a diagnosis of Merkel cell carcinoma is made on histopathology, when the diagnosis is made it is most appropriate for the patient to be referred for specialist assessment and treatment.

  • Guidelines:Keratinocyte carcinoma/Pathology rare tumours#Practice_point_1
  • When a diagnosis of Merkel cell carcinoma is made on histopathology, when the diagnosis is made it is most appropriate for the patient to be referred for specialist assessment and treatment.
  • Good practice point
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When a diagnosis of extramammary Paget’s disease is made on histopathology, referral of the patient for specialist assessment and treatment should be considered.

  • Guidelines:Keratinocyte carcinoma/Pathology rare tumours#Practice_point_2
  • When a diagnosis of extramammary Paget’s disease is made on histopathology, referral of the patient for specialist assessment and treatment should be considered.
  • Good practice point
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When a diagnosis of mammary Paget’s disease is made on histopathology, the patient should be referred to a breast surgeon.

  • Guidelines:Keratinocyte carcinoma/Pathology rare tumours#Practice_point_3
  • When a diagnosis of mammary Paget’s disease is made on histopathology, the patient should be referred to a breast surgeon.
  • Good practice point
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When a diagnosis of atypical fibroxanthoma is made on histopathology, consider whether referral for specialist assessment and treatment is necessary.

  • Guidelines:Keratinocyte carcinoma/Pathology rare tumours#Practice_point_4
  • When a diagnosis of atypical fibroxanthoma is made on histopathology, consider whether referral for specialist assessment and treatment is necessary.
  • Good practice point

Biopsy considerations and the biopsy report

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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
  • 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
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Samples from different anatomical sites should be carefully labelled and placed in separate specimen containers.

  • Guidelines:Keratinocyte carcinoma/Pathology biopsy report#Practice_point_2
  • Samples from different anatomical sites should be carefully labelled and placed in separate specimen containers.
  • Good practice point
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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_3
  • 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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The pathology request should include:

  • the patient’s full name, age and sex
  • site of biopsy
  • a description and duration of the lesion and any associated symptoms
  • relevant clinical history (e.g. other skin tumours, the presence of scars, burns or ulceration)
  • previous biopsies and treatment
  • diagnoses under consideration
  • Guidelines:Keratinocyte carcinoma/Pathology biopsy report#Practice_point_4
  • The pathology request should include:
  • the patient’s full name, age and sex
  • site of biopsy
  • a description and duration of the lesion and any associated symptoms
  • relevant clinical history (e.g. other skin tumours, the presence of scars, burns or ulceration)
  • previous biopsies and treatment
  • diagnoses under consideration
  • Good practice point
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The pathologist’s report should contain:

  • the clinical notes
  • the macroscopic description
  • the microscopic findings
  • margins of excision
  • a summary of prognostic factors including tumour type, tumour subtype or degree of differentiation, thickness in the dermis, perineural invasion, and vascular or lymphatic spread.
  • Guidelines:Keratinocyte carcinoma/Pathology biopsy report#Practice_point_5
  • The pathologist’s report should contain:
  • the clinical notes
  • the macroscopic description
  • the microscopic findings
  • margins of excision
  • a summary of prognostic factors including tumour type, tumour subtype or degree of differentiation, thickness in the dermis, perineural invasion, and vascular or lymphatic spread.
  • Good practice point
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If there is uncertainty in the pathology report, the clinician, in consultation with the pathologist, should seek further evaluations of the slides and/or specimen.

  • Guidelines:Keratinocyte carcinoma/Pathology biopsy report#Practice_point_6
  • If there is uncertainty in the pathology report, the clinician, in consultation with the pathologist, should seek further evaluations of the slides and/or specimen.
  • Good practice point

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Prognosis

Prognosis of basal cell carcinoma

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Patients with basal cell carcinoma without high-risk features can be reassured that the prognosis is generally excellent.

  • Guidelines:Keratinocyte carcinoma/Prognosis BCC#Practice_point_1
  • Patients with basal cell carcinoma without high-risk features can be reassured that the prognosis is generally excellent.
  • Good practice point
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When a patient has a basal cell carcinoma that is larger than 2cm, is on the face, or has recurred after a previous treatment, the clinician should explain that there is a risk of recurrence or spread. The clinician should offer follow-up or further treatment as appropriate, and carefully explain the risks and benefits of each management option.

  • Guidelines:Keratinocyte carcinoma/Prognosis BCC#Practice_point_2
  • When a patient has a basal cell carcinoma that is larger than 2cm, is on the face, or has recurred after a previous treatment, the clinician should explain that there is a risk of recurrence or spread. The clinician should offer follow-up or further treatment as appropriate, and carefully explain the risks and benefits of each management option.
  • Good practice point
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When incomplete excision of a basal cell carcinoma is reported, the surgeon or treating clinician should explain to the patient that there is a significant risk of the cancer recurring, and should offer further treatment as appropriate, carefully explaining the risks and benefits of each management option.

  • Guidelines:Keratinocyte carcinoma/Prognosis BCC#Practice_point_3
  • When incomplete excision of a basal cell carcinoma is reported, the surgeon or treating clinician should explain to the patient that there is a significant risk of the cancer recurring, and should offer further treatment as appropriate, carefully explaining the risks and benefits of each management option.
  • Good practice point

Prognosis of cutaneous squamous cell carcinoma

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

  • Guidelines:Keratinocyte carcinoma/Prognosis SCC#Practice_point_1
  • Incompletely excised cutaneous squamous cell carcinomas should be prophylactically re-excised or treated with radiotherapy.
  • Good practice point
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Recurrent, persistent or inadequately treated cutaneous squamous cell carcinomas require more aggressive clinical treatment.

  • Guidelines:Keratinocyte carcinoma/Prognosis SCC#Practice_point_2
  • Recurrent, persistent or inadequately treated cutaneous squamous cell carcinomas require more aggressive clinical treatment.
  • Good practice point
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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_3
  • 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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When discussing salvage management options for a patient with advanced cutaneous squamous cell carcinoma, the clinician should fully explain the cancer's lethal potential.

