Is surgery still the best answer for basal cell carcinoma?

Surgery remains the most effective treatment modality for basal cell carcinoma (BCC) in terms of reducing recurrences, and there may be a slightly reduced recurrence rate with Mohs micrographic surgery compared with surgical excision (SE). Regarding improvement of participant and observer‐rated cosmetic outcomes, there may be little to no difference between Mohs micrographic surgery and SE (low‐certainty evidence). Radiotherapy is effective but probably worse than surgery in terms of the number of good cosmetic outcomes (moderate‐certainty evidence); therefore, it is best reserved for tumours not amenable to surgery. Radiotherapy may also lead to increased recurrence compared with SE (low‐certainty evidence).

Non‐surgical treatments are less effective, but the evidence suggests recurrence rates are acceptable, and they are important options to offer patients. Of the non‐surgical options, imiquimod has the best evidence to support its efficacy. It probably results in more recurrences than SE (moderate‐certainty evidence), and there is probably little to no difference in the number of participant‐rated good/excellent cosmetic outcomes (low‐certainty evidence). However, imiquimod may increase the number of observer‐rated good/excellent cosmetic outcomes compared with SE (low‐certainty evidence).

Moderate‐certainty evidence indicates imiquimod probably leads to fewer recurrences than methyl aminolevulinate photodynamic therapy (MAL‐PDT), and there is probably little to no difference in observer‐rated good/excellent cosmetic outcomes between these treatments (participant‐rated cosmetic outcomes were not measured). MAL‐PDT may result in more recurrences at 3 years than SE (low‐certainty evidence; no useable data at 5 years) but probably increases the number of good/excellent cosmetic results (moderate‐certainty evidence).

Adverse effects with surgical interventions include wound infections, graft necrosis and post‐operative bleeding. Local adverse effects, such as itching, weeping, pain and redness, occur frequently with non‐surgical interventions. Treatment‐related adverse effects resulting in study modification or withdrawal occurred with imiquimod and MAL‐PDT.