Beyond clear margins: What matters to patients with basal cell carcinoma?

A common assumption in the management of basal cell carcinoma (BCC), is that tumour clearance trumps all other concerns from the patient's perspective. Histological clearance is often a key performance indicator, while regard for form and function, the founding principle of our specialty, may go unexamined. Frequently audits – whether local, regional or national – focus on histological clearance rates, without regard for other outcomes, beyond infection or readmission.1Nolan G.S. Dunne J.A. Lee A.E. et al.National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK.Br J Surg. 2022; 109: 1040-1043Crossref PubMed Scopus (1) Google Scholar This is at odds with a trend toward greater emphasis on patient-related outcome measures (PROMs), and shared decision-making. The corollary of the adage 'you can't improve what you don't measure', is that if only one metric is considered, it may be the only that 'improves' at the expense of others. A singular emphasis on histological clearance may inculcate a culture of overtreatment and over-excision amongst surgeons of all levels. BCCs are well recognised by clinicians to be low-grade tumours, which slowly enlarge, and seldom metastasise. Patients, however, may misperceive the risk. Almost half of patients surveyed with BCC were worried about mortality risk, while the word 'cancer', in conjunction with BCC, induced anxiety.2Aymonier M. Taieb C. Corgibet F. et al.Patient perception of the diagnosis announcement and its impact on quality of life of patients with primary melanoma or basal cell carcinoma.Acta Derm Venereol. 2022; 102: adv00717Crossref PubMed Scopus (1) Google Scholar 'Cancer' may engender an availability bias, where patients conflate the aggression of other feared cancers with that of BCCs and acquiesce to correspondingly aggressive treatment strategies. Within the field of skin cancers alone, patients do not seem readily able to discriminate between different types, with worry scores fairly equivalent across BCC, SCC and melanoma.3Khoshab N. Vaidya T.S. Dusza S. Nehal K.S. Lee E.H. Factors contributing to cancer worry in the skin cancer population.J Am Acad Dermatol. 2020; 83: 626-628Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar In discrete choice experiments, investigating what matters to patients with BCC, recurrence features highly, but so too does appearance, and to lesser extents, convenience, treatment side-effects, and hospital attendances. There has been little exploration of the particular priorities of the elderly and frail with BCCs, despite this demographic potentially having the most to lose and least to gain from surgery. Higher rates of complications, unplanned hospital attendances, and unrelated deaths have been reported.4Chicco M. Borsky K. Goodall R. Harrison C. Rodrigues J. Outcomes of skin cancer excision in frail patients: A retrospective cohort study.J Plast Reconstr Aesthet Surg. 2023; 84: 32-36Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Furthermore, where the focus is somewhat binary - complete or incomplete excision - there is scant regard to excess margins of clearance. This blind spot extends even to the BAD guidelines, which while welcome, are limited by the granularity of supporting data; determining a clinical margin that on average yields a high rate of clearance, potentially misses nuance hidden in unreported data. Surgeons may additionally err towards a more 'generous', or defensive, clinical margin. Beyond involved or close (<1 mm) margins, we may neglect excessive histological margins, or regard them as an inconsequential over-shoot. However, resultant larger defects have repercussions on both form and function. Avoidable flaps, grafts and donor site morbidity can lead to embarrassment and impaired self-confidence. Flap and graft reconstructions yield inferior patient satisfaction to direct closure.5Vaidya T.S. Mori S. Khoshab N. et al.Patient-reported aesthetic satisfaction following facial skin cancer surgery using the FACE-Q skin cancer module.Plast Reconstr Surg Glob Open. 2019; 7e2423PubMed Google Scholar Functionally, difficulty wearing hearing aids or glasses, ectropion, alar collapse and breathing difficulty may ensue. Infections may hospitalise the frail, and delayed healing may produce healthcare dependence. While there is a large body of literature focusing on involved and close margins, there is scant examining the prevalence of over-excision and its sequelae. Margin-controlled surgical techniques such as Mohs, might seem a solution, but has its disadvantages, including limited availability, resource-intensiveness, greater cost and staging of reconstruction. Alternatives include cryotherapy, topicals, radiotherapy and electrochemotherapy; or no intervention at all. Serial excision may be preferable to some patients if, say, it means two stages separated by a number of weeks, each a quick, low-risk intervention with minimal downtime involving excision and direct closure, rather than one, more extensive, episode involving the morbidity of a flap or graft. This may be especially so in the cosmetically sensitive area of the face, or the lower limb, where delayed healing from grafts is common. Incomplete excision, far from being a sin warranting the stigma of failure, may at times result from a pragmatic and patient-centred approach; one which may not necessarily incur greater financial cost, once the averted burden of wound care and complications is factored. We suggest four considerations. Firstly, ensuring patients understand the harm or lack thereof posed by BCCs, and are aided in making informed decisions, in relation to their overall circumstances. Ultimately, we might ask who we are treating – the patient, or our own conditioned preference for definitive cure? Studies exploring the counterfactual scenario of observation in the elderly and frail, might establish whether our commission bias toward treatment is beneficial. Secondly, as a specialty and as trainers, we should broaden our focus beyond histological clearance alone, incorporating PROMs such as the FACE-Q into audits. Thirdly, when auditing, we might reflect on negative as well as positive margins, with a view to reducing over-excision. And fourthly, we should explore patients' views on the trade-off between clearance and other considerations, such as cosmesis, wound healing, healthcare attendances and no intervention, so that they are better equipped to decide on the scale of intervention and reconstruction that they consent to. N/A. None. None.