  • Guidelines:Keratinocyte carcinoma/Prognosis SCC#Practice_point_4
  • When discussing salvage management options for a patient with advanced cutaneous squamous cell carcinoma, the clinician should fully explain the cancer's lethal potential.
  • Good practice point
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For a patient with cutaneous squamous cell carcinoma in a site likely to heal poorly (e.g. below the knee, pretibial, sites affected by peripheral vascular disease or other comorbid conditions), provide information about the prognosis and counselling about treatment options, making sure the person (and carers) have understood well.

  • Guidelines:Keratinocyte carcinoma/Prognosis SCC#Practice_point_5
  • For a patient with cutaneous squamous cell carcinoma in a site likely to heal poorly (e.g. below the knee, pretibial, sites affected by peripheral vascular disease or other comorbid conditions), provide information about the prognosis and counselling about treatment options, making sure the person (and carers) have understood well.
  • Good practice point
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For a patient with facial cutaneous squamous cell carcinoma who is anxious about the cosmetic results of treatment, carefully explain the potential consequences of delaying treatment or failing to achieve tumour clearance, as well as the potential adverse outcomes each treatment option, so that the person can make a treatment decision based on realistic expectations.

  • Guidelines:Keratinocyte carcinoma/Prognosis SCC#Practice_point_6
  • For a patient with facial cutaneous squamous cell carcinoma who is anxious about the cosmetic results of treatment, carefully explain the potential consequences of delaying treatment or failing to achieve tumour clearance, as well as the potential adverse outcomes each treatment option, so that the person can make a treatment decision based on realistic expectations.
  • Good practice point
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When incomplete excision of a cutaneous squamous cell carcinoma is reported, the surgeon or treating clinician should explain to the patient that there is a significant risk of the cancer recurring, and should offer further treatment as appropriate, carefully explaining the risks and benefits of each management option.

  • Guidelines:Keratinocyte carcinoma/Prognosis SCC#Practice_point_7
  • When incomplete excision of a cutaneous squamous cell carcinoma is reported, the surgeon or treating clinician should explain to the patient that there is a significant risk of the cancer recurring, and should offer further treatment as appropriate, carefully explaining the risks and benefits of each management option.
  • Good practice point

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Surgical treatment

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 basal cell carcinoma or cutaneous squamous cell carcinoma?

Evidence-based recommendationQuestion mark transparent.png Grade
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
  • Both surgical and nonsurgical treatment modalities can be considered for superficial and nodular basal cell carcinomas in favourable sites.
  • Recommendation
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Both surgical and nonsurgical treatment modalities can be considered for low-risk keratinocyte cancers in favourable sites. The decision must balance the probability of achieving clearance, recurrence risk, cosmetic and functional outcome, and patient preference.

  • 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?#Practice_point_1
  • Both surgical and nonsurgical treatment modalities can be considered for low-risk keratinocyte cancers in favourable sites. The decision must balance the probability of achieving clearance, recurrence risk, cosmetic and functional outcome, and patient preference.
  • Good practice point

Optimal primary excision techniques

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When submitting a biopsy specimen to pathology, the specimen orientation must be described unambiguously and stated clearly on the pathology request form.

  • Guidelines:Keratinocyte carcinoma/Optimal primary excision techniques#Practice_point_1
  • When submitting a biopsy specimen to pathology, the specimen orientation must be described unambiguously and stated clearly on the pathology request form.
  • Good practice point
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For complex specimens or sites, photographs and/or diagrams should be provided with the pathology request.

  • Guidelines:Keratinocyte carcinoma/Optimal primary excision techniques#Practice_point_2
  • For complex specimens or sites, photographs and/or diagrams should be provided with the pathology request.
  • Good practice point

What factors need to be considered when determining the optimal surgical technique for those with basal cell carcinoma?

Evidence-based recommendationQuestion mark transparent.png Grade
Patients with basal cell carcinomas with a high risk of recurrence (e.g. due to unfavourable histological type or anatomical site) should be offered wide surgical excision. Adequate follow-up should be provided.
C
  • Clinical question:Factors to consider to determine optimal BCC treatment#Recommendation_1
  • Patients with basal cell carcinomas with a high risk of recurrence (e.g. due to unfavourable histological type or anatomical site) should be offered wide surgical excision. Adequate follow-up should be provided.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
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
  • 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
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Patients with basal cell carcinomas with a high risk of recurrence (e.g. due to unfavourable histological type or anatomical site) should be offered wide surgical excision, where possible. Mohs micrographic surgery can be considered as an alternative. Adequate follow-up should be provided.

  • Clinical question:Factors to consider to determine optimal BCC treatment#Practice_point_1
  • Patients with basal cell carcinomas with a high risk of recurrence (e.g. due to unfavourable histological type or anatomical site) should be offered wide surgical excision, where possible. Mohs micrographic surgery can be considered as an alternative. Adequate follow-up should be provided.
  • Good practice point

In patients undergoing surgical treatment for cutaneous squamous cell carcinoma, which surgery-related factors (margin width, depth of excision) or tumour-related factors (size, histological features, anatomical site) influence clinical outcomes (cure rate, local recurrence, regional lymph node involvement, metastasis)?

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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
  • 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).
  • Consensus based recommendation

Post-surgical care, interpretation of the pathology report and follow-up

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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
  • 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
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Preoperative magnetic resonance imaging should be considered for patients with clinical evidence of large nerve involvement.

  • Guidelines:Keratinocyte carcinoma/Post-surgical care follow-up#Practice_point_2
  • Preoperative magnetic resonance imaging should be considered for patients with clinical evidence of large nerve involvement.
  • Good practice point
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When incomplete deep margin is reported on an excision specimen, the clinician should discuss the implications of potential recurrence with the patient. If recurrence would significantly compromise the person’s quality of life, further treatment should be offered.

  • Guidelines:Keratinocyte carcinoma/Post-surgical care follow-up#Practice_point_3
  • When incomplete deep margin is reported on an excision specimen, the clinician should discuss the implications of potential recurrence with the patient. If recurrence would significantly compromise the person’s quality of life, further treatment should be offered.
  • Good practice point

What should be the protocol to manage incompletely resected basal cell carcinoma?

Evidence-based recommendationQuestion mark transparent.png Grade
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
  • Incompletely excised basal cell carcinomas should be assessed and treatment selected on a case-by-case basis.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
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
  • Incompletely excised basal cell carcinomas that have high-risk features, or occur in high-risk anatomical sites, should be re-excised, where possible.
  • Recommendation

What should be the protocol to manage rapidly growing tumours?

