Surgical management section – Clinical practice guide for BCCs and SCCs
Background:
On Thursday December 18 2008 ACSCM discussed the final version of the Australian Cancer Network’s BCC / SCC Guide with ACNs Professor Tom Reeve. ACSCM indicated that despite the promise of substantial improvement on the draft edition, the Guide produced by the ACN was still very concerning and promoted dangerous practice in the management of skin cancer.
Professor Reeve asked ACSCM to put these concerns in writing to ACN. We advised that as there were so many serious concerns this would be an enormous task. During that conversation, we agreed to select one chapter and highlight some of the problems in that chapter by way of an example of identifying the deficiencies in the Guide.
We chose chapter 6 of the guide. The following is the document prepared by ACSCM urgently over the subsequent three weeks. We thank all those in ACSCM and the American Society for Mohs Surgery who assisted in the production of this critique and thank them, especially for undertaking the task so quickly and for giving up so much of their Christmas holiday break to do so.
Critique:
We refer in this analysis to the “Clinical Practice Guide – Basal cell carcinoma, squamous cell carcinoma (and related lesions) – a guide to clinical management in Australia” (the guide). This publication dated November 2008 was produced by the Australian Cancer Network with Federal Government funding.
While many of the chapters in the guide are well written, well cited and reflect current knowledge, the content of other chapters could lead to dangerous management of skin cancer.
The chapter in the guide that has caused greatest concern to Australasian College of Skin Cancer Medicine (ACSCM) is Chapter 6 (the chapter) which relates to the all important topic of surgical management of skin cancer.
Among the dangerous concepts that are suggested in the chapter are:
1. A 2 – 3 mm margin is probably adequate for the majority of simple BCCs
2. Aggressive BCCs be managed with a 3 – 4 mm margin
3. Recommended surgical margins for excision of SCCs vary from 2mm to 10 mm
4. Most patients do not need long term follow up after their skin cancer is excised
5. BCCs and SCCs that are incompletely excised can be considered for observation only
6. Surgery, radiotherapy, curettage and electrodessication all produce similar high cure rates for most tumours
ACSCM rejects all of these suggestions and will deal with each in turn.
1 – 2 ACSCM strongly discourages such narrow excision margins for BCCs and SCCs. ACSCM policy is that simple BCCs should usually be excised with 4 mm margins1, 2.
On exceptional occasions a 3 mm margin may be considered. For example, if a further 1 mm in one plane would involve a vital structure, then avoiding that structure, and seeking specific clearance at that point with an orientated specimen can at times be appropriate. A 2 mm clinical margin is never acceptable and a 3 mm margin of clearance is inadequate for the majority of small well defined basal cell carcinomas2, 3. The only support for 2mm margins comes from small studies or reports with inadequate follow up periods2, 4, 5.
Aggressive BCCs should be considered for margin control surgery6-10. If surgical excision is chosen then 3 mm is never acceptable for such aggressive tumours and at times margins over 4 mm are appropriate. In the hands of skilled surgeons, even difficult BCCs in difficult locations can be excised with a long term recurrence rate below 5%6, 11. ACSCM believes that a recurrence rate below 5% is the benchmark for surgical management of skin cancers. Clinicians with long term recurrence rates above 5% are encouraged to reflect on their practice to identify areas for improvement.
3 ACSCM policy is that the minimum clinical margin of clearance for invasive SCC is 4 mm12, 13. This 4 mm margin only applies to small well differentiated low risk tumours. Higher risk tumours require larger margins, often 6 mm or margin control surgery13-15. Two references were offered to support the chapter contention of accepting margins as low as 2 mm. One reference was a paper by Brodland and Zitelli12. The paper in fact reflects ACSCM policy exactly and does not support 2 mm margins. The other paper cited dates back to 1964 and compares management of skin tumours with irradiation versus surgery versus curettage and electrodessication16. It is not a paper about SCC surgical margins. At the other end of the spectrum we are puzzled by the suggestion that some SCCs might require very large margins. There is little evidence that this is beneficial to patients. The one paper cited to support this in fact relates to adnexal tumours and not SCCs. Indeed this paper is not a trial but just a comment piece with no level of evidence other than expert opinion17.
