NCCN Clinical Practice Guidelines in Oncology on Basal Cell and Squamous Cell Skin Cancers
NCCN Categories of Evidence and Consensus
Category 1: The recommendation is based on high-level evidence (e.g., randomized controlled trials) and there is uniform NCCN consensus.
Category 2A: The recommendation is based on lower-level evidence and there is uniform NCCN consensus.
Category 2B: The recommendation is based on lower-level evidence and there is nonuniform NCCN consensus (but no major disagreement).
Category 3: The recommendation is based on any level of evidence but reflects major disagreement.
All recommendations are category 2A unless otherwise noted.
Clinical trials: NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) are a statement of consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines™ is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representation or warranties of any kind regarding their content, use, or application and disclaims any responsibility for their applications or use in any way.
© National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN.
Disclosures for the NCCN Guidelines Panel for Basal Cell and Squamous Cell Skin Cancers
At the beginning of each NCCN Guidelines panel meeting, panel members disclosed any financial support they have received from industry. Through 2008, this information was published in an aggregate statement in JNCCN and online. Furthering NCCN's commitment to public transparency, this disclosure process has now been expanded by listing all potential conflicts of interest respective to each individual expert panel member.
Individual disclosures for the NCCN Guidelines on Basal Cell and Squamous Cell Skin Cancers panel members can be found on page 864. (The most recent version of these guidelines and accompanying disclosures, including levels of compensation, are available on the NCCN Web site at www.NCCN.org.)
These guidelines are also available on the Internet. For the latest update, please visit www.NCCN.org.
ChristensonLJBorrowmanTAVachonCM. Incidence of basal cell and squamous cell carcinomas in a population younger than 40 years. JAMA2005;294:681–690.
WeinstockMA. Epidemiology of ultraviolet radiation. In:MillerSJMaloneyME eds. Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden: Blackwell Science; 1998:121–128.
PerkinsJLLiuYMitbyPA. Nonmelanoma skin cancer in survivors of childhood and adolescent cancer: a report from the Childhood Cancer Survivor Study. J Clin Oncol2005;23:3733–3741.
MillerSJMoresiJM. Actinic keratosis, basal cell carcinoma and squamous cell carcinoma. In:BologniaJJorizzoJLRapiniRVHornT eds. Dermatology. London: Harcourt Health Sciences Publishers; 2003.
RhodesAR. Public education and cancer of the skin. What do people need to know about melanoma and nonmelanoma skin cancer?Cancer1995;75:613–636.
Clowers-WebbHEChristensonLJPhillipsPK. Educational outcomes regarding skin cancer in organ transplant recipients: randomized intervention of intensive vs standard education. Arch Dermatol2006;142:712–718.
GailaniMRBaleAE. Developmental genes and cancer: role of patched in basal cell carcinoma of the skin. J Natl Cancer Inst1997;89:1103–1109.
BrashDERudolphJASimonJA. A role for sunlight in skin cancer: UV-induced p53 mutations in squamous cell carcinoma. Proc Natl Acad Sci U S A1991;88:10124–10128.
NaganoTUedaMIchihashiM. Expression of p53 protein is an early event in ultraviolet light-induced cutaneous squamous cell carcinogenesis. Arch Dermatol1993;129:1157–1161.
BaleAE. Molecular genetics (basal cell carcinoma). In:MillerSJMaloneyME eds. Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden: Blackwell Science; 1998:586–591.
ReesJR. Molecular biology (squamous cell carcinoma). In:MillerSJMaloneyME eds. Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden: Blackwell Science; 1998:353–360.
CobbMW. Skin cancer in the immunosuppressed host. In:MillerSJMaloneyME eds. Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden: Blackwell Science; 1998:51–60.
McGregorJMHawkJL. Genetic syndromes predisposing to skin cancer development. In:MillerSJMaloneyME eds. Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden: Blackwell Science; 1998:158–168.
Boeta-AngelesLBennettRG. Features associated with recurrence (basal cell carcinoma). In:MillerSJMaloneyME eds. Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden: Blackwell Science; 1998:646–656.
HaasAF. Features associated with metastasis (squamous cell carcinoma). In:MillerSJMaloneyME eds. Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden: Blackwell Science; 1998:500–505.