Evidence-based recommendationQuestion mark transparent.png Grade
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 monitoring for locoregional or distant recurrence should be provided.
C
  • Clinical question:Management protocol for rapidly growing tumours#Recommendation_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 monitoring for locoregional or distant recurrence should be provided.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
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
  • 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 recommendationQuestion mark transparent.png Grade
Cutaneous squamous cell carcinomas with high-risk features should be managed with wider surgical margins, adjuvant radiotherapy, and regular observation for locoregional or distant recurrence.
C
  • Clinical question:Management protocol for rapidly growing tumours#Recommendation_3
  • Cutaneous squamous cell carcinomas with high-risk features should be managed with wider surgical margins, adjuvant radiotherapy, and regular observation for locoregional or distant recurrence.
  • Recommendation
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GPs should offer specialist referral to patients with cutaneous squamous cell carcinomas with poor prognostic factors (e.g. high-risk anatomical site or histopathological features).

  • Clinical question:Management protocol for rapidly growing tumours#Practice_point_1
  • GPs should offer specialist referral to patients with cutaneous squamous cell carcinomas with poor prognostic factors (e.g. high-risk anatomical site or histopathological features).
  • Good practice point
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Patients with rapidly growing squamous cell carcinomas should be referred promptly for assessment for specialised therapies or combination therapies.

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

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

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For patients with high-risk recurrent facial basal cell carcinomas, consider referral for assessment for Mohs micrographic surgery.

  • Guidelines:Keratinocyte carcinoma/Criteria for Mohs surgery#Practice_point_1
  • For patients with high-risk recurrent facial basal cell carcinomas, consider referral for assessment for Mohs micrographic surgery.
  • Good practice point
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Mohs micrographic surgery may be considered in the treatment of basal cell carcinomas with any of the following features:

  • poorly defined borders (particularly those of an aggressive histological subtype that are located in an anatomically sensitive area)
  • recurrent or residual following previous treatment
  • high-risk at facial site
  • extensive.
  • Guidelines:Keratinocyte carcinoma/Criteria for Mohs surgery#Practice_point_2
  • Mohs micrographic surgery may be considered in the treatment of basal cell carcinomas with any of the following features:
  • poorly defined borders (particularly those of an aggressive histological subtype that are located in an anatomically sensitive area)
  • recurrent or residual following previous treatment
  • high-risk at facial site
  • extensive.
  • Good practice point
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Mohs micrographic surgery can be useful for histologically confirmed recurrent basal cell carcinomas of the face greater that are large (>10mm in diameter), show aggressive histological features, or are located on the H-zonethe area of the face that includes the central face, eyelids, eyebrows, periorbital, nose, lips, chin, mandible, preauricular and postauricular skin and sulci, temple, and ear of the face.

  • Guidelines:Keratinocyte carcinoma/Criteria for Mohs surgery#Practice_point_3
  • Mohs micrographic surgery can be useful for histologically confirmed recurrent basal cell carcinomas of the face greater that are large (>10mm in diameter), show aggressive histological features, or are located on the H-zonethe area of the face that includes the central face, eyelids, eyebrows, periorbital, nose, lips, chin, mandible, preauricular and postauricular skin and sulci, temple, and ear of the face.
  • Good practice point
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The decision to offer Mohs micrographic surgery should be made by a medical practitioner experienced in skin cancer diagnosis and management who has a clear understanding of the technique and its value.

  • Guidelines:Keratinocyte carcinoma/Criteria for Mohs surgery#Practice_point_4
  • The decision to offer Mohs micrographic surgery should be made by a medical practitioner experienced in skin cancer diagnosis and management who has a clear understanding of the technique and its value.
  • Good practice point

Surgical management of advanced cutaneous squamous cell carcinoma

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For patients with lymph node involvement who have a significant risk of recurrence, adjuvant postoperative radiotherapy should be considered after lymphadenectomy.

  • Guidelines:Keratinocyte carcinoma/Surgical management advanced SCC#Practice_point_1
  • For patients with lymph node involvement who have a significant risk of recurrence, adjuvant postoperative radiotherapy should be considered after lymphadenectomy.
  • Good practice point
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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_2
  • Dermal lymphatic spread (in-transit metastasis) should be managed by wide surgical excision followed by adjuvant radiotherapy.
  • Good practice point
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Any patient with advanced cutaneous squamous cell carcinoma should be referred to a specialist unit or multidisciplinary team.

  • Guidelines:Keratinocyte carcinoma/Surgical management advanced SCC#Practice_point_3
  • Any patient with advanced cutaneous squamous cell carcinoma should be referred to a specialist unit or multidisciplinary team.
  • Good practice point

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Radiotherapy

When should radiotherapy be used alone, or in combination with surgical excision to treat those with keratinocyte cancers?

Evidence-based recommendationQuestion mark transparent.png Grade
Radiotherapy can be used alone in the treatment of keratinocyte cancers when surgery is not possible or the patient refuses surgery.
D
  • Clinical question:RT with or without surgery for KC treatment#Recommendation_1
  • Radiotherapy can be used alone in the treatment of keratinocyte cancers when surgery is not possible or the patient refuses surgery.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
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
  • Radiotherapy may be used in combination with surgical excision with the aim of improving locoregional control.
  • Recommendation
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Histological assessment of margins and other associated pathological features by the histopathologist are essential for predicting the need for further therapy.

  • Clinical question:RT with or without surgery for KC treatment#Practice_point_1
  • Histological assessment of margins and other associated pathological features by the histopathologist are essential for predicting the need for further therapy.
  • Good practice point
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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_2
  • 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

In which patients with basal cell carcinoma does a radiotherapy modality achieve equal or better outcomes than conventional surgery?

