Non-surgical treatments for non-melanoma skin cancers

2 Sep
 
2021

Most skin cancers start by affecting just the top part of the skin. These early skin cancers are usually called superficial or in situ and because they are thin, they can be treated from the surface by cryotherapy (freezing) or applying a cream or ointment, as well as by excision (cutting out). The best treatment depends on a combination of factors:

  • how well the treatment works
  • side effects (including scarring and discomfort)
  • cost
  • convenience

The following table summarises these factors for the most common treatments for superficial basal cell carcinoma and superficial squamous cell carcinoma (Bowen's disease). Note that photodynamic therapy can also be used effectively for thicker (nodular) basal cell carcinoma.

  Excision (surgical removal) Cryotherapy (freezing) Topical treatment (fluorouracil, fluorouracil / calcipotriol or imiquimod cream) Photodynamic therapy

How well does it work?

98.6% cure rate (Liebovitch 2005)

97-98% cure rate (Holt 1988, Kuflik 1991)

Imiquimod: up to 82% cure rate for superficial basal cell carcinoma (Geisse 2004)

Fluorouracil: up to 92% cure rate for Bowen's disease (superficial squamous cell carcinoma) (Moreno 2007)

Combination fluorouracil/calcipotriol treatment has been shown to reduce the risk of squamous cell carcinoma in the treated area for up to three years (Rosenberg 2019). This benefit has not been shown with other treatments for superficial skin cancers.

Studies have demonstrated higher cure rates for photodynamic therapy when compared with topical treatments or cryotherapy. (Morton 2006, Basset-Seguin 2008).

Note that in these studies, success rates for cryotherapy treatment were generally less than in trials where cryotherapy was not compared with PDT.

What are the side effects?

Short term: bleeding, bruising, swelling, pain, infection

Long term: scarring in almost all cases, wound breakdown, nerve damage

Short term: pain, blistering (including blood-filled blisters), swelling

Long term: changes in skin pigmentation. The treated area is commonly lighter or darker than the surrounding skin.

 

Short term: irritation of the treated area: redness, pain, blistering, crusts and pustules

Long-term: side effects are uncommon. Scarring sometimes occurs after severe reactions during treatment.

Short term: pain during and soon after treatment. irritation , redness, blistering and crusts of the the treated area.

Long term: side effects are uncommon. Sacrring sometimes occurs after severe skin reactions.

Side effects are less common and the long term cosmetic outcome is superior to treatment with either cryotherapy or topical treatments. (Morton 2006)


How much does it cost?

The cost of excision varies, according to the size and the anatomical location of the skin cancer.

Spot Check Clinic generally charges at least $200 for surgical removal. The fee varies according to the size of the skin cancer and the location on the body. This fee is usually discounted for pensioners and Health Care Card holders so that there is minimal or no out of-pocket expense.

If the procedure is performed by a plastic surgeon and/or more complicated techniques such as Moh's surgery or skin flaps or grafts are used, the cost can be thousands of dollars.

Approximately $40.

In most cases, the cost is completely covered by Medicare, but only if the diagnosis has previously been confirmed by a biopsy.

In biopsy-proven cases of superficial basal cell carcinoma, the Pharmaceutical Benefits Scheme subsidises the cost of imiquimod. In these cases, the out-of-pocket expense is about $40-80 (less for pensioners and Health Care Card holders).

In cases where the PBS does not subsidise imiquimod, the typical cost is $120 or more.

The PBS subsidises the cost of fluorouracil only for Department of Veterans' Affairs cardholders. For others, the out-of-pocket expense is about $80.

Combination fluorouraci/calcipotriol is not commercially available at pharmacies and is not covered by the PBS. It must be prepared by a compounding pharmacy. Typically, the cost of a course of treatment is about $120.

 

Treatment costs are variable and are influenced by:

  • whether skin preparation treatment (e.g. microneedling) is performed on the day of treatment
  • amount of ALA cream used
  • type of light used to activate the ALA (i.e. LED red light phototherapy vs intense pulsed light)
  • whether post-treatment LED phototherapy sessions are used to speed wound healin

Costs generally vary between $500 to $1000 for treatment of a single skin cancer.

How convenient is it?

Surgical removal must be performed by a doctor. it usually takes 30-60 minutes.

After the procedure, there is a period of aftercare lasting several weeks. Activities and exercise may be restricted during this period.

 

Cryotherapy is performed by a doctor and takes a few minutes.

Cryotherapy aftercare is relatively simple and the wound is usually healed in about three weeks.

Imiquimod cream must be applied daily to the affected area and surrounding region daily, 5 days a week for six weeks.

Fluorouracil cream must be applied twice daily to the affected area and surrounding region for four weeks.

Combination 5-FU/calcipotriol cream is applied to the cancer twice daily for 6 days, followed by a break of 14 days and a further course of 6 days. In some cases a further 6 day course must be applied 2 weeks later. (Bricknell 2021)

During treatment, the area usually becomes red, irritated and painful. Direct sunlight must be avoided during the treatment period.

Treatment can usually be completed in a single visit to the skin cancer clinic, lasting several hours.

Due to inflammation and pain after treatment, it may be necessary to limit work and other activities for several days after treatment.

More information

References

  • Leibovitch I, Huilgol S, Selva D et al
    2005
    Basal cell carcinoma treated with Mohs surgery in Australia II. Outcome at 5-year follow-up.
    Journal of the American Academy of Dermatology, 2005 Sep; 53(3): 452-7
    https://doi.org/10.1016/j.jaad.2005.04.087
    Accessed
    24/7/2021
  • Holt P.
    1988
    Cryotherapy for skin cancer: results over a 5-year period using liquid nitrogen spray cryosurgery
    British Journal of Dermatology, volume 119, issue 2, August 1988, pages 231-240
    https://doi.org/10.1111/j.1365-2133.1988.tb03205.x
    Accessed
    24/7/2021
  • Geisse J, Caro I, Lindholm J et al
    2004
    Imiquimod 5% cream for the treatment of superficial basal cell carcinoma: results from two phase III, randomized, vehicle-controlled studies
    Journal of the American Academy of Dermatology
    https://doi.org/10.1016/j.jaad.2003.11.066
    Accessed
    24/7/2021
  • Morton C, Horn M, Leman J et al
    2006
    Comparison of topical methyl aminolevulinate photodynamic therapy with cryotherapy or Fluorouracil for treatment of squamous cell carcinoma in situ: Results of a multicenter randomized trial
    Arch Dermatol 2006 Jun; 142(6): 729-35.
    https://doi.org/10.1001/archderm.142.6.729
    Accessed
    24/7/2021
  • Basset-Seguin N, Ibbotson S, Emtestam L et al
    2008
    Topical methyl aminolaevulinate photodynamic therapy versus cryotherapy for superficial basal cell carcinoma: a 5 year randomized trial
    Eur J Dermatol Sep-Oct 2008; 18(5): 547-53.
    https://doi.org/10.1684/ejd.2008.0472
    Accessed
    24/7/2021