4 ACSCM policy is that all patients who have had one skin cancer need long term monitoring18, 19.
We know that patients who have had one skin cancer frequently develop further tumours and a critical part of managing skin cancer patients is management of their entire skin including surveillance of new tumours19-21. This imperative is irrespective of whether or not the patient’s first tumour was high risk or had narrow margins.
5 ACSCM recognises that even with adequate apparent clinical margins there will be times when subclinical involvement will lead to a pathology report of tumour at the margins 18, 22. It is ACSCM policy that, almost invariably in these circumstances, further surgery should be undertaken23, 24. The chapter even describes the risks and outcomes that can result from simply observing but still contemplates this as a real management alternative25-27. For example the chapter cites a reference that 6% of patients who do not have further treatment develop recurrent disease that cannot be controlled!28
When one searches the chapter for justification for observing positive margins, - there is none. The chapter comments that, “It has been suggested that incompletely excised BCCs can be followed up unless there are unfavourable characteristics . . .”. This comment is not cited, nor the authority suggesting this identified. Even Australian experience has demonstrated that incompletely excised BCCs are those most at risk of later recurrence29. ACSCM is aware of an argument from New Zealand for observation of positive margins. This argument was not cited in the chapter. The New Zealand report30 argues that only one third of tumours recur and hence two thirds do not need further surgery. The flaw in this argument is that the sequelae of recurrent tumours are frequently unsatisfactory, as outlined in the chapter. Excision of residual tumour at the earliest opportunity is almost always in the patient’s best interests. Furthermore, pathologists can also face difficulties in the call regarding whether a margin is truly free of tumour or otherwise31.
Later the chapter comments that, “It must be remembered, however, that many of the patients with persistent BCC are elderly and infirm and further surgery may not be appropriate . . .”. – But let us reflect on the clinical situation. In the last week or so a clinical decision was made that this elderly and / or infirm patient has a skin cancer that, on balance, warrants surgical excision. Now our surgery shows positive margins. What has changed? The patient is just as elderly or infirm as last week. Therefore the need for tumour removal is just as important. Indeed it is arguably more important now that we know that the tumour is extending beyond our clinical suspicions. There is a greater risk of later repercussions and hence a greater imperative for the tumour to have adequate surgical excision through a second procedure.
6 The suggestion that electrodesiccation32, curettage33-36, radiotherapy26 and surgery all have similar high cure rates is patently untrue and grossly misleading. One paper cited to support this statement37 is 24 years old and precedes most of the established data on margin control surgery, delineating curettage, etc,. Unfortunately a careful reading of the cited paper shows it makes no mention of electrodessication, curettage or radiotherapy statistical outcomes including cure rates. In contrast, Cochrane review in 2003 and 2007 found that surgery results in the lowest recurrence rates followed by radiotherapy38, 39. While the ACSCM benchmark for surgery is a long term recurrence rate of below 5%, no non surgical management approach can consistently demonstrate such high cure rates.
Indeed there are many papers cited in the chapter for other purposes that demonstrate that cure rates with appropriate surgery are substantially and consistently better and dissimilar to the non excisional approaches mentioned.
The chapter cites another reference as apparently showing that there is little evidence that radiotherapy, cryotherapy, curettage and electrodessication are associated with a higher risk of further local recurrence27. This paper is a small study out of Massachusetts that makes no mention of cryotherapy, curettage or electrodessication. It mentions radiotherapy, but not favourably, and endorses Mohs’ surgery as an optimal treatment method to minimise recurrence with difficult face BCCs.
Having said that, if doctors; (1) incorrectly removed tumours with the scanty margins suggested in the chapter and (2) observed positive margins, then unacceptably high recurrence rates could be expected from surgical excision.
ACSCM urges the important principle that appropriate surgical excision with adequate margins will produce benchmark long term clearance rates below 5% that cannot be matched by non excisional techniques. ACSCM endorses the appropriate usage of margin control surgery and alternative planned multi-step strategies with high risk tumours to ensure even these tumours have benchmark low recurrence rates.
Curious
Other suggestions in the chapter are somewhat curious and we are at a loss to understand the basis for the suggestions. For example, take the following key point;
“In high risk tumours or in high-risk areas, microscopic margins of less than 1 mm require a discussion with the pathologist about further pathology sections to assess adequacy of the margin. High risk cancers that are not re-excised to achieve histological complete clearance should be followed up long term. Recurrence following inadequate margin clearance may take years to become apparent. (See section 4.4.3)”
Let us take this key point one sentence at a time.