Evidence-based recommendationQuestion mark transparent.png Grade
Radiotherapy using curative doses can be considered as an alternative to surgical excision in the definitive treatment of basal cell carcinoma if surgery cannot be offered.
B
  • Clinical question:Patient outcomes of RT modality vs conventional surgery for BCC#Recommendation_1
  • Radiotherapy using curative doses can be considered as an alternative to surgical excision in the definitive treatment of basal cell carcinoma if surgery cannot be offered.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
External-beam radiation therapy should be used in preference to brachytherapy for basal cell carcinoma when cosmesis is a priority.
D
  • Clinical question:Patient outcomes of RT modality vs conventional surgery for BCC#Recommendation_2
  • External-beam radiation therapy should be used in preference to brachytherapy for basal cell carcinoma when cosmesis is a priority.
  • Recommendation
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For patients with T3/T4 primary persistent or recurrent basal cell carcinoma, consideration should be given to obtaining in 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
  • For patients with T3/T4 primary persistent or recurrent basal cell carcinoma, consideration should be given to obtaining in opinion from a radiation oncologist as part of multidisciplinary care.
  • Consensus based recommendation
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Radiotherapy can be considered an alternative to re-excision in the management of incompletely excised basal cell carcinoma 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 BCC#Practice_point_2
  • Radiotherapy can be considered an alternative to re-excision in the management of incompletely excised basal cell carcinoma if further treatment is deemed advisable and re-excision is disadvantageous or not feasible.
  • Good practice point
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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_3
  • 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
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Radiotherapy can be considered as an alternative to excision surgery as a definitive treatment for T1 and T2 BCC when surgery is difficult due to patient-related factors (e.g. frailty), tumour-related factors (e.g. where tissue conservation or cosmesis is a high priority, such as in BCC of the eyelid), or treatment-related factors (e.g. concurrent anticoagulant therapy).

  • Clinical question:Patient outcomes of RT modality vs conventional surgery for BCC#Practice_point_4
  • Radiotherapy can be considered as an alternative to excision surgery as a definitive treatment for T1 and T2 BCC when surgery is difficult due to patient-related factors (e.g. frailty), tumour-related factors (e.g. where tissue conservation or cosmesis is a high priority, such as in BCC of the eyelid), or treatment-related factors (e.g. concurrent anticoagulant therapy).
  • Good practice point
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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
  • perineural invasion (major and minor nerves)
  • lymphovascular invasion
  • in-transit metastases
  • regional nodal involvement
  • histological subtype associated with poor prognosis (micronodular, infiltrative or metatypicalshowing evidence of squamatisation (descriptor applicable to basaloid tumours and indicating aggressive subtype))
  • immunosuppression (e.g. organ transplant recipient, patient with chronic lymphocytic leukaemia, patient on long-term corticosteroid therapy).
  • Clinical question:Patient outcomes of RT modality vs conventional surgery for BCC#Practice_point_5
  • 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
  • perineural invasion (major and minor nerves)
  • lymphovascular invasion
  • in-transit metastases
  • regional nodal involvement
  • histological subtype associated with poor prognosis (micronodular, infiltrative or metatypicalshowing evidence of squamatisation (descriptor applicable to basaloid tumours and indicating aggressive subtype))
  • immunosuppression (e.g. organ transplant recipient, patient with chronic lymphocytic leukaemia, patient on long-term corticosteroid therapy).
  • Good practice point

In which patients with cutaneous squamous cell carcinoma does a radiotherapy modality achieve equal or better outcomes than conventional surgery?

Evidence-based recommendationQuestion mark transparent.png Grade
Radiotherapy using curative doses can be considered as an alternative to surgery for cutaneous squamous cell carcinomas if surgery cannot be offered or is declined by the patient.
B
  • Clinical question:Patient outcomes of RT modality vs conventional surgery for SCC#Recommendation_1
  • Radiotherapy using curative doses can be considered as an alternative to surgery for cutaneous squamous cell carcinomas if surgery cannot be offered or is declined by the patient.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
The addition of concurrent carboplatin-based chemotherapy to postoperative radiotherapy is not recommended in the treatment of locally advanced or high-risk node-positive cutaneous squamous cell carcinoma of the head and neck.
A
  • Clinical question:Patient outcomes of RT modality vs conventional surgery for SCC#Recommendation_2
  • The addition of concurrent carboplatin-based chemotherapy to postoperative radiotherapy is not recommended in the treatment of locally advanced or high-risk node-positive cutaneous squamous cell carcinoma of the head and neck.
  • Recommendation
Consensus-based recommendationQuestion mark transparent.png

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
  • If surgical excision of a cutaneous squamous cell carcinoma is not possible, referral for a radiotherapy opinion should be considered.
  • Consensus based recommendation
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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
  • 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.
  • Consensus based recommendation
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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
  • poorly differentiated tumour
  • perineural invasion (major and minor nerves)
  • lymphovascular invasion
  • in-transit metastases
  • regional nodal involvement
  • immunosuppression (e.g. organ transplant recipient, patient with chronic lymphocytic leukaemia, patient on long-term corticosteroid therapy).
  • Clinical question:Patient outcomes of RT modality vs conventional surgery for SCC#Practice_point_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
  • poorly differentiated tumour
  • perineural invasion (major and minor nerves)
  • lymphovascular invasion
  • in-transit metastases
  • regional nodal involvement
  • immunosuppression (e.g. organ transplant recipient, patient with chronic lymphocytic leukaemia, patient on long-term corticosteroid therapy).
  • Good practice point
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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
  • 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
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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
  • 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

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

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Clinically suspected lymph node metastases of keratinocyte cancer should be confirmed by fine needle aspiration cytology (under radiological guidance, if required). Open surgical biopsy should be avoided.

  • Guidelines:Keratinocyte carcinoma/Radiotherapy for regional metastatic disease#Practice_point_1
  • Clinically suspected lymph node metastases of keratinocyte cancer should be confirmed by fine needle aspiration cytology (under radiological guidance, if required). Open surgical biopsy should be avoided.
  • Good practice point
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Symptoms of perineural invasion should be elicited at the time of patient assessment of cutaneous squamous cell carcinoma, especially in cases of persistent, recurrent or locally advanced lesions. A positive response should prompt referral to a specialist clinic for further investigations, which may include magnetic resonance imaging.

