Patient Preferences and Cosmetic Outcomes Following Destructive Treatments for Non-facial Basal Cell Carcinoma: A Mixed Methods Study
DOI:
https://doi.org/10.2340/actadv.v105.41325Keywords:
basal cell carcinoma, cryosurgery, curettage, patient preference, patient satisfaction, treatment outcomeAbstract
The high prevalence of basal cell carcinoma (BCC) entails a substantial burden on healthcare systems. Interest in non-surgical treatment methods for low-risk BCCs, including destructive treatments, is increasing. Dermatologists often highlight suboptimal cosmetic outcomes as drawbacks of destructive treatments, also for non-facial lesions. Patient perspectives regarding scarring and cosmetic outcomes in relation to other relevant factors are largely unknown, yet important to consider in shared decision-making when choosing treatment. This study investigates patient perceptions of scarring following destructive treatments and explores important factors in treatment decisions for non-facial BCCs. Through a mixed-methods design, cosmetic outcomes, patient satisfaction, scarring concerns, and treatment preferences were evaluated within an ongoing randomized clinical trial on destructive treatments for low-risk BCCs. Overall, 157 patients with 425 non-facial scars were assessed. Most patients were not concerned about scar appearance, highlighting a discrepancy compared with dermatologists’ general concerns regarding inferior cosmetic outcome. Instead, when opting for specific treatments, patients listed clearance rates as the most important factor, followed by convenience and time consumption. We believe the results are important both in the context of patient-centred care and in “choosing wisely” when deciding between BCC treatments.
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Lomas A, Leonardi-Bee J, Bath-Hextall F. A systematic review of worldwide incidence of nonmelanoma skin cancer. Br J Dermatol 2012; 166: 1069-1080.
https://doi.org/10.1111/j.1365-2133.2012.10830.x DOI: https://doi.org/10.1111/j.1365-2133.2012.10830.x
Cameron MC, Lee E, Hibler BP, Barker CA, Mori S, Cordova M, et al. Basal cell carcinoma: Epidemiology; pathophysiology; clinical and histological subtypes; and disease associations. J Am Acad Dermatol 2019; 80: 303-317.
https://doi.org/10.1016/j.jaad.2018.03.060 DOI: https://doi.org/10.1016/j.jaad.2018.03.060
Rogers HW, Coldiron BM. Analysis of skin cancer treatment and costs in the United States Medicare population, 1996-2008. Dermatol Surg 2013; 39: 35-42.
https://doi.org/10.1111/dsu.12024 DOI: https://doi.org/10.1111/dsu.12024
Eriksson T TG. Samhällskostnader för hudcancer 2011. Swedish radiation safety authority. Rapportnummer: 2014:49 ISSN:2000-0456 Available from www.stralsakerhetsmyndigheten.se. 2014.
Noels E, Hollestein L, Luijkx K, Louwman M, de Uyl-de Groot C, van den Bos R, et al. Increasing costs of skin cancer due to increasing incidence and introduction of pharmaceuticals, 2007-2017. Acta Derm Venereol 2020; 100: adv00147.
https://doi.org/10.2340/00015555-3463 DOI: https://doi.org/10.2340/00015555-3463
Arits AH, Schlangen MH, Nelemans PJ, Kelleners-Smeets NW. Trends in the incidence of basal cell carcinoma by histopathological subtype. J Eur Acad Dermatol Venereol 2011; 25: 565-569.
https://doi.org/10.1111/j.1468-3083.2010.03839.x DOI: https://doi.org/10.1111/j.1468-3083.2010.03839.x
Bernard P, Dupuy A, Sasco A, Brun P, Duru G, Nicoloyannis N, et al. Basal cell carcinomas and actinic keratoses seen in dermatological practice in France: a cross-sectional survey. Dermatology 2008; 216: 194-199.
https://doi.org/10.1159/000112925 DOI: https://doi.org/10.1159/000112925
Backman E, Oxelblom M, Gillstedt M, Dahlen Gyllencreutz J, Paoli J. Basal cell carcinoma: epidemiological impact of clinical versus histopathological diagnosis. J Eur Acad Dermatol Venereol 2022; n/a.