Why would one ring the pathologist every time a margin was less than 1 mm? Good clinical management of skin cancer requires a working relationship with the pathologist. A good pathology report is one that provides succinct though complete information to the clinician so as the clinician can make a sound clinical decision. If there was not a working relationship before a clinician works with a pathologist, there soon will be after the first few phone calls. The ongoing “compulsory” phone calls would seem very annoying to both the pathologist and the clinician if any doctor actually adopted this guideline.
Pathologist Professor David Weedon has often said that a pathology report that results in a phone call from the clinician is a failed report. On this basis the chapter’s key point suggests that every time a clinician takes out a tumour with a narrow margin the pathologist must have failed.
ACSCM recommends that if a clinician is uncertain regarding best management in the event of narrow margins then rather than ring the pathologist it might be more appropriate to ring a senior clinician to seek advice on further management. Certainly ACSCM fellows are frequently asked for advice in these circumstances. We would hope that other senior skin cancer clinicians would similarly be prepared to offer such phone advice.
The suggestion that high risk tumours with narrow margins require follow up is puzzling and against one of the basic concepts that ACSCM teaches junior doctors. The key point, as written, could inadvertently encourage doctors not to effect long term follow up the majority of their skin cancer patients.
The final sentence of this key point invites us to read section 4.4.3 of the guide. There is no such section in the guide.
Evidence base issues
The Australian Cancer Network has also recently published an excellent guide to melanoma management. This guide is strongly evidence based. Recommendations are given with an attributed level of evidence. This quality publication is strongly supported by ACSCM.
The guide to BCCs and SCCs is very different. Some chapters in the guide have little regard to evidence base. Most of the surgical chapter bases advice and recommendations on the lowly evidence base of expert advice. In many circumstances there is material published of much higher evidence level that provides evidence to guide management, often very different management to that suggested in the chapter.
In any guide of this type resorting to ‘expert opinion’ or ‘consensus opinion’ should only be considered when and if there are no recommendations based on a higher level of evidence to base recommendations. Yet frequently the guide makes recommendations on expert opinion despite the existence of published high level evidence.
The stand out example in the chapter is the section on anticoagulants and surgery. The very short section says that, “At this time, there is a need for adequately powered prospective studies to clarify the risk of intra and post operative bleeding and other complications of the continued use of aspirin and warfarin during surgery. . . . The decision to continue or to discontinue either aspirin or warfarin before surgery will remain in controversy until appropriate trials are done. “
Such evidence does exist and there is very direct advice that can be given to clinicians as a result of such studies40-46. It appears the authors were unaware of these studies.
Indeed rather than fail to give advice, ACSCM has a firm policy on anticoagulants and this is readily available on the ACSCM web site. - http://www.skincancercollege.com/Home/Warfarin_Aspirin.aspx
It was strange that the chapter chose not to give anticoagulant direction on the basis of a (perceived) lack of evidence base. – This did not stop the same chapter proclaim all sorts of other recommendations based on no evidence what so ever! Indeed in many cases there is evidence published, (not cited in the chapter) that suggests each of the following is quite contentious. Such uncited and / or apparent baseless recommendations include:
· The chapter suggests ratio of length to width for the ellipse is 3 or 4 to 1.
o ACSCM is aware of many recent publications raising serious doubt about this traditional approach47-49.
· The chapter encourages that a 30 gauge needle should be used on a Luer lock syringe to minimise discomfort to the patient.
o ACSCM questions why always 30? How does Luer lock (lok) reduce pain?
· The Chapter recommends buried absorbable sutures be considered to avoid suture marks and allow earlier removal of simple interrupted sutures.
o While commonly performed ACSCM stresses the lack of evidence that buried sutures do, in fact, produce such advantages.
· The chapter repeatedly mentions circumstances when a patient should be referred to certain specialists
o ACSCM notes that at no stage is any evidence cited that such referrals have been shown to be advantageous to the patient.
Chapter gaps
The surgical chapter is not just full of mistakes but also notable for its gaps. Many aspects of the surgical management of skin cancers that ought to be included are not mentioned at all!