  • Guidelines:Keratinocyte carcinoma/Radiotherapy for regional metastatic disease#Practice_point_2
  • Symptoms of perineural invasion should be elicited at the time of patient assessment of cutaneous squamous cell carcinoma, especially in cases of persistent, recurrent or locally advanced lesions. A positive response should prompt referral to a specialist clinic for further investigations, which may include magnetic resonance imaging.
  • Good practice point
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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_3
  • 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
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Modern radiotherapy techniques, such as volumetric modulated arc therapy, 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_4
  • Modern radiotherapy techniques, such as volumetric modulated arc therapy, 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

Radiotherapy for actinic keratosis and cutaneous squamous cell carcinoma in situ

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For patients with persistent or recurrent actinic keratosis, consider referral to a radiation oncologist for assessment.

  • Guidelines:Keratinocyte carcinoma/Radiotherapy actinic keratosis SCC in situ#Practice_point_1
  • For patients with persistent or recurrent actinic keratosis, consider referral to a radiation oncologist for assessment.
  • Good practice point

Radiotherapy for keratoacanthoma

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Radiotherapy may be considered in the treatment of keratoacanthoma to hasten the natural history of resolution.

  • Guidelines:Keratinocyte carcinoma/Radiotherapy keratoacanthoma#Practice_point_1
  • Radiotherapy may be considered in the treatment of keratoacanthoma to hasten the natural history of resolution.
  • Good practice point
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Regular follow-up must be provided for patients with keratoacanthoma if they are not referred for radiotherapy, because these may represent undiagnosed squamous cell carcinoma.

  • Guidelines:Keratinocyte carcinoma/Radiotherapy keratoacanthoma#Practice_point_2
  • Regular follow-up must be provided for patients with keratoacanthoma if they are not referred for radiotherapy, because these may represent undiagnosed squamous cell carcinoma.
  • Good practice point


Management of radiotherapy side effects

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

  • Guidelines:Keratinocyte carcinoma/Management of radiotherapy side effects#Practice_point_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 to ascertain the dose and location of prior radiation.
  • Good practice point

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Cryotherapy and electrodessication and curettage

Cryotherapy and electrodessication and curettage for basal cell carcinoma

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For patients with primary basal cell carcinomas in sites other than face and ears, with optimal tumour selection and treatment protocols, cryotherapy may be considered as a treatment option.

  • Guidelines:Keratinocyte carcinoma/Cryotherapy curettage diathermy BCC#Practice_point_1
  • For patients with primary basal cell carcinomas in sites other than face and ears, with optimal tumour selection and treatment protocols, cryotherapy may be considered as a treatment option.
  • Good practice point
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Cryotherapy is not recommended for basal cell carcinomas at high-risk facial sites, where it achieves lower cure rates.

  • Guidelines:Keratinocyte carcinoma/Cryotherapy curettage diathermy BCC#Practice_point_2
  • Cryotherapy is not recommended for basal cell carcinomas at high-risk facial sites, where it achieves lower cure rates.
  • Good practice point
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Cryotherapy is not recommended for the treatment of basal cell carcinomas larger than 2cm in diameter.

  • Guidelines:Keratinocyte carcinoma/Cryotherapy curettage diathermy BCC#Practice_point_3
  • Cryotherapy is not recommended for the treatment of basal cell carcinomas larger than 2cm in diameter.
  • Good practice point
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Cryotherapy is contraindicated for ill-defined or sclerosingscar-like (morphoeic) (morphoeic or infiltrative) basal cell carcinomas at any site.

  • Guidelines:Keratinocyte carcinoma/Cryotherapy curettage diathermy BCC#Practice_point_4
  • Cryotherapy is contraindicated for ill-defined or sclerosingscar-like (morphoeic) (morphoeic or infiltrative) basal cell carcinomas at any site.
  • Good practice point
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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_5
  • Long-term follow-up is essential after treatment of basal cell carcinoma with cryotherapy, as late recurrences may occur.
  • Good practice point

Cryotherapy and electrodessication and curettage for cutaneous squamous cell carcinoma

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Cryotherapy may be considered as a treatment option for patients with actinic keratosis.

  • Guidelines:Keratinocyte carcinoma/Cryotherapy curettage diathermy SCC#Practice_point_1
  • Cryotherapy may be considered as a treatment option for patients with actinic keratosis.
  • Good practice point
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Cryotherapy may be considered as treatment option for patients with Bowen’s diseasecutaneous squamous cell carcinoma in situ (also known as intra-epidermal squamous cell carcinoma). Patients should be informed about the potential delayed healing that may occur on lower limbs.

  • Guidelines:Keratinocyte carcinoma/Cryotherapy curettage diathermy SCC#Practice_point_2
  • Cryotherapy may be considered as treatment option for patients with Bowen’s diseasecutaneous squamous cell carcinoma in situ (also known as intra-epidermal squamous cell carcinoma). Patients should be informed about the potential delayed healing that may occur on lower limbs.
  • Good practice point
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Cryotherapy may be a reasonable treatment option for smaller keratoacanthomas. If the diagnosis is in doubt then treatment should be as for cutaneous squamous cell carcinoma.

  • Guidelines:Keratinocyte carcinoma/Cryotherapy curettage diathermy SCC#Practice_point_3
  • Cryotherapy may be a reasonable treatment option for smaller keratoacanthomas. If the diagnosis is in doubt then treatment should be as for cutaneous squamous cell carcinoma.
  • Good practice point
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For patients with low-risk cutaneous squamous cell carcinomas on the trunk and limbs, cryotherapy may be considered as a treatment option.

  • Guidelines:Keratinocyte carcinoma/Cryotherapy curettage diathermy SCC#Practice_point_4
  • For patients with low-risk cutaneous squamous cell carcinomas on the trunk and limbs, cryotherapy may be considered as a treatment option.
  • Good practice point
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Cryotherapy is contraindicated for recurrent cutaneous squamous cell carcinoma.

  • Guidelines:Keratinocyte carcinoma/Cryotherapy curettage diathermy SCC#Practice_point_5
  • Cryotherapy is contraindicated for recurrent cutaneous squamous cell carcinoma.
  • Good practice point

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Topical treatments and photodynamic therapy

What role does ingenol mebutate gel have in the treatment and management of basal cell carcinoma and/or cutaneous squamous cell carcinoma?

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All prescribers should discuss the relative harms and benefits of ingenol mebutate gel with patients offered this treatment option.

