Management of incompletely excised carcinoma of the skin.

The excellent article by Liu et al. (5) deals with two important issues in today’s health care: a) the impact that a thorough understanding of the natural history of the disease may have on management and b) cost-effectiveness considerations in two different management schemas. It has been known for some time that 35% to 40% of patients with incompletely excised basal cell carcinoma who are not immediately treated will develop recurrence. These data are confirmed in the present analysis. Furthermore, several reports have documented a high tumor control rate (80% or higher) when recurrent lesions are irradiated, although this is below the control rate in untreated basal cell carcinoma with similar characteristics (2, 6, 7). The observation that more relapses are noted when the patients are not treated if the deep margin is involved by tumor, in contrast to lateral margins, confirms the experience reported by others (9). Since the long-term outcome reported by Liu et al. (5) is comparable with either immediate treatment or observation and treatment when patients with positive margins show clinical evidence of recurrence, and provided the patients do not suffer psychological trauma or anxiety because of the development of a recurrence, the analysis of cost is a very poignant one, at a time when shrinking resources require the critical analysis of efficacy and costeffectiveness in health care. Obviously, the issue is even more important in the United States, where the cost of treating these patients would be significantly higher than that calculated in the paper by Liu et al. (5). We treated 242 patients with basal cell carcinoma, 17 1 at the time of initial diagnosis and 71 when recurrence occurred after initial surgical excision. The 5-year tumor control rates were 95% and 82%, respectively (6) confirming the results reported by Liu et al. (5). We certainly agree with the recommendation of Liu et al. (5) to observe closely those patients with small lesions who have positive margins after excision, unless there is a significant concern on the part of the patient. A different matter is the philosophy of treatment for patients with residual carcinoma following excision of squamous cell carcinoma of the skin. Glass et al. (3, 4) reported a 53% (8/ 15) recurrence rate in these patients when not immediately treated, with 4 patients dying of cancer. Furthermore, in our experience, whereas the probability of tumor control in initially treated lesions was 87% (40/46), in those treated for recurrent tumors it was significantly less (33/5 1, 65%). The incidence of lymph node metastasis in basal cell carcinoma is practically zero, even in recurring lesions. In squamous cell carcinoma approximately 10% to 15% of patients with initially treated tumors have regional lymph node metastasis, in contrast to 39% (20/5 I), in our experience, for recurrent lesions. Tumor control and survival are significantly lower in these patients. Shapiro et al. have observed 42% (8/ 19) tumor control in patients treated for squamous cell carcinoma with gross lymph node metastases, in comparison to 92% (26/28) in patients receiving adjuvant postoperative irradiation (Shapiro, S. J.; Lovett, R. D.; Lockett, M. A. et al., unpublished data, 1990). In summary, the paper by Liu et al. (5) correctly applies the knowledge of natural history of the disease to management philosophy in selected groups of patients and presents a thoughtful consideration of economic issues in cancer therapy. The Canadian system of health care delivery has been far more inclined to implement cost-containment measures than its U.S. counterpart (1, 8). As more pressure is borne by health care providers to lower the cost of health care delivery in the United States, I am sure that we will see more of these treatment efficacy and cost-effectiveness analyses. Nevertheless, we must always give the welfare of the patient the highest priority above all cost considerations if we are to continue the highest tradition of medicine.