For example the following topics are all important aspects of surgical management of SCCs and BCCs and have had substantial studies published since the last guide. In each case there could have been a section written in the chapter that could have been of great guidance to Australian doctors managing skin cancers.
Topics that should have been incorporated include:
· Wound dressings and post operative care
· Techniques of specimen orientation and marking to facilitate coordination with pathology
· Indications for antibiotics and usage of antibiotic prophylaxis
· Risk factors for skin surgery and how to manage them
· Patient co morbidities and their impact on surgical management
· The role of Breuninger type margin control surgery with urgent paraffin pathology50-53
· Delineating curettage prior to surgical excision for tumour margin determination54-56 **
** [Connelly et al (in press Journal Plastic Recons Surgery) demonstrates that in the hands of the experienced and trained delineating curettage can approach Mohs’ surgery with respect to BCC recurrence rates except on the nose.]
It is not as if space limitations prevented inclusion of such vital aspects. There are many aspects of the chapter that are extremely repetitious. For example, discussions of perineural invasion and high risk tumours are needlessly repetitive.
The section on Mohs’ surgery is also inadequate. At one point 8 references are cited to justify the statement that Mohs’ is undertaken at several specialised centres in Australia8-10, 57-61. Indeed all 8 studies hail from the one centre, though quote data from many centres.
It is a pity that the real point and lessons of these 8 excellent Australian studies was not explained at length in the chapter. These studies significantly help identify the role of Mohs’ Surgery and the outcomes and expectations that can be predicted with its usage in Australia for appropriate BCC and SCC cases8-10, 57-61. The valuable messages from these studies was not explained in the chapter.
No research team has done more to help us clarify the clinical indications of Mohs’ surgery than the Netherlands team of Klara Mosterd, Gertruud Krekels, Fred Nieman. Brigitte Essers, Nicole Kelleners-Smeets and others. 7, 62, 63.The chapter quoted the early results of their randomized controlled surgery63. However the longer (5 year data) is now available demonstrating significantly fewer recurrences when recurrent BCCs on the face are treated with Mohs’ surgery compared with standard surgical excision64. The study did not demonstrate significant differences in the management of primary BCCs between Mohs’ surgery and surgical excision.
Interestingly the Glossary of the guide does not define Mohs’ surgery as requiring frozen section processing. Nor does it specify that the pathologist and surgeon must be the same person. Yet these concepts are considered part of the definition of Mohs’ surgery in chapter 6.
It is important to recognise that margin control approaches can be undertaken with urgent paraffin sections undertaken at a distant laboratory by a trained pathologist65, 66. Margin control surgery for BCCs offers tissue sparing advantages, which have also been demonstrated with delayed closure following urgent paraffin techniques66. The outcomes can be comparable to frozen section Mohs’ surgery in experienced hands with no apparent detrimental sequelae from the delays in closure67. The Slow Mohs’ technique can also be used for SCCs68.
In the Australian context of large distances for many rural patients it means that more methodical approaches can be undertaken for difficult tumours in rural and remote areas without the need for patient and family displacement. It is for this reason that Margin control surgery of “Slow Mohs” type is an integral part of ACSCM curriculum at both diploma and fellowship level.
Yet this guide, in attempting to be inclusive of all approaches, makes no mention of Slow Mohs’ or margin control surgery with urgent paraffin sections.
Summary
The chapter advocates clearance margins and surgical management standards well below the policy that ACSCM considers safe practice in the management of SCCs and BCCs. It concerns ACSCM that senior specialists might actually implement these inadequate standards of management.
In the same chapter GPs are frequently advised when they might consider referral to specialists. It would be alarming if referrals encouraged by the chapter resulted in the inadequate management of skin cancers advocated in the chapter.
Acknowledgement: ACSCM wishes to acknowledge the assistance from several senior dermatologists from the American Society for Mohs’ surgery (ASMS) in preparing this analysis. ASMS concurs with ACSCM that the chapter is not reflective of current best practice in surgical management of BCCs and SCCs. The ASMS was, if anything, more critical of the chapter than the position outlined in this statement.