  • Clinical question:Topical treatments#Practice_point_1
  • All prescribers should discuss the relative harms and benefits of ingenol mebutate gel with patients offered this treatment option.
  • Good practice point
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Imiquimod 5% cream, a topical cytokine- and interferon-inducer, can be considered for the treatment of actinic keratoses and primary basal cell carcinomas where surgery or other therapies are inappropriate or contraindicated.

  • Clinical question:Topical treatments#Practice_point_2
  • Imiquimod 5% cream, a topical cytokine- and interferon-inducer, can be considered for the treatment of actinic keratoses and primary basal cell carcinomas where surgery or other therapies are inappropriate or contraindicated.
  • Good practice point
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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_3
  • 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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Skin biopsy is not required when treating actinic keratoses with imiquimod 5% cream.

  • Clinical question:Topical treatments#Practice_point_4
  • Skin biopsy is not required when treating actinic keratoses with imiquimod 5% cream.
  • Good practice point
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Imiquimod 5% cream is contraindicated for sclerosingscar-like (morphoeic), infiltrative and micronodular basal cell carcinoma subtypes.

  • Clinical question:Topical treatments#Practice_point_5
  • Imiquimod 5% cream is contraindicated for sclerosingscar-like (morphoeic), infiltrative and micronodular basal cell carcinoma subtypes.
  • Good practice point
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Long-term follow-up is essential after treatment of basal cell carcinoma with imiquimod 5% cream.

  • Clinical question:Topical treatments#Practice_point_6
  • Long-term follow-up is essential after treatment of basal cell carcinoma with imiquimod 5% cream.
  • Good practice point
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The use of 5-fluorouracil 5% cream can be considered for the treatment of actinic keratoses and Bowen’s diseasecutaneous squamous cell carcinoma in situ (also known as intra-epidermal squamous cell carcinoma).

  • Clinical question:Topical treatments#Practice_point_7
  • The use of 5-fluorouracil 5% cream can be considered for the treatment of actinic keratoses and Bowen’s diseasecutaneous squamous cell carcinoma in situ (also known as intra-epidermal squamous cell carcinoma).
  • Good practice point
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Supervision of 5-fluorouracil 5% cream therapy in first-time users is essential.

  • Clinical question:Topical treatments#Practice_point_8
  • Supervision of 5-fluorouracil 5% cream therapy in first-time users is essential.
  • Good practice point
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Whilst they are effective as spot treatments, the principal role of topical therapies is field therapy for multiple actinic keratoses or for superficial keratinocyte carcinomas (Bowen’s diseasecutaneous squamous cell carcinoma in situ (also known as intra-epidermal squamous cell carcinoma) and superficial basal cell carcinoma).

  • Clinical question:Topical treatments#Practice_point_9
  • Whilst they are effective as spot treatments, the principal role of topical therapies is field therapy for multiple actinic keratoses or for superficial keratinocyte carcinomas (Bowen’s diseasecutaneous squamous cell carcinoma in situ (also known as intra-epidermal squamous cell carcinoma) and superficial basal cell carcinoma).
  • Good practice point

Photodynamic therapy

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Specialised equipment and training are required with photodynamic therapy.

  • Guidelines:Keratinocyte carcinoma/Photodynamic therapy#Practice_point_1
  • Specialised equipment and training are required with photodynamic therapy.
  • Good practice point
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Methyl aminolevulinate photodynamic therapy and 5-aminolevulinic acid photodynamic therapy can be considered for the treatment of actinic keratoses, Bowen’s diseasecutaneous squamous cell carcinoma in situ (also known as intra-epidermal squamous cell carcinoma) and superficial basal cell carcinoma.

  • Guidelines:Keratinocyte carcinoma/Photodynamic therapy#Practice_point_2
  • Methyl aminolevulinate photodynamic therapy and 5-aminolevulinic acid photodynamic therapy can be considered for the treatment of actinic keratoses, Bowen’s diseasecutaneous squamous cell carcinoma in situ (also known as intra-epidermal squamous cell carcinoma) and superficial basal cell carcinoma.
  • Good practice point
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Thin nodular basal cell carcinoma can be treated with photodynamic therapy with low 5-year recurrence rates.

  • Guidelines:Keratinocyte carcinoma/Photodynamic therapy#Practice_point_3
  • Thin nodular basal cell carcinoma can be treated with photodynamic therapy with low 5-year recurrence rates.
  • Good practice point
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Photodynamic therapy is not recommended for invasive squamous cell carcinoma.

  • Guidelines:Keratinocyte carcinoma/Photodynamic therapy#Practice_point_4
  • Photodynamic therapy is not recommended for invasive squamous cell carcinoma.
  • Good practice point

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Organ transplantation

Epidemiology of keratinocyte cancers in immunosuppressed patients

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Regular and close skin cancer surveillance should be provided routinely for patients with conditions characterised by immune-system dysregulation, such as HIV and chronic lymphocytic leukaemia.

  • Guidelines:Keratinocyte carcinoma/Organ transplantation immunosuppression epidemiology#Practice_point_1
  • Regular and close skin cancer surveillance should be provided routinely for patients with conditions characterised by immune-system dysregulation, such as HIV and chronic lymphocytic leukaemia.
  • Good practice point

Management of keratinocyte cancer risk in organ transplant recipients

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Organ transplant recipients should be educated about sun-protection measures and regularly encouraged to practise them.

  • Guidelines:Keratinocyte carcinoma/Organ transplant management#Practice_point_1
  • Organ transplant recipients should be educated about sun-protection measures and regularly encouraged to practise them.
  • Good practice point
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Where resources permit, patients undergoing organ transplant should be offered preventive and ongoing care for keratinocyte cancers within dedicated specialist clinics. Where access to dedicated clinics is not available, organ transplant recipients need to be closely and regularly monitored for skin cancer, especially those with previous skin cancer.

  • Guidelines:Keratinocyte carcinoma/Organ transplant management#Practice_point_2
  • Where resources permit, patients undergoing organ transplant should be offered preventive and ongoing care for keratinocyte cancers within dedicated specialist clinics. Where access to dedicated clinics is not available, organ transplant recipients need to be closely and regularly monitored for skin cancer, especially those with previous skin cancer.
  • Good practice point

Strategies to manage keratinocyte cancer in organ transplant recipients

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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
  • Chemoprophylaxis with systemic acitretin should be considered for reducing tumour burden in patients who develop multiple keratinocyte cancers.
  • Good practice point
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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
  • Reduction of immunosuppression should be considered in organ transplant recipients who develop multiple keratinocyte cancers.
  • Good practice point
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The use of MTOR inhibitors can be considered as a strategy in organ transplant recipients who develop multiple keratinocyte cancers.