https://doi.org/10.1111/jdv.18774 DOI: https://doi.org/10.1111/jdv.18774
Altamura D, Menzies SW, Argenziano G, Zalaudek I, Soyer HP, Sera F, et al. Dermatoscopy of basal cell carcinoma: morphologic variability of global and local features and accuracy of diagnosis. J Am Acad Dermatol 2010; 62: 67-75.
https://doi.org/10.1016/j.jaad.2009.05.035 DOI: https://doi.org/10.1016/j.jaad.2009.05.035
Work G, Invited R, Kim JYS, Kozlow JH, Mittal B, Moyer J, et al. Guidelines of care for the management of basal cell carcinoma. J Am Acad Dermatol 2018; 78: 540-559.
https://doi.org/10.1016/j.jaad.2017.10.006 DOI: https://doi.org/10.1016/j.jaad.2017.10.006
Arits AH, Mosterd K, Essers BA, Spoorenberg E, Sommer A, De Rooij MJ, et al. Photodynamic therapy versus topical imiquimod versus topical fluorouracil for treatment of superficial basal-cell carcinoma: a single blind, non-inferiority, randomised controlled trial. Lancet Oncol 2013; 14: 647-654.
https://doi.org/10.1016/S1470-2045(13)70143-8 DOI: https://doi.org/10.1016/S1470-2045(13)70143-8
Peikert JM. Prospective trial of curettage and cryosurgery in the management of non-facial, superficial, and minimally invasive basal and squamous cell carcinoma. Int J Dermatol 2011; 50: 1135-1138.
https://doi.org/10.1111/j.1365-4632.2011.04969.x DOI: https://doi.org/10.1111/j.1365-4632.2011.04969.x
Backman EJ, Polesie S, Berglund S, Gillstedt M, Sjoholm A, Modin M, et al. Curettage vs. cryosurgery for superficial basal cell carcinoma: a prospective, randomised and controlled trial. J Eur Acad Dermatol Venereol 2022; 36: 1758-1765.
https://doi.org/10.1111/jdv.18209 DOI: https://doi.org/10.1111/jdv.18209
Nordin P, Larko O, Stenquist B. Five-year results of curettage-cryosurgery of selected large primary basal cell carcinomas on the nose: an alternative treatment in a geographical area underserved by Mohs' surgery. Br J Dermatol 1997; 136: 180-183.
https://doi.org/10.1111/j.1365-2133.1997.tb14892.x DOI: https://doi.org/10.1111/j.1365-2133.1997.tb14892.x
Mallon E, Dawber R. Cryosurgery in the treatment of basal cell carcinoma. Assessment of one and two freeze-thaw cycle schedules. Dermatol Surg 1996; 22: 854-858.
https://doi.org/10.1111/j.1524-4725.1996.tb00588.x DOI: https://doi.org/10.1111/j.1524-4725.1996.tb00588.x
Backman E, Polesie S, Gillstedt M, Sjoholm A, Nerwey A, Paoli J. Curettage plus one or two cycles of cryosurgery for basal cell carcinoma with clinically nodular features - a prospective randomized controlled trial. J Am Acad Dermatol 2023; 10.1016/j.jaad.2023.04.070.
Wang I, Bendsoe N, Klinteberg CA, Enejder AM, Andersson-Engels S, Svanberg S, et al. Photodynamic therapy vs. cryosurgery of basal cell carcinomas: results of a phase III clinical trial. Br J Dermatol 2001; 144: 832-840.
https://doi.org/10.1046/j.1365-2133.2001.04141.x DOI: https://doi.org/10.1046/j.1365-2133.2001.04141.x
Basset-Seguin N, Ibbotson SH, Emtestam L, Tarstedt M, Morton C, Maroti M, et al. Topical methyl aminolaevulinate photodynamic therapy versus cryotherapy for superficial basal cell carcinoma: a 5 year randomized trial. Eur J Dermatol 2008; 18: 547-553.
