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Cancer Screening, Prevention, Control

Follow-up of Patients With Keratinocyte CarcinomaA Systematic Review of Clinical Practice Guidelines

To identify the key insights or developments described in this article

1 Credit CME

JAMA Dermatology

Published Online: November 2, 2022

Review

Article Information and Disclosures

Sara Mirali, PhD^1,2,3;

Evan Tang, BScN^1,2,3;

Aaron M. Drucker, MD^1,2,3,4;

Irina Turchin, MD^3,5,6;

Melinda Gooderham, MD^3,6,7,8;

Nick Levell, MD^3,9,10;

Jennifer Beecker, MD^3,11;

Robert Bissonnette, MD^3,12;

Helen Catherall, BSR³;

Jo-Ann Lapointe McKenzie, MN^3,13;

Nicole Hawkins, MD^3,14,15;

Chih-Ho Hong, MD^3,6,16;

Sunil Kalia, MD, MHSc^3,17;

Kim Papp, MD, PhD^3,6,18;

An-Wen Chan, MD, DPhil^1,2,3,4