  • Guidelines:Keratinocyte carcinoma/Organ transplant keratinocyte cancer strategies#Practice_point_3
  • The use of MTOR inhibitors can be considered as a strategy in organ transplant recipients who develop multiple keratinocyte cancers.
  • Good practice point

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Metastatic disease and systemic therapies

Systemic therapies for advanced and metastatic basal cell carcinoma

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Patients with advanced basal cell carcinoma should be assessed by a multidisciplinary team.

  • Guidelines:Keratinocyte carcinoma/Metastatic disease systemic therapies BCC#Practice_point_1
  • Patients with advanced basal cell carcinoma should be assessed by a multidisciplinary team.
  • Good practice point
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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_2
  • 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
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Hedgehog pathway inhibitors should be considered for patients with advanced basal cell carcinoma where curative-intent treatment (surgery, radiotherapy or both) is not appropriate. Some patients who have a marked response may become candidates for surgery.

  • Guidelines:Keratinocyte carcinoma/Metastatic disease systemic therapies BCC#Practice_point_3
  • Hedgehog pathway inhibitors should be considered for patients with advanced basal cell carcinoma where curative-intent treatment (surgery, radiotherapy or both) is not appropriate. Some patients who have a marked response may become candidates for surgery.
  • Good practice point
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Patients distant metastatic basal cell carcinoma should be referred to a medical oncologists or multidisciplinary team for consideration of hedgehog signalling pathway inhibitor treatment.

  • Guidelines:Keratinocyte carcinoma/Metastatic disease systemic therapies BCC#Practice_point_4
  • Patients distant metastatic basal cell carcinoma should be referred to a medical oncologists or multidisciplinary team for consideration of hedgehog signalling pathway inhibitor treatment.
  • Good practice point
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Patients treated with hedgehog pathway inhibitors should be monitored carefully for side effects.

  • Guidelines:Keratinocyte carcinoma/Metastatic disease systemic therapies BCC#Practice_point_5
  • Patients treated with hedgehog pathway inhibitors should be monitored carefully for side effects.
  • Good practice point
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Health professionals treating patients who are receiving Hedgehog pathway inhibitors should be aware of the potential side effects of these agents.

  • Guidelines:Keratinocyte carcinoma/Metastatic disease systemic therapies BCC#Practice_point_6
  • Health professionals treating patients who are receiving Hedgehog pathway inhibitors should be aware of the potential side effects of these agents.
  • Good practice point
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Patients being treated with Hedgehog inhibitors should be made aware of their potential side effects by their clinician.

  • Guidelines:Keratinocyte carcinoma/Metastatic disease systemic therapies BCC#Practice_point_7
  • Patients being treated with Hedgehog inhibitors should be made aware of their potential side effects by their clinician.
  • Good practice point

Systemic therapies for advanced and metastatic basal cell carcinoma

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Patients with advanced basal cell carcinoma should be assessed by a multidisciplinary team.

  • Guidelines:Keratinocyte carcinoma/Metastatic disease systemic therapies BCC#Practice_point_1
  • Patients with advanced basal cell carcinoma should be assessed by a multidisciplinary team.
  • Good practice point
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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_2
  • 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
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Hedgehog pathway inhibitors should be considered for patients with advanced basal cell carcinoma where curative-intent treatment (surgery, radiotherapy or both) is not appropriate. Some patients who have a marked response may become candidates for surgery.

  • Guidelines:Keratinocyte carcinoma/Metastatic disease systemic therapies BCC#Practice_point_3
  • Hedgehog pathway inhibitors should be considered for patients with advanced basal cell carcinoma where curative-intent treatment (surgery, radiotherapy or both) is not appropriate. Some patients who have a marked response may become candidates for surgery.
  • Good practice point
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Patients distant metastatic basal cell carcinoma should be referred to a medical oncologists or multidisciplinary team for consideration of hedgehog signalling pathway inhibitor treatment.

  • Guidelines:Keratinocyte carcinoma/Metastatic disease systemic therapies BCC#Practice_point_4
  • Patients distant metastatic basal cell carcinoma should be referred to a medical oncologists or multidisciplinary team for consideration of hedgehog signalling pathway inhibitor treatment.
  • Good practice point
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Patients treated with hedgehog pathway inhibitors should be monitored carefully for side effects.

  • Guidelines:Keratinocyte carcinoma/Metastatic disease systemic therapies BCC#Practice_point_5
  • Patients treated with hedgehog pathway inhibitors should be monitored carefully for side effects.
  • Good practice point
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Health professionals treating patients who are receiving Hedgehog pathway inhibitors should be aware of the potential side effects of these agents.

  • Guidelines:Keratinocyte carcinoma/Metastatic disease systemic therapies BCC#Practice_point_6
  • Health professionals treating patients who are receiving Hedgehog pathway inhibitors should be aware of the potential side effects of these agents.
  • Good practice point
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Patients being treated with Hedgehog inhibitors should be made aware of their potential side effects by their clinician.

  • Guidelines:Keratinocyte carcinoma/Metastatic disease systemic therapies BCC#Practice_point_7
  • Patients being treated with Hedgehog inhibitors should be made aware of their potential side effects by their clinician.
  • Good practice point

What should be the protocol to manage or treat locoregionally advanced cutaneous squamous cell carcinoma?