SwansonNAJohnsonTM. Management of basal and squamous cell carcinoma. In:CummingsC ed. Otolaryngology Head and Neck Surgery. New York: Mosby Yearbook; 1998:486–501.
RoweDECarrollRJDayCLJr. 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 Dermatol1992;26:976–990.
SilvermanMKKopfAWGrinCM. Recurrence rates of treated basal cell carcinomas. Part 2: curettage-electrodesiccation. J Dermatol Surg Oncol1991;17:720–726.
Medicare Part B Newsletter No. 023. February 61998.
RoweDECarrollRJDayCLJr. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol1989;15:315–328.
SternRSLangeR. Non-melanoma skin cancer occurring in patients treated with PUVA five to ten years after first treatment. J Invest Dermatol1988;91:120–124.
SternRSLiebmanEJVakevaL. Oral psoralen and ultraviolet-A light (PUVA) treatment of psoriasis and persistent risk of nonmelanoma skin cancer. PUVA follow-up study. J Natl Cancer Inst1998;90:1278–1284.
BrodlandDG. Features associated with metastasis (basal cell carcinoma). In:MillerSJMaloneyME eds. Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden: Blackwell Science; 1998:657–663.
EdwardsMJHirschRMBroadwaterJR. Squamous cell carcinoma arising in previously burned or irradiated skin. Arch Surg1989;124:115–117.
GallowayTJMorrisCGMancusoAA. Impact of radiographic findings on prognosis for skin carcinoma with clinical perineural invasion. Cancer2005;103:1254–1257.
SalascheSJ. Features associated with recurrence (squamous cell carcinoma). In:MillerSJMaloneyME eds. Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden: Blackwell Science; 1998:494–499.
DinehartSMDodgeRStanleyWE. Basal cell carcinoma treated with Mohs surgery. A comparison of 54 younger patients with 1050 older patients. J Dermatol Surg Oncol1992;18:560–566.
MilroyCJHorlockNWilsonGDSandersR. Aggressive basal cell carcinoma in young patients: fact or fiction?Br J Plast Surg2000;53:393–396.
Roudier-PujolCAuperinANguyenT. Basal cell carcinoma in young adults: not more aggressive than in older patients. Dermatology1999;199:119–123.
LoweL. Histology (basal cell carcinoma). In:MillerSJMaloneyME eds. Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden: Blackwell Science; 1998:633–645.
MaloneyMEMillerSJ. Aggressive vs nonaggressive subtypes (basal cell carcinoma). In:MillerSJMaloneyME eds. Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden: Blackwell Science; 1998:609–613.
CostantinoDLoweLBrownDL. Basosquamous carcinomaan under-recognized, high-risk cutaneous neoplasm: case study and review of the literature. J Plast Reconstr Aesthet Surg2006;59:424–428.
MartinRCIIEdwardsMJCawteTG. Basosquamous carcinoma: analysis of prognostic factors influencing recurrence. Cancer2000;88:1365–1369.
SchullerDEBergJWShermanGKrauseCJ. Cutaneous basosquamous carcinoma of the head and neck: a comparative analysis. Otolaryngol Head Neck Surg1979;87:420–427.
JohnsonTMRoweDENelsonBRSwansonNA. Squamous cell carcinoma of the skin (excluding lip and oral mucosa). J Am Acad Dermatol1992;26:467–484.
BrantschKDMeisnerCSchonfischB. Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study. Lancet Oncol2008;9:713–720.
BreuningerHSchaumburg-LeverGHolzschuhJHornyHP. Desmoplastic squamous cell carcinoma of skin and vermilion surface: a highly malignant subtype of skin cancer. Cancer1997;79:915–919.
ChenKCraigJCShumackS. Oral retinoids for the prevention of skin cancers in solid organ transplant recipients: a systematic review of randomized controlled trials. Br J Dermatol2005;152:518–523.
KovachBTMurphyGOtleyCC. Oral retinoids for chemoprevention of skin cancers in organ transplant recipients: results of a survey. Transplant Proc2006;38:1366–1368.
OtleyCCStaskoTTopeWDLebwohlM. Chemoprevention of nonmelanoma skin cancer with systemic retinoids: practical dosing and management of adverse effects. Dermatol Surg2006;32:562–568.
