Background
Systematic review and network meta-analysis comparing 18 treatment interventions across 40 randomized trials and 5 nonrandomized studies for primary basal cell carcinoma (BCC). Assessed recurrence, histologic clearance, cosmetic outcomes, and quality of life. Published in Ann Intern Med 2018.
Interventions and follow up
Arm A: External-beam radiation therapy (EBRT) — one of 18 interventions compared
Arm B: Excision, Mohs micrographic surgery, curettage+diathermy, cryotherapy, 5-FU, imiquimod, photodynamic therapy (MAL-PDT, ALA-PDT), and others; network meta-analysi
Primary endpoint: Recurrence rate
mFollow up: Variable across included studie
Arm B: Excision, Mohs micrographic surgery, curettage+diathermy, cryotherapy, 5-FU, imiquimod, photodynamic therapy (MAL-PDT, ALA-PDT), and others; network meta-analysi
Primary endpoint: Recurrence rate
mFollow up: Variable across included studie
Results
Recurrence (EBRT): 3.5% (95% CI 0.7–16.8%)
Recurrence (Excision): 3.8% (95% CI 1.5–9.5%)
Recurrence (Mohs): 3.8% (95% CI 0.7–18.2%)
Recurrence (Imiquimod): 14.1%; cryotherapy 22.3%; PDT 16.6–18.8%
Cosmesis: Better with PDT vs excision (93.8% vs 77.8% good/excellent)
Recurrence (Excision): 3.8% (95% CI 1.5–9.5%)
Recurrence (Mohs): 3.8% (95% CI 0.7–18.2%)
Recurrence (Imiquimod): 14.1%; cryotherapy 22.3%; PDT 16.6–18.8%
Cosmesis: Better with PDT vs excision (93.8% vs 77.8% good/excellent)
Adverse events
Main adverse events: EBRT: late skin changes (telangiectasia, fibrosis), inferior cosmesis vs PDT in some sites; surgery (excision/Mohs): wound complications, scarring; topical therapies: local skin reactions.
Conclusions
EBRT, excision, Mohs surgery, and curettage+diathermy all achieve similarly low BCC recurrence rates (~3.5–7%) for low-risk lesions. Topical therapies (imiquimod, PDT, cryotherapy) have significantly higher recurrence rates. Cosmetic outcomes favor PDT/topical approaches over surgery or RT for many facial sites.
Key Limitations
Key Limitations: Network meta-analysis relies heavily on indirect comparisons; trials heterogeneous in BCC subtype (nodular vs superficial vs infiltrative), size, and location; limited data for high-risk BCC subtypes; sparse quality-of-life data; results may not apply to high-risk or large lesions.
Clinical Context
Provides evidence that RT is equivalent to surgical approaches for low-risk BCC local control. Supports RT's role as a non-surgical alternative with 3.5% recurrence, comparable to excision and Mohs. Important for patients who are poor surgical candidates or in cosmetically sensitive sites. High recurrence with non-ablative topical therapies underscores their limitation for definitive treatment.