References
1. Breuninger H, Schippert W, Black B, Rassner G. [The margin of safety and depth of excision in surgical treatment of basalioma. Use of 3-dimensional histologic study of 2,016 tumors]. Hautarzt 1989;40:693-700.
2. Wolf DJ, Zitelli JA. Surgical margins for basal cell carcinoma. Arch Dermatol 1987;123:340-4.
3. Kimyai-Asadi A, Alam M, Goldberg LH, Peterson SR, Silapunt S, Jih MH. Efficacy of narrow-margin excision of well-demarcated primary facial basal cell carcinomas. J Am Acad Dermatol 2005;53:464-8.
4. Lalloo MT, Sood S. Head and neck basal cell carcinoma: treatment using a 2-mm clinical excision margin. Clin Otolaryngol Allied Sci 2000;25:370-3.
5. Griffiths RW. Skin malignancy and the reconstructive plastic surgeon. Ann R Coll Surg Engl 1989;71:150-8.
6. Sei JF, Chaussade V, Zimmermann U, Tchakerian A, Clerici T, Franc B, Saiag P. [Mohs' micrographic surgery: history, principles, critical analysis of its efficacy and indications]. Ann Dermatol Venereol 2004;131:173-82.
7. Smeets NW, Kuijpers DI, Nelemans P, Ostertag JU, Verhaegh ME, Krekels GA, Neumann HA. Mohs' micrographic surgery for treatment of basal cell carcinoma of the face--results of a retrospective study and review of the literature. Br J Dermatol 2004;151:141-7.
8. Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Basal cell carcinoma treated with Mohs surgery in Australia III. Perineural invasion. J Am Acad Dermatol 2005;53:458-63.
9. Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Basal cell carcinoma treated with Mohs surgery in Australia II. Outcome at 5-year follow-up. J Am Acad Dermatol 2005;53:452-7.
10. Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Basal cell carcinoma treated with Mohs surgery in Australia I. Experience over 10 years. J Am Acad Dermatol 2005;53:445-51.
11. Hamada S, Kersey T, Thaller VT. Eyelid basal cell carcinoma: non-Mohs excision, repair, and outcome. Br J Ophthalmol 2005;89:992-4.
12. Brodland DG, Zitelli JA. Surgical margins for excision of primary cutaneous squamous cell carcinoma. J Am Acad Dermatol 1992;27:241-8.
13. Tan PY, Ek E, Su S, Giorlando F, Dieu T. Incomplete excision of squamous cell carcinoma of the skin: a prospective observational study. Plast Reconstr Surg 2007;120:910-6.
14. Leibovitch I, Huilgol SC, Selva D, Hill D, Richards S, Paver R. Cutaneous squamous cell carcinoma treated with Mohs micrographic surgery in Australia I. Experience over 10 years. J Am Acad Dermatol 2005;53:253-60.
15. Rowe DE, Carroll RJ, Day CL, Jr. Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip. Implications for treatment modality selection. J Am Acad Dermatol 1992;26:976-90.
16. Freeman RG, Knox JM, Heaton CL. The Treatment of Skin Cancer. A Statistical Study of 1,341 Skin Tumors Comparing Results Obtained with Irradiation, Surgery, and Curettage Followed by Electrodesiccation. Cancer 1964;17:535-8.
17. Roth JJ, Granick MS. Squamous cell and adnexal carcinomas of the skin. Clin Plast Surg 1997;24:687-703.
18. Czarnecki D, Sutton T, Czarnecki C, Culjak G. A 10-year prospective study of patients with skin cancer. J Cutan Med Surg 2002;6:427-9.
19. Nguyen TH, Ho DQ. Nonmelanoma skin cancer. Curr Treat Options Oncol 2002;3:193-203.
20. Friedman HI, Cooper PH, Wanebo HJ. Prognostic and therapeutic use of microstaging of cutaneous squamous cell carcinoma of the trunk and extremities. Cancer 1985;56:1099-105.
21. Pitman KT, Johnson JT. Skin metastases from head and neck squamous cell carcinoma: incidence and impact. Head Neck 1999;21:560-5.
22. Fleischer AB, Jr., Feldman SR, Barlow JO, Zheng B, Hahn HB, Chuang TY, Draft KS, Golitz LE, Wu E, Katz AS, Maize JC, Knapp T, Leshin B. The specialty of the treating physician affects the likelihood of tumor-free resection margins for basal cell carcinoma: results from a multi-institutional retrospective study. J Am Acad Dermatol 2001;44:224-30.