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For patients with resected high-risk cutaneous squamous cell carcinoma, adjuvant radiotherapy should be considered to reduce the risk of local recurrence.
D
  • Clinical question:Protocol to treat local regional SCC#Recommendation_1
  • For patients with resected high-risk cutaneous squamous cell carcinoma, adjuvant radiotherapy should be considered to reduce the risk of local recurrence.
  • Recommendation
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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
  • 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
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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
  • 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
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Patients with resected primary cutaneous squamous cell carcinoma should be assessed for high-risk features and referred for consideration of adjuvant treatment if appropriate.
C
  • Clinical question:Protocol to treat local regional SCC#Recommendation_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
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Do not routinely offer carboplatin chemotherapy in addition to adjuvant radiotherapy for patients who have undergone excision of high-risk cutaneous squamous cell carcinoma.
B
  • Clinical question:Protocol to treat local regional SCC#Recommendation_5
  • Do not routinely offer carboplatin chemotherapy in addition to adjuvant radiotherapy for patients who have undergone excision of high-risk cutaneous squamous cell carcinoma.
  • Recommendation
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Recurrences of cutaneous squamous cell carcinoma in the axillary, epitrochlear or inguinal lymph nodes should be treated with surgery and adjuvant radiotherapy.
B
  • Clinical question:Protocol to treat local regional SCC#Recommendation_6
  • Recurrences of cutaneous squamous cell carcinoma in the axillary, epitrochlear or inguinal lymph nodes should be treated with surgery and adjuvant radiotherapy.
  • Recommendation
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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
  • Patients with cutaneous squamous cell carcinoma involving the parotid or cervical lymph nodes should be offered adjuvant radiotherapy after surgery.
  • Consensus based recommendation
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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_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
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Patients with high-risk resected cutaneous squamous cell carcinoma should be encouraged to participate in clinical trials of adjuvant therapy including radiotherapy, chemotherapy and immunotherapy.

  • Clinical question:Protocol to treat local regional SCC#Practice_point_3
  • Patients with high-risk resected cutaneous squamous cell carcinoma should be encouraged to participate in clinical trials of adjuvant therapy including radiotherapy, chemotherapy and immunotherapy.
  • Good practice point
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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
  • Patients with unresectable local cutaneous squamous cell carcinoma can be considered for radiotherapy and, if fit for chemotherapy, platinum-based chemoradiation
  • Good practice point
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Cemiplimab 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
  • Cemiplimab 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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Follow-up after treatment for keratinocyte cancer

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For patients with histological clearance of primary keratinocyte cancers and low-risk tumours, such as basal cell carcinomas and well-differentiated cutaneous squamous cell carcinomas, no specific evidence-based follow-up scheme is recommended.

  • Guidelines:Keratinocyte carcinoma/Follow-up#Practice_point_1
  • For patients with histological clearance of primary keratinocyte cancers and low-risk tumours, such as basal cell carcinomas and well-differentiated cutaneous squamous cell carcinomas, no specific evidence-based follow-up scheme is recommended.
  • Good practice point
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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_2
  • 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
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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_3
  • 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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All patients with a previous skin cancer are advised to undergo annual skin examination for life, as part of routine health checks by their health care provider, to look for the development of new lesions.

  • Guidelines:Keratinocyte carcinoma/Follow-up#Practice_point_4
  • All patients with a previous skin cancer are advised to undergo annual skin examination for life, as part of routine health checks by their health care provider, to look for the development of new lesions.
  • Good practice point
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Patients need to receive counselling about their risk for further primary tumours, local persistence of their previous primary tumour and for metastatic disease.

  • Guidelines:Keratinocyte carcinoma/Follow-up#Practice_point_5
  • Patients need to receive counselling about their risk for further primary tumours, local persistence of their previous primary tumour and for metastatic disease.
  • Good practice point

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

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Uncomplicated small tumours should be removed by an elliptical excision and direct closure.

  • Guidelines:Keratinocyte carcinoma/Problems to refer#Practice_point_1
  • Uncomplicated small tumours should be removed by an elliptical excision and direct closure.
  • Good practice point
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GPs should use caution when managing keratinocyte cancers on the head and neck.

  • Guidelines:Keratinocyte carcinoma/Problems to refer#Practice_point_2
  • GPs should use caution when managing keratinocyte cancers on the head and neck.
  • Good practice point
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GPs should be aware of indications for referral of patients for management of keratinocyte cancers.

  • Guidelines:Keratinocyte carcinoma/Problems to refer#Practice_point_3
  • GPs should be aware of indications for referral of patients for management of keratinocyte cancers.
  • Good practice point
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Total body cutaneous examination should occur opportunistically in all patients, particularly those with Fitzpatrick skin types 1–3 skin and those with significant sun exposure.

  • Guidelines:Keratinocyte carcinoma/Problems to refer#Practice_point_4
  • Total body cutaneous examination should occur opportunistically in all patients, particularly those with Fitzpatrick skin types 1–3 skin and those with significant sun exposure.
  • Good practice point
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GPs should offer all patients regular skin examinations according to their level of risk for keratinocyte cancers, assessed based on the individual’s skin type, signs and history of ultraviolet exposure, and other risk factors such as history of keratinocyte cancers or immunosuppression.

  • Guidelines:Keratinocyte carcinoma/Problems to refer#Practice_point_5
  • GPs should offer all patients regular skin examinations according to their level of risk for keratinocyte cancers, assessed based on the individual’s skin type, signs and history of ultraviolet exposure, and other risk factors such as history of keratinocyte cancers or immunosuppression.
  • Good practice point

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Economics of keratinocyte cancer

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To encourage patients to seek medical attention for any suspicious skin lesions without delay and to reduce high out-of-pocket medical expenses, clinicians should consider whether cost is a barrier to treatment for individuals and consider strategies for minimising out-of-pocket costs to the patient needing keratinocyte cancer services and especially those patients returning for multiple skin cancer treatments.

  • Guidelines:Keratinocyte carcinoma/Economics#Practice_point_1
  • To encourage patients to seek medical attention for any suspicious skin lesions without delay and to reduce high out-of-pocket medical expenses, clinicians should consider whether cost is a barrier to treatment for individuals and consider strategies for minimising out-of-pocket costs to the patient needing keratinocyte cancer services and especially those patients returning for multiple skin cancer treatments.
  • Good practice point
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Clinicians should encourage patients to avoid excessive UV exposure by using a combination of sun protection measures including protective clothing, hats, sunscreen, sunglasses and shade.

  • Guidelines:Keratinocyte carcinoma/Economics#Practice_point_2
  • Clinicians should encourage patients to avoid excessive UV exposure by using a combination of sun protection measures including protective clothing, hats, sunscreen, sunglasses and shade.
  • Good practice point

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References

  1. 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.

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