Skin cancers

Does watchful waiting have a larger role in BCC management?


Watchful waiting on BCCs, especially asymptomatic nodular or superficial BCCs, might be an appropriate approach in selected dermatology patients such as those with a limited life expectancy, new research suggests.

A Dutch study, published in JAMA Dermatology, defined watchful waiting as no active BCC treatment for at least 3 months after initial presentation, including patients who refused active BCC treatment even if this was strongly advised by treating physicians.

With all patients and proxies informed on possible consequences of a watchful waiting approach, the study comprised 280 BCCs in 89 patients.

The median follow-up duration of all tumours was 9 months, with a maximum of 78 months.

The study found most patients (83%) chose watchful waiting because of patient-related factors or preferences such as prioritisation of comorbidities, severe frailty or limited life expectancy (LLE).

Other factors were treatment-related such as the expected treatment burden, circumstantial reasons such as planning or transportation difficulties, and insufficient understanding or processing of the information on BCC.

The study also found tumour size increased in 46.8% of BCCs. Of those tumours which did not grow, some even showed a decrease in diameter.

“Significantly more low risk BCCs (nodular/superficial/clinical BCCs) showed a stable or decreasing tumour diameter compared with high-risk BCCs (infiltrative/micronodular) in univariate analyses (61.9% vs 35.0%; P = .006),” the study said.

“Moreover, 78.6% of low-risk BCCs showed a maximum tumour growth of 2 mm, vs 45.0% of high-risk BCCs (P < .001).”

The study said that 38.2% of lesions were subsequently treated after the initial watchful waiting period.

Conventional excision was most frequently initiated (73.6%) and only 2.8% of BCCs required a more invasive intervention (eg, reconstructive surgery) than the estimated intervention at initial presentation.

The study said refraining from treatment could be in the best interest of patients with a LLE or in cases with other specific reasons outweighing the benefit of early treatment.

“However, the definition of LLE and the natural tumour behaviour naturally influence the time to benefit. For instance, if the time to develop BCC-related complaints in an individual patient is hypothetically 2 years, this patient probably still benefits from treatment if life expectancy is estimated at 5 years.”

“Because it currently remains challenging to predict life expectancy in individual patients, a multidisciplinary approach involving other specialists or general practitioners could aid in decision-making,” the investigators said.

They noted that watchful waiting involves regular follow-up and reconsideration of management options at each follow-up visit to confirm if watchful waiting remains medically justified or if the risk-to-benefit ratio has changed over time.

“Naturally, the frequency of hospital visits should be adjusted to what is feasible for individual patients (ie, should not be more burdensome than the treatment burden associated with active treatment).”

The investigators called for more research to provide evidence-based guidance on the expected natural tumour behaviour and prognostic factors on both tumour growth and patient prognosis.

Follow the lead in other cancers

An editorial in the journal said treatments for BCC were typically well tolerated but for a variety of reasons patients sometimes wanted to avoid or delay treatment.

“Active surveillance is close, active monitoring without treatment. It is already part of the standard of care in prostate cancer and is an emerging concept in other areas of oncology as well,” the author said.

“We know that most BCCs are slow growing, but what, in practical terms, does that mean for the patient in front of us?”

Assistant Professor Mackenzie Wehner, from the University of Texas MD Anderson Cancer Centre in the US, said BCCs were fairly easy to monitor which should make them a good candidate for active surveillance.

However, despite the low mortality and indolent growth pattern of BCC, there were no current guidelines or recommendations for active surveillance as an evidence-based option for patients.

“But this does not mean that incorporating active surveillance in the care of BCC is not worthwhile. There are millions of patients diagnosed with BCCs each year in the US, some of whom would certainly benefit from the existence of an evidence-based standard of care that includes active surveillance.”

“While active surveillance of BCC is a controversial topic in dermatology, we should be empowered by our colleagues in oncology to study it with rigour and explore it as part of the personalised options we can offer patients with BCC.”

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