23. Fernandes JD, de Lorenzo Messina MC, de Almeida Pimentel ER, Castro LG. Presence of residual basal cell carcinoma in re-excised specimens is more probable when deep and lateral margins were positive. J Eur Acad Dermatol Venereol 2008;22:704-6.
24. Friedman HI, Williams T, Zamora S, al-Assaad ZA. Recurrent basal cell carcinoma in margin-positive tumors. Ann Plast Surg 1997;38:232-5.
25. Richmond JD, Davie RM. The significance of incomplete excision in patients with basal cell carcinoma. Br J Plast Surg 1987;40:63-7.
26. Silverman MK, Kopf AW, Gladstein AH, Bart RS, Grin CM, Levenstein MJ. Recurrence rates of treated basal cell carcinomas. Part 4: X-ray therapy. J Dermatol Surg Oncol 1992;18:549-54.
27. Smith SP, Grande DJ. Basal cell carcinoma recurring after radiotherapy: a unique, difficult treatment subclass of recurrent basal cell carcinoma. J Dermatol Surg Oncol 1991;17:26-30.
28. Liu FF, Maki E, Warde P, Payne D, Fitzpatrick P. A management approach to incompletely excised basal cell carcinomas of skin. Int J Radiat Oncol Biol Phys 1991;20:423-8.
29. Rippey JJ, Rippey E. Characteristics of incompletely excised basal cell carcinomas of the skin. Med J Aust 1997;166:581-3.
30. Sussman LA, Liggins DF. Incompletely excised basal cell carcinoma: a management dilemma? Aust N Z J Surg 1996;66:276-8.
31. Seidman JD, Berman JJ, Moore GW. Basal cell carcinoma: importance of histologic discontinuities in the evaluation of resection margins. Mod Pathol 1991;4:325-30.
32. Wagner RF, Jr., Cottel WI. Multifocal recurrent basal cell carcinoma following primary tumor treatment by electrodesiccation and curettage. J Am Acad Dermatol 1987;17:1047-9.
33. Silverman MK, Kopf AW, Grin CM, Bart RS, Levenstein MJ. Recurrence rates of treated basal cell carcinomas. Part 2: Curettage-electrodesiccation. J Dermatol Surg Oncol 1991;17:720-6.
34. Suhge d'Aubermont PC, Bennett RG. Failure of curettage and electrodesiccation for removal of basal cell carcinoma. Arch Dermatol 1984;120:1456-60.
35. Rodriguez-Vigil T, Vazquez-Lopez F, Perez-Oliva N. Recurrence rates of primary basal cell carcinoma in facial risk areas treated with curettage and electrodesiccation. J Am Acad Dermatol 2007;56:91-5.
36. Kuijpers DI, Thissen MR, Berretty PJ, Ideler FH, Nelemans PJ, Neumann MH. Surgical excision versus curettage plus cryosurgery in the treatment of basal cell carcinoma. Dermatol Surg 2007;33:579-87.
37. Dellon AL, DeSilva S, Connolly M, Ross A. Prediction of recurrence in incompletely excised basal cell carcinoma. Plast Reconstr Surg 1985;75:860-71.
38. Bath FJ, Bong J, Perkins W, Williams HC. Interventions for basal cell carcinoma of the skin. Cochrane Database Syst Rev 2003:CD003412.
39. Bath-Hextall FJ, Perkins W, Bong J, Williams HC. Interventions for basal cell carcinoma of the skin. Cochrane Database Syst Rev 2007:CD003412.
40. Dixon AJ, Dixon MP, Dixon JB. Bleeding complications in skin cancer surgery are associated with warfarin but not aspirin therapy. Br J Surg 2007;94:1356-60.
41. Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med 1997;336:1506-11.
42. Blasdale C, Lawrence CM. Perioperative international normalized ratio level is a poor predictor of postoperative bleeding complications in dermatological surgery patients taking warfarin. Br J Dermatol 2008;158:522-6.
43. Shalom A, Klein D, Friedman T, Westreich M. Lack of complications in minor skin lesion excisions in patients taking aspirin or warfarin products. Am Surg 2008;74:354-7.
