Taking treatment decisions in non-melanoma skin cancer—The place for topical photodynamic therapy (PDT)

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Summary

Background

Epithelial non-melanoma skin cancer (NMSC) like actinic keratosis (AK), Bowen's disease (BD) and basal cell carcinoma (BCC) represent the most common malignancies in the fair skinned population. Epidemiological data reveal high incidences, especially for actinic keratoses, which are basically non-invasive squamous cell carcinomas, but fortunately bear a low risk of mortality for a single lesion. Nevertheless these lesions should be generally treated if other factors such as the state of the patient indicate that this is appropriate. The appearance of new treatment modalities like immuno-modulating topical agents, topical diclofenac, and photodynamic therapy in addition to a long list of already established treatments (curettage, surgery, cryotherapy, topical 5-fluorouracil, and many others) have led to the fact that patients and treating physicians have a large spectrum of therapeutic options to choose from. The same – with some variations – holds true forBowen's disease and BCC.

Methods

Aim of this article is to offer an overview over NMSCs and their treatment options with emphasis on photodynamic therapy (PDT) as classical indications for PDT, to provide resources for guidelines for the treatment of these diseases, and to position PDT in this context by helping selecting patients that would profit most from topical PDT.

Results

Sufficient evidence is available to regard PDT as a standard treatment modality for NMSC. In addition to randomized controlled trials, long-term experience helps to find out the most appropriate treatment modality in a given patient.

Conclusion

Physicians treating NMSC should have access to PDT and be trained and experienced in its use.

Introduction

Epithelial non-melanoma skin cancer (NMSC) like actinic keratosis (AK), Bowen's disease (BD) and basal cell carcinoma (BCC) represent the most common malignancies in the fair skinned population. Epidemiological data reveal high incidences, especially for actinic keratoses, which are basically non-invasive squamous cell carcinomas, but fortunately bear a low risk of mortality for a single lesion. Nevertheless these lesions have to be treated. The appearance of new treatment modalities like immuno-modulating topical agents, topical diclofenac, and photodynamic therapy in addition to a long list of already established treatments (curettage, surgery, cryotherapy, topical 5-fluorouracil (5-FU), and many others) have led to the fact that patients and treating physicians have a large spectrum of therapeutic options to choose from. The same – with some variations – holds true for Bowen's disease and BCC. Aim of this article is to offer an overview over NMSCs as classical indications for PDT, to provide resources for guidelines for the treatment of these diseases, and to position PDT in this context by helping selecting patients that would profit most from topical PDT.

Section snippets

Materials and methods

By combining data from the literature with the (statistically unstructured) clinical experience of an outpatient clinic having about 25,000 patient contacts a year we try to approach the process of decision taking in the treatment of patients with NMSC with emphasis on the value of topical PDT in this context.

Actinic keratosis/carcinoma in situ

Actinic keratoses are cutaneous lesions induced by UV-light and develop mostly in fair skinned patients being susceptible to solar damage [1]. The term actinic keratosis (AK) though, is a source of confusion and ongoing debate. Interpreting the name of these lesions literally bears the danger to wrongly conclude that these sun-induced rough spots are basically benign lesions and little more than cosmetic nuisances (sometimes being confused with seborrhoeic keratoses and other benign lesions).

Recommendations and guidelines

Many recommendations for the treatment of AK and Bowen's disease have been published [2], [26], [30], [34], [38], [53], [54], [55]. They are all mainly based on the evidence level available (see Appendix A) for the different treatment options (Table 1, Table 2). Treatment guidelines for BCCs have been briefly summarized recently by Breuninger et al. [56]. It is clear that in this context the gold standard are randomized controlled trials. For PDT a long list of appropriate trials has been

General aspects in the treatment of NMSC

Although these publications attest PDT an important role in the treatment of NMSC it is remarkable that this therapeutic modality is not being generally offered to patients. This strongly differs from country to country and – within countries – from centre to centre or even from physician to physician. Amongst others, we think that a major reason for this is the fact that in these publications not enough emphasis is put on the fact that the choice of a specific treatment is not a matter of cure

PDT vs. surgery

As has been shown by many clinical studies and our own clinical experience PDT delivers excellent cosmetic results, scarring being an exception and usually not the consequence of the procedure but of the tissue destruction by the original underlying tumour. But the avoidance of scars is not only a cosmetic issue. Depending on the localization surgery bears the risk of functional impairment (e.g. over digital joints), which is rather improbable due to the relative selectivity of the photodynamic

PDT in AKs

A vast list of therapeutic options has been described for the treatment of AK (see Table 1). Some have been used for decades, some have hit the market only recently. Only very few of them have been compared with each other in randomized controlled trials. A comparison of all of them would be neither feasible nor would it make sense especially if AKs would be cumulatively seen as one disease not taking into consideration the variety of clinical appearances and patients’ needs. The approach will

Summary and conclusions

In this overview we tried not to look at the individual disease states, but give a general help for comparing PDT with other treatment methods and emphasizing its position in the treatment of different kinds on NMSC. Even if summarized under the term non-melanoma skin cancer the spectrum of these lesions is very broad. As a consequence there cannot be one single treatment of choice that will be equally suitable for all of these lesions. In addition not only the variability of the lesions but

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