Interventions for basal cell carcinoma: abridged Cochrane systematic review and GRADE assessments.

Summary: Background: Basal cell carcinoma (BCC) is the most common cancer affecting white‐skinned individuals, and the worldwide incidence is increasing. Although rarely fatal, BCC is associated with significant morbidity and costs. Objectives: To assess the effects of interventions for primary BCC in immunocompetent adults. Methods: We updated our searches of the following databases to November 2019: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and LILACS. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation method. We used standard methodological procedures expected by Cochrane. Results: We included 52 randomized controlled trials with 6990 participants (median age 65 years; range 20–95). Mean study duration was 13 months (range 6 weeks–10 years). Ninety‐two per cent (n = 48/52) of studies exclusively included histologically low‐risk BCC (nodular and superficial subtypes). The certainty of evidence was predominantly low or moderate for the outcomes of interest. Overall, surgical interventions have the lowest recurrence rates, and there may be slightly fewer recurrences with Mohs micrographic surgery over surgical excision for primary, facial BCC (high‐risk histological subtype or located in the 'H‐zone' or both) (low‐certainty evidence). Nonsurgical treatments, when used for low‐risk BCC, are less effective than surgical treatments, but recurrence rates are acceptable and cosmetic outcomes are probably superior. Conclusions: Surgical interventions have lower recurrence rates and remain the gold standard for high‐risk BCC. Of the nonsurgical treatments, topical imiquimod has the best evidence to support its efficacy for low‐risk BCC. Priorities for future research include agreement on core outcome measures and studies with longer follow‐up. What is already known about this topic? Basal cell carcinoma (BCC) is the most common cancer to affect white‐skinned individuals, and worldwide incidence is increasing.A 2007 Cochrane review concluded that there was very little good‐quality research on treatments for BCC and that surgical interventions and radiotherapy had the lowest recurrence rates. What does this study add? The body of evidence has now doubled to 52 trials, but most deal with low‐risk lesions.The quality of evidence remains generally low to moderate.Surgical interventions still have the lowest recurrence rates, and there may be slightly fewer recurrences with Mohs micrographic surgery over surgical excision for high‐risk facial primary BCC.Nonsurgical treatments are less effective than surgery, but recurrence rates are acceptable for low‐risk lesions and cosmetic outcomes are probably superior. Linked Comment: L.C.J. van Delft and N.W.J. Kelleners-Smeets. Br J Dermatol 2021; 185:475. [ABSTRACT FROM AUTHOR]