MarghoobAASladeJSalopekTG. Basal cell and squamous cell carcinomas are important risk factors for cutaneous malignant melanoma. Screening implications. Cancer1995;75:707–714.
RoweDECarrollRJDayCLJr. Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol1989;15:424–431.
FreemanRGKnoxJMHeatonCL. The treatment of skin cancer: a statistical study of 1,341 skin tumors comparing results obtained with irradiation, surgery, and curettage followed by electrodesiccation. Cancer1964;17:535–538.
MendenhallWMParsonsJTMendenhallNPMillionRR. T2-T4 carcinoma of the skin of the head and neck treated with radical irradiation. Int J Radiat Oncol Biol Phys1987;13:975–981.
PetrovichZKuiskHLangholzB. Treatment results and patterns of failure in 646 patients with carcinoma of the eyelids, pinna, and nose. Am J Surg1987;154:447–450.
AvrilMFAuperinAMargulisA. Basal cell carcinoma of the face: surgery or radiotherapy? Results of a randomized study. Br J Cancer1997;76:100–106.
BarrettTLGreenwayHTJrMassulloVCarlsonC. Treatment of basal cell carcinoma and squamous cell carcinoma with perineural invasion. Adv Dermatol1993;8:277–304; discussion 305.
ChaoCKGerberRMPerezCA. Reirradiation of recurrent skin cancer of the face. A successful salvage modality. Cancer1995;75:2351–2355.
ChildersBJGoldwynRMRamosD. Long-term results of irradiation for basal cell carcinoma of the skin of the nose. Plast Reconstr Surg1994;93:1169–1173.
MazeronJJChassagneDCrookJ. Radiation therapy of carcinomas of the skin of nose and nasal vestibule: a report of 1676 cases by the Groupe Europeen de Curietherapie. Radiother Oncol1988;13:165–173.
PetrovichZKuiskHLangholzB. Treatment of carcinoma of the skin with bone and/or cartilage involvement. Am J Clin Oncol1988;11:110–113.
PetrovichZParkerRGLuxtonG. Carcinoma of the lip and selected sites of head and neck skin. A clinical study of 896 patients. Radiother Oncol1987;8:11–17.
SilvermanMKKopfAWBartRS. Recurrence rates of treated basal cell carcinomas. Part 3: surgical excision. J Dermatol Surg Oncol1992;18:471–476.
SilvermanMKKopfAWGladsteinAH. Recurrence rates of treated basal cell carcinomas. Part 4: x-ray therapy. J Dermatol Surg Oncol1992;18:549–554.
SmithSPFoleyEHGrandeDJ. Use of Mohs micrographic surgery to establish quantitative proof of heightened tumor spread in basal cell carcinoma recurrent following radiotherapy. J Dermatol Surg Oncol1990;16:1012–1016.
SmithSPGrandeDJ. Basal cell carcinoma recurring after radiotherapy: a unique, difficult treatment subclass of recurrent basal cell carcinoma. J Dermatol Surg Oncol1991;17:26–30.
BraathenLRSzeimiesRMBasset-SeguinN. Guidelines on the use of photodynamic therapy for nonmelanoma skin cancer: an international consensus. International Society for Photodynamic Therapy in Dermatology, 2005. J Am Acad Dermatol2007;56:125–143.
MarmurESSchmultsCDGoldbergDJ. A review of laser and photodynamic therapy for the treatment of nonmelanoma skin cancer. Dermatol Surg2004;30:264–271.
ZeitouniNOseroffAShiehS. Photodynamic therapy for nonmelanoma skin cancers. Current review and update. Mol Immunol2003;39:1133–1136.
RhodesLEde RieMALeifsdottirR. Five-year follow-up of a randomized, prospective trial of topical methyl aminolevulinate photodynamic therapy vs surgery for nodular basal cell carcinoma. Arch Dermatol2007;143:1131–1136.
PatelGKGoodwinRChawlaM. Imiquimod 5% cream monotherapy for cutaneous squamous cell carcinoma in situ (Bowen's disease): a randomized, double-blind, placebo-controlled trial. J Am Acad Dermatol2006;54:1025–1032.
GuptaAKDaveyVMcPhailH. Evaluation of the effectiveness of imiquimod and 5-fluorouracil for the treatment of actinic keratosis: critical review and meta-analysis of efficacy studies. J Cutan Med Surg2005;9:209–214.
