Treatment for Nonmelanoma Skin Cancer:

A number of options are available for treating nonmelanoma skin cancer, including:

• Surgery
• Cryosurgery
• Photodynamic therapy
• Radiation
• Topical 5-fluorouracil
• Topical immunotherapy with imiquimod

Most basal and squamous cell cancers are treated with surgery or radiation. Research has found that surgery has the best results, but because it can have cosmetic effects, many patients opt for radiation.

The first step in nonmelanoma skin cancers is to determine the risk of aggressive types of these tumors. Basal cell tumors are considered high-risk.

Squamous cell cancers of the skin are considered to be high-risk if any of the following are present:

• Recurrence at the same place where there was a previously treated squamous cell tumor
• Poorly defined borders
• Lymph nodes
• Occurred in a patient with a suppressed immune system
• Microscopic appearance

Surgery

For any skin cancer and for some keratoses that need to be removed, surgery is the first treatment. One of the following surgeries is usually used:

Excisional Surgery. Cutting out the tumor and then assessing the tumor borders (margins).

Curettage and Electrodesiccation. This procedure involves scraping away the cancerous tissue, followed by electric cauterization to stop the bleeding.

Mohs Micrographic Surgery. Mohs surgery is a procedure used for skin cancers at high risk for returning or becoming invasive. The technique removes very thin layers of skin one at a time. Each layer is examined immediately under a microscope. When the layers are shown to be cancer-free, the surgery is complete.

Good candidates for Mohs surgery include:

• People with basal cell cancer greater than 1 cm (about half an inch)
• People with basal cell cancer on the face, ear, or neck
• People with basosquamous carcinoma (a specific type of basal cell cancer)
• Young people with skin cancer

Mohs surgery saves more healthy tissue than other procedures and is highly effective. It results in a 99% cure rate for primary tumors and a 95% cure rate for cancers that return. It can be safely performed in the doctor's office. Complications are uncommon but can include bleeding and infection.

Lasers. Laser surgery may be useful for certain basal cells and for keratoses that appear on the lips, although it is not clear whether lasers offer any advantages over other surgical treatments. Lasers do not appear to be very effective for thick or tough squamous cell cancers.

Cryosurgery

Cryosurgery removes skin cancer cells or actinic keratoses by freezing the affected tissue with liquid nitrogen. Studies have shown that cyrosurgery can be used to remove even wide areas of actinic keratoses, and that it may be more successful over the long term than treatment with 5-fluorouracil, the standard drug. Cryosurgery also appears to reduce the risk for squamous cell cancer in these patients.

Cryotherapy achieves good cosmetic results for many patients. However, it may cause blistering and ulceration, leading to pain and infection, as well as harmless, but undesirable, skin-color changes.

The disadvantage of cryosurgery is that no tissue is taken to examine under a microscope and show that the cancer was completely removed.

Radiation

In unusual cases where the skin cancer may be in an inoperable position (such as the eyelid or the tip of the nose) or if cancer has come back multiple times, radiation therapy may be indicated. Radiation therapy is more often used in the elderly.

Radiation is directed at the tumor. It may take 1 - 4 weeks, with treatments done several times a week. One technique being investigated for basal and squamous cell cancer uses radiation implants (brachytherapy) and custom-made molds to specifically target the radiation to the cancer site. Studies suggest that this treatment is very effective with few complications.

Topical Phototherapy and Aminolevulinic Acid (ALA)

Topical phototherapy with the drug aminolevulinic acid (ALA) is a nonsurgical method that is proving to be a good choice for treating actinic keratoses and nonmelanoma skin cancers. The technique involves shining blue light onto the cancer area after the patient has taken ALA. ALA accumulates in the skin cells. When the cells are exposed to intense light, the chemical causes them to die. This approach allows precise targeting of one or more lesions, leaving healthy skin unaffected.

It does not penetrate deeper than the epidermis (the top layer of the skin), so it does not produce scarring or changes in skin color, as cryotherapy or other more invasive treatments do. However, it can cause pain and irritation, including stinging, itching, and burning.

ALA Phototherapy for Actinic Keratoses. Phototherapy works best on flat lesions when it is performed in two treatments, and is more effective for clearing lesions on the face than those on the scalp. Phototherapy can also treat multiple lesions at the same time instead of one after another, as in cryotherapy. Studies suggest that it may work as well as cryotherapy and achieve better cosmetic results. (More patients report burning and itching with phototherapy, however.) Phototherapy is also equal to topical 5-fluorouracil in effectiveness and achieving a satisfactory appearance.

ALA Phototherapy for Nonmelanoma Skin Cancers. In patients with squamous cell cancer in situ, Bowen disease, and superficial basal cell cancer, phototherapy has been equal to cryotherapy, with better healing and appearance afterward.

Some studies have shown that about 10% of patients using phototherapy have a recurrence within 1 year. These recurrence rates are higher than with surgery and other standard treatments. Longer-term studies are required before ALA phototherapy can be recommended for most patients with nonmelanoma skin cancers.

Medications

A number of medications are being used for keratoses and some may be helpful for skin cancers as well. Besides cryotherapy, 5-fluorouracil is the other most commonly used treatment for actinic keratoses. Other medications are also available.