7.10 Surgical treatment: health system implications and discussion

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Clinical practice guidelines for keratinocyte cancer > 7.10 Surgical treatment: health system implications and discussion


Health system implications

Clinical practice

Implementation of recommendations for surgical management of keratinocyte cancers (KCs) would not change the way that care is currently organised. However, adherence to these guidelines may prevent unnecessary surgery on occasion.

Resourcing

Resourcing needs to be allocated for continuous training of GPs in management of KCs as well as appropriate Medicare reimbursement and funding for such management.

Barriers to implementation

No barriers to the implementation of these recommendations is envisaged.

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Discussion

Unresolved issues

Based on currently available evidence, the risks and benefits of surgical treatment for KCs, compared with non-surgical treatments, cannot be defined because outcome measures are not consistent between studies. Different perspectives for surgical and non-surgical interventions result in different endpoints being considered relevant. If clearance or non-recurrence is the end point, it may theoretically be possible to achieve 100% with surgery by taking very wide margins, but that may be cosmetically and functionally unacceptable. Accordingly, a certain rate of recurrence is acceptable with surgical interventions if we are to minimise morbidity. There is a need for further studies comparing surgical and non-surgical treatments using the same well-defined endpoints and outcome measures.

Studies currently underway

No relevant clinical trials are known to be underway.

Future research priorities

Further research, including appropriately designed randomised controlled trials, where feasible, is needed to:

  • define adequate excision margins for cutaneous squamous cell carcinomas (cSCCs) and basal cell carcinomas (BCCs) according to other features identified before surgery
  • identify features of cSCCs that predict superior outcomes with Mohs micrographic surgery, compared with conventional excision
  • identify optimal management of high-risk primary facial BCCs
  • determine whether antibiotic prophylaxis prevents endocarditis or prosthetic joint infections in patients undergoing excision of BCCs or cSCCs
  • determine whether the use of dermoscopy, confocal microscopy, or other techniques to identify tumour margins is associated with reductions in recurrence rates.

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