TanghettiEWerschlerP. Comparison of 5% 5-fluorouracil cream and 5% imiquimod cream in the management of actinic keratoses on the face and scalp. J Drugs Dermatol2007;6:144–147.
MortonCHornMLemanJ. 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 Dermatol2006;142:729–735.
PariserDMLoweNJStewartDM. Photodynamic therapy with topical methyl aminolevulinate for actinic keratosis: results of a prospective randomized multicenter trial. J Am Acad Dermatol2003;48:227–232.
Ch'ngSMaitraAAllisonRS. Parotid and cervical nodal status predict prognosis for patients with head and neck metastatic cutaneous squamous cell carcinoma. J Surg Oncol2008;98:101–105.
PalmeCEO'BrienCJVenessMJ. Extent of parotid disease influences outcome in patients with metastatic cutaneous squamous cell carcinoma. Arch Otolaryngol Head Neck Surg2003;129:750–753.
AudetNPalmeCEGullanePJ. Cutaneous metastatic squamous cell carcinoma to the parotid gland: analysis and outcome. Head Neck2004;26:727–732.
HanARatnerD. What is the role of adjuvant radiotherapy in the treatment of cutaneous squamous cell carcinoma with perineural invasion?Cancer2007;109:1053–1059.
VenessMJPalmeCESmithM. Cutaneous head and neck squamous cell carcinoma metastatic to cervical lymph nodes (nonparotid): a better outcome with surgery and adjuvant radiotherapy. Laryngoscope2003;113:1827–1833.
VenessMJMorganGJPalmeCEGebskiV. Surgery and adjuvant radiotherapy in patients with cutaneous head and neck squamous cell carcinoma metastatic to lymph nodes: combined treatment should be considered best practice. Laryngoscope2005;115:870–875.
LaramoreGEScottCBal-SarrafM. Adjuvant chemotherapy for resectable squamous cell carcinomas of the head and neck: report on Intergroup study 0034. Int J Radiat Oncol Biol Phys1992;23:705–713.
BernierJDomengeCOzsahinM. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. N Engl J Med2004;350:1945–1952.
CooperJSPajakTFForastiereAA. Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. N Engl J Med2004;350:1937–1944.
BernierJCooperJSPajakTF. Defining risk levels in locally advanced head and neck cancers: a comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORTC (#22931) and RTOG (# 9501). Head Neck2005;27:843–850.
RobinsonJK. Follow-up and prevention (basal cell carcinoma). In:MillerSJMaloneyME eds. Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden: Blackwell Science; 1998:695–698.
ShinDMMaloneyMELippmanSM. Follow-up and prevention (squamous cell carcinoma). In:MillerSJMaloneyME eds. Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden: Blackwell Science; 1998.
WiemanTJShivelyEHWoodcockTM. Responsiveness of metastatic basal-cell carcinoma to chemotherapy. A case report. Cancer1983;52:1583–1585.
GuthrieTHJrPorubskyESLuxenbergMN. Cisplatin-based chemotherapy in advanced basal and squamous cell carcinomas of the skin: results in 28 patients including 13 patients receiving multimodality therapy. J Clin Oncol1990;8:342–346.
CarneiroBAWatkinWGMehtaUKBrocksteinBE. Metastatic basal cell carcinoma: complete response to chemotherapy and associated pure red cell aplasia. Cancer Invest2006;24:396–400.
JeffordMKifferJDSomersG. Metastatic basal cell carcinoma: rapid symptomatic response to cisplatin and paclitaxel. ANZ J Surg2004;74:704–705.
ShinDMGlissonBSKhuriFR. Phase II and biologic study of interferon alfa, retinoic acid, and cisplatin in advanced squamous skin cancer. J Clin Oncol2002;20:364–370.
BrewsterAMLeeJJClaymanGL. Randomized trial of adjuvant 13-cis-retinoic acid and interferon alfa for patients with aggressive skin squamous cell carcinoma. J Clin Oncol2007;25:1974–1978.
MartinezJCOtleyCCOkunoSH. Chemotherapy in the management of advanced cutaneous squamous cell carcinoma in organ transplant recipients: theoretical and practical considerations. Dermatol Surg2004;30:679–686.