44. Sugden P, Siddiqui H. Continuing warfarin during cutaneous surgery. Surgeon 2008;6:148-50.
45. Garcia DA, Regan S, Henault LE, Upadhyay A, Baker J, Othman M, Hylek EM. Risk of thromboembolism with short-term interruption of warfarin therapy. Arch Intern Med 2008;168:63-9.
46. Dhiwakar M, Khan NA, McClymont LG. Surgical resection of cutaneous head and neck lesions: does aspirin use increase hemorrhagic risk? Arch Otolaryngol Head Neck Surg 2006;132:1237-41.
47. Tilleman TR, Neumann MH, Smeets NW, Tilleman MM. Waste of skin in elliptical excision biopsy of non-melanomatous skin cancer. Scand J Plast Reconstr Surg Hand Surg 2006;40:352-6.
48. Tilleman TR, Neumann MH, Tilleman MM. Analyses of skin waste during excision of benign skin lesions: is the surgical ellipse cut necessary? Plast Reconstr Surg 2007;119:2343-5.
49. Raveh Tilleman T, Tilleman MM, Krekels GA, Neumann MH. Skin waste, vertex angle, and scar length in excisional biopsies: comparing five excision patterns--fusiform ellipse, fusiform circle, rhomboid, mosque, and S-shaped. Plast Reconstr Surg 2004;113:857-61.
50. Breuninger H. Micrographic surgery of malignant skin tumors: a comparison of the frozen technique with paraffin sectioning. Facial Plast Surg 1997;13:79-82.
51. Breuninger H, Schaumburg-Lever G. Control of excisional margins by conventional histopathological techniques in the treatment of skin tumours. An alternative to Mohs' technique. J Pathol 1988;154:167-71.
52. Breuninger H, Castanet P. [Method of histological control of the edges of surgical specimens of basal cell epitheliomas]. Ann Dermatol Venereol 1987;114:511-4.
53. Breuninger H. Histologic control of excised tissue edges in the operative treatment of basal-cell carcinomas. J Dermatol Surg Oncol 1984;10:724-8.
54. Ratner D, Bagiella E. The efficacy of curettage in delineating margins of basal cell carcinoma before Mohs micrographic surgery. Dermatol Surg 2003;29:899-903.
55. Chiller K, Passaro D, McCalmont T, Vin-Christian K. Efficacy of curettage before excision in clearing surgical margins of nonmelanoma skin cancer. Arch Dermatol 2000;136:1327-32.
56. Johnson TM, Tromovitch TA, Swanson NA. Combined curettage and excision: a treatment method for primary basal cell carcinoma. J Am Acad Dermatol 1991;24:613-7.
57. Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Basosquamous carcinoma: treatment with Mohs micrographic surgery. Cancer 2005;104:170-5.
58. Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Basosquamous carcinoma. Cancer 2005;104:170-5.
59. Malhotra R, Huilgol SC, Huynh NT, Selva D. The Australian Mohs database, part II: periocular basal cell carcinoma outcome at 5-year follow-up. Ophthalmology 2004;111:631-6.
60. Malhotra R, Huilgol SC, Huynh NT, Selva D. The Australian Mohs database, part I: periocular basal cell carcinoma experience over 7 years. Ophthalmology 2004;111:624-30.
61. Malhotra R, Huilgol SC, Huynh NT, Selva D. The Australian Mohs database: periocular squamous cell carcinoma. Ophthalmology 2004;111:617-23.
62. Thissen MR, Neumann MH, Schouten LJ. A systematic review of treatment modalities for primary basal cell carcinomas. Arch Dermatol 1999;135:1177-83.
63. Smeets NW, Krekels GA, Ostertag JU, Essers BA, Dirksen CD, Nieman FH, Neumann HA. Surgical excision vs Mohs' micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial. Lancet 2004;364:1766-72.
64. Mosterd K, Krekels GA, Nieman FH, Ostertag JU, Essers BA, Dirksen CD, Steijlen PM, Vermeulen A, Neumann H, Kelleners-Smeets NW. Surgical excision versus Mohs' micrographic surgery for primary and recurrent basal-cell carcinoma of the face: a prospective randomised controlled trial with 5-years' follow-up. Lancet Oncol 2008;9:1149-56.