Thissen MR, Nieman FH, Ideler AH, Berretty PJ, Neumann HA. Cosmetic results of cryosurgery versus surgical excision for primary uncomplicated basal cell carcinomas of the head and neck. Dermatol Surg 2000; 26: 759-764.
https://doi.org/10.1046/j.1524-4725.2000.ds00064.x DOI: https://doi.org/10.1046/j.1524-4725.2000.ds00064.x
Kelleners-Smeets NWJ, Mosterd K, Nelemans PJ. Treatment of low-risk basal cell carcinoma. J Invest Dermatol 2017; 137: 539-540.
https://doi.org/10.1016/j.jid.2016.11.021 DOI: https://doi.org/10.1016/j.jid.2016.11.021
Johnson RB, Onwuegbuzie AJ, Turner LA. Toward a definition of mixed methods research. Journal of Mixed Methods Research 2007; 1: 112-133.
https://doi.org/10.1177/1558689806298224 DOI: https://doi.org/10.1177/1558689806298224
Draaijers LJ, Tempelman FR, Botman YA, Tuinebreijer WE, Middelkoop E, Kreis RW, et al. The patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation. Plast Reconstr Surg 2004; 113: 1960-1965; discussion 1966-1967.
https://doi.org/10.1097/01.PRS.0000122207.28773.56 DOI: https://doi.org/10.1097/01.PRS.0000122207.28773.56
Mosterd K, Arits AHMM, Nelemans PJ, Kelleners-Smeets NWJ. Aesthetic evaluation after non-invasive treatment for superficial basal cell carcinoma. J Eur Acad Dermatol Venereol 2013; 27: 647-650.
https://doi.org/10.1111/j.1468-3083.2011.04347.x DOI: https://doi.org/10.1111/j.1468-3083.2011.04347.x
Krippendorff K. Content analysis : an introduction to its methodology. Fourth edition ed: Thousand Oaks, California : SAGE; 2019.
https://doi.org/10.4135/9781071878781 DOI: https://doi.org/10.4135/9781071878781
Bath-Hextall F, Ozolins M, Armstrong SJ, Colver GB, Perkins W, Miller PSJ, et al. Surgical excision versus imiquimod 5% cream for nodular and superficial basal-cell carcinoma (SINS): a multicentre, non-inferiority, randomised controlled trial. Lancet Oncology 2014; 15: 96-105.
https://doi.org/10.1016/S1470-2045(13)70530-8 DOI: https://doi.org/10.1016/S1470-2045(13)70530-8
Peris K, Fargnoli MC, Kaufmann R, Arenberger P, Bastholt L, Seguin NB, et al. European consensus-based interdisciplinary guideline for diagnosis and treatment of basal cell carcinoma-update 2023. Eur J Cancer 2023; 192: 113254.
https://doi.org/10.1016/j.ejca.2023.113254 DOI: https://doi.org/10.1016/j.ejca.2023.113254
Schmults CD, Blitzblau R, Aasi SZ, Alam M, Amini A, Bibee K, et al. Basal cell skin cancer, version 2.2024, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2023; 21: 1181-1203.
https://doi.org/10.6004/jnccn.2023.0056 DOI: https://doi.org/10.6004/jnccn.2023.0056
Gordon LG, Lindsay D, Olsen CM, Whiteman DC. Health utilities and health‐related quality of life of patients with keratinocyte skin cancers. J Eur Acad Dermatol Venereol Clin Pract 2023; 2: 983-993.
https://doi.org/10.1002/jvc2.227 DOI: https://doi.org/10.1002/jvc2.227
Essers BAB, Arits AH, Hendriks MR, Mosterd K, Kelleners‐Smeets NW. Patient preferences for the attributes of a noninvasive treatment for superficial basal cell carcinoma: a discrete choice experiment. Br J Dermatol 2018; 178: e26-e27.
https://doi.org/10.1111/bjd.15782 DOI: https://doi.org/10.1111/bjd.15782
Patel PV, Pixley JN, Dibble HS, Feldman SR. Recommendations for cost-conscious treatment of basal cell carcinoma. Dermatol Ther (Heidelb) 2023; 13: 1959-1971.
https://doi.org/10.1007/s13555-023-00989-x DOI: https://doi.org/10.1007/s13555-023-00989-x
Kappelin J, Green AC, Ingvar A, Ahnlide I, Nielsen K. Incidence and trends of basal cell carcinoma in Sweden: a population-based registry study. Br J Dermatol 2022; 186: 963-969.
https://doi.org/10.1111/bjd.20964 DOI: https://doi.org/10.1111/bjd.20964
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Copyright (c) 2025 Eva Backman, Birgit Heckemann, Martin Gillstedt, Sam Polesie, John Paoli

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