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A topical skin cream could be used as a viable alternative to surgery for patients with a common type of skin cancer, a study led by researchers at The University of Nottingham found.
The research, published in the Journal of Investigative Dermatology , found that imiquimod had high levels of success when used to treat basal cell carcinoma (BCC) over a period of five years.
Hywel Williams , Professor of Dermato-Epidemiology and Co-Director of the Centre of Evidence-based Dermatology at the University, led the study along with Professor Fiona Bath-Hextall , Professor of Evidence-Based Healthcare in the University’s School of Health Sciences.
He said: “The absolute response rate for topical imiquimod of 83 per cent at five years, although clearly inferior to the 98 per cent for excisional surgery for low-risk BCC, might still represent a clinically useful treatment modality, because a cream treatment can be carried out in a primary care setting, and some patients may also prefer the option of a cream rather than surgery.
“If you had told me 15 years ago that one day we would be treating low risk nodular and superficial BCC with a cream that enhanced the body’s local immune response, I would have walked away. But it is a reality nowadays.”
Rising demand
The skin cancer BCC is the most common form of human cancer. With a growing population, BCC rates are climbing at an alarming rate, with reported cases rising by as much as 10 per cent per year. Rising demand makes a simple and effective treatment appealing to both practitioners and patients.
Currently, the gold standard treatment for BCC is excisional or Mohs surgery, both of which require a dermatologist or plastic surgeon. Requiring specialised care for such a ubiquitous and mostly low-risk cancer can tie up resources that are needed for more serious and difficult cases.
In order to help alleviate some of the burden, alternative treatments for BCC are emerging, many of which can be administered by general practitioners. One of these treatments is imiquimod, a topical treatment cream that boosts the body’s immune response.
The latest research is an extension of a prior randomised control trial that followed BCC patients for three years post-treatment and had an 83.6 per cent success rate for patients treated with imiquimod, versus 98.4 per cent for traditional surgery.
In the additional two years of follow up time tracked in this new study, researchers found that 82.5 per cent of imiquimod patients had successful outcomes at the five-year mark compared to 97.7 per cent for surgery.
Doctors have expressed concerns that the use of topical treatments instead of surgery may leave patients vulnerable to so-called ‘submarine lesions’ which can emerge after the superficial cancer appears to have been treated. However, mirroring the results of the three-year follow up, the extended five-year study illustrates that if imiquimod treatment is successful in the first year, BCC reoccurrence is unlikely.
“Most treatment failures with topical imiquimod occurred in the first year of treatment, a finding that throws light on the possible mechanisms of topical immunotherapy of skin cancer, suggesting that once an immunological response has occurred, such a response is sustained,” said Professor Williams.
Treatment options
These new data are important information for practitioners and their patients to consider with treatment options for low-risk BCC. This new study confirms that if a benefit is seen from imiquimod treatment, those results are likely to hold over a five-year period.
Professor Williams added: “Very few randomised controlled trials have been conducted for BCC, which is odd considering that it is the most common form of human cancer. Only a handful of such RCT’s have been followed up for five years, which is important as some treatments such as photodynamic therapy produce reasonable results in the short term, but seem to result in more recurrences the longer patients are tracked.”
Investigators hope that these findings will encourage further research to develop creams that work in a similar way, yet produce better results. For now, this information provides an important part of the roadmap for treating BCC and potentially alleviating some of the burden on specialised health care providers.
“The most important results are the precise estimates of threeand five-year tumour clearance for imiquimod cream versus surgery,” said Professor Williams.
“This will allow patients and their doctors to engage in a shared decision-making conversation on a range of treatment options. Because BCC is reaching epidemic proportions, some countries like the UK are struggling to keep up. One possible strategy for the future is to treat more low-risk (biopsy proven) BCCs with imiquimod cream and only refer those who don’t respond to secondary care services.”
