# Presentation: 427979

## Presented by

**Robert S. Stern, M.D.**
**at the**
**September 10, 2003**
**meeting of the**
**Dermatologic and Ophthalmic **
**Drugs Advisory Committee**

## Recurrence Rates in Primary Basal Cell Carcinoma According to Treatment Modality

- Jean C. Lee, Harvard Medical Student

## Treatment Modalities for Basal Cell Carcinoma

- Surgical Excision
- Cryosurgery
- Curettage and Electrodesiccation
- Mohs' Micrographic Surgery

## Predictors of BCC Recurrence

- Size of tumor
- Clinically indistinct margins
- Location (embryonic fusion planes provide little resistance to tumor growth)
- Histologic type (morpheaform, micronodular, sclerosing, or mixed type)
- Perineural invasion
- Recurrent tumor
- Previously irradiated tumor
- Skill of the operator

## Defining Recurrence Rates

- Raw recurrence rate: total number of recurrences divided by the total number of tumors treated
- Strict recurrence rate: total number of patients with recurrence divided by number of treated patients observed for at least 5 years
- Life table cumulative 5 year recurrence rate: Adjusts recurrence rates for the number of patients lost to follow-up each year

## BCC recurrence rates for Mohs’ Surgery

| Study | Comments | No of Patients | Cumm Recurr Rate (%) < 5 yr | Cumm Recurr Rate (%)  5yr |
| --- | --- | --- | --- | --- |
| Julian and Bowers, 1997 | 1981-1995 | 145 |  | 0.7- 0.8 |
| Mohs, et al, 1988 | Ear | 1032 |  | 1.3- 1.7 |
| Mohs, 1986 | Eyelid | 1483 |  | 0.5- 0.6 |
| Lindgren, et al 2000 | Eyelid, medial canthus
Mean f/u 49 mos | 64 | 5* |  |
| Roenigk et al, 1986 | F/u 2-4 yrs | 367** | 1.4* |  |
| Robins, 1981 |  | 1483** |  | 1.8* |
| Mohs, 1978 |  | 6187** |  | 0.7* |

- Data from Thissen M et al. “A Systematic Review of Treatment Modalities for Primary Basal Cell Carcinomas”, Archives of Dermatology 1999;135(10):1177-1183.”
- * Represents raw recurrence rate
- **Represents total number of tumors, not number of patients

## BCC recurrence rates for Surgical Excision

| Study | Comments | No of Patients | Cumm Recurr Rate (%) < 5 yr | Cumm Recurr Rate (%)  5yr |
| --- | --- | --- | --- | --- |
| Baur et al, 1977 |  | 443 |  | 8.0 |
| Germann et al, 1992 |  | 272 |  | 3.2
 |
| Silverman et al, 1992 | 1955-1982 | 588 |  | 4.8 |
| Werlinger et al, 2002 | Private practice | 90** |  | 1.7 |
| Van der Meer, 2001 | Frozen section analysis
Mean f/u 59 mos | 108 | 1.9* |  |
| Spraul et al, 2000 | Periocular
Mean f/u 31.3 mos | 141** | 11.8* pos margins
2.3* neg margins |  |
| Rowe et al, 1989 | Metanalysis (27) | 5560** | 2.8* |  |
| Rowe et al, 1989 | Metanalysis (10) | 2606** |  | 10.1* |

- *Represents raw recurrence rate
- **Represents total number of tumors, not number of patients

## BCC recurrence rates for Cryosurgery

| Study | Comments | No of Patients | Cumm Rate (%) < 5 yr | Cumm Rate (%) 5yr |
| --- | --- | --- | --- | --- |
| Nordin et al, 1997 | Nose, >10mm | 61 |  | 1.6-2.0 |
| Lindgren and Larko, 1997 | Eyelid | 214 |  | 0 |
| Anders et al 1995 | Eyelid | 254 |  | 3.5 |
| Fraunfelder et al, 1984 | Eyelid (<=10mm)
Eyelid (> 10mm) | 181
88 |  | 4.7
16.5 |
| Kuflik and Gage, 1991 | Single provider | 628* |  | 1.0 |
| Rowe et al, 1989 | Metanalysis (13) | 2462** | 3.7* |  |
| Rowe et al, 1989 | Metanalysis (1) | 269** |  | 7.5* |

- * Represents raw recurrence rate
- **Represents total number of tumors, not number of patients

## BCC recurrence rates for Curettage and Electrodesiccation

| Study | Comments | No of Patients | Cumm Recurr Rate (%) < 5 yr | Cumm Recurr Rate (%)  5yr |
| --- | --- | --- | --- | --- |
| Kopf et al, 1977 | 1958-1962, trainees
1970
1962-1973, certified | 597
91
210 |  | 18.8
9.6
5.7 |
| Launis, 1993 |  | 356 |  | 6.2* |
| McDaniel, 1983 | Curettage only | 88 |  | 4.3- 8.5 |
| Welinger et al, 2002 | Private practice | 102** |  | 3.7 |
| Nordin, 1999 | Curettage-Cryosurg
External ear | 39** |  | 2.6 |
| Nordin et al, 1997
 | Curettage-Cryosurg
Nose | 50 |  | 2.0 |
| Silverman et al, 1991 | 1955-1982, includes lesions > 10 mm | 2258** |  | 8.6 (low risk)
12.9 (med risk)
17.5 (high risk) |
| Rowe et al, 1989 | Metanalysis (12) | 3664** | 4.7* |  |
| Rowe et al, 1989 | Metanalysis (10) | 3573** |  | 7.7* |
| Dubin and Kopf, 1983 | Trainees | 758** |  | 26.0 |

## Summary

- The range of recurrence rates appear to be similar for most physical modalities, including surgical excision, cryosurgery, curettage and electrodesiccation, curettage and cryosurgery, and curettage alone.
- For follow-up period of 3-4 years, this rate falls between 3 to 5%
- For a follow-up period of 5 years or more, this rate is about double, approximately 5 to 12%
- Recurrence rates for tumors treated by Moh’s Micrographic Surgery appear to be lower at all points in time and averages between 1-2%.

## Conclusions

- The key predictors of tumor recurrence are size and site of the lesion, histology of tumor, and skill of the operator
- All of the non-Mohs' modalities have roughly equal and excellent cure rates for BCC without high-risk prognostic factors
- There is an increased risk of BCC recurrence regardless of treatment modality with increasing time. This underscores the importance of long term follow-up for evaluating the effectiveness of a therapy.