65. Pichardo-Velazquez P, Dominguez-Cherit J, Vega-Memije ME, Moreno-Coutino G, Proy H. Surgical option for nonmelanoma skin cancer. Int J Dermatol 2004;43:148-50.
66. Hsuan JD, Harrad RA, Potts MJ, Collins C. Small margin excision of periocular basal cell carcinoma: 5 year results. Br J Ophthalmol 2004;88:358-60.
67. Morris DS, Elzaridi E, Clarke L, Dickinson AJ, Lawrence CM. Periocular Basal Cell Carcinoma: Five Year Outcome following Slow Mohs Surgery with Formalin-Fixed Paraffin-Embedded Sections and Delayed Closure. Br J Ophthalmol 2008.
68. Turner RJ, Leonard N, Malcolm AJ, Lawrence CM, Dahl MG. A retrospective study of outcome of Mohs' micrographic surgery for cutaneous squamous cell carcinoma using formalin fixed sections. Br J Dermatol 2000;142:752-7.
ACN Response to Critique:
Five weeks after this critique was forwarded to ACN , ACSCM received a short response from Professor Reeve. ACN was not able to identify a single issue that we raised that they could object to or counter. Indeed their response did not cite a single paper by way of suggesting there were other aspects to our concerns that we were not aware of or had not considered.
In the response ACN forgot to thank those who had gone to the trouble of producing the critique at such short notice and at such a difficult time of the year. Rather the response simply advised that the guide would not be withdrawn because it was too late. – We are not sure how it could be possibly have been produced any sooner.
The letter from ACN also suggested that ACSCM had sent our concerns about chapter 6 to the media and politicians prior to sending them to ACN. ACN must have been mistaken. Indeed to this day ACSCM has not sent these concerns to any media or discussed or engaged any politician over the surgical chapter concerns. Rather we gave ACN every chance to engage ACSCM to improve this chapter without the involvement of other parties.
As such, ACN’s response of “too late” and “you spoke to media and politicians” are disappointing, especially given their apparent acceptance of the science and evidence that we submitted.
We at ACSCM have confined our distribution of information regarding the concerning surgical chapter to our own members and College associates through email direct to members and through this web site.
PROCESS
Indeed this raises its own serious questions about the process of establishing this Guide in the first place.
The Guide working group decided the Guide would be a “consensus approach” rather than one based on research evidence. This raises major concerns and we addressed some of these in our appraisal of chapter 6.
Expert opinion is the lowest level of evidence to establish such a Guide. Consensus is simply a collection of experts and their opinions.
Having decided to take this approach, a working group was established that took an exclusive approach. ACSCM was denied any participation in the group. When the draft guide was circulated in May 2008 ACSCM requested the opportunity to at least meet with the working group and discuss our concerns at that time. This offer was first accepted by Professor Reeve but soon after denied to ACSCM. We do not know which other bodies and skin cancer academics were also excluded from the process but must comment that such is hardly an appropriate methodology when attempting to establish a “consensus”.
The Guide was prepared with Government funds. ACSCM is a charity and attracts no Government funds. Those from ACSCM that assisted in this regard have done so, as usual, in an entirely voluntary capacity. ACSCM feels it had no option given the health interests of Australians who stand to suffer as a result of the Guide.
ACSCM invited the working Group to present at out College Summer Conference on the weekend of February 20 / 21 / 22, 2009. There was no response to this offer. The Guide was discussed at the meeting with agreement reached (without dissent) to advise all ACSCM members to follow ACSCM recommendations regarding management of BCCs and SCCs and to urge all members not to manage skin cancers as outlined in the Guide.
The Result
The Guide remains dangerous and flawed.
Doctors following this Guide could inadvertently face difficulties addressing a negligence claim despite following Guide recommendations in good faith. More importantly, patients will suffer needlessly through inappropriate recommendations made in this Guide.
Doctors are advised not to follow the recommendations of this Guide. Too many of them are concerning and the guide is unsafe. We strongly advise our members to follow the carefully developed and evidence based guidelines that ACSCM has established for the management of skin cancer.
ACSCM will continue to set and fight for the highest standards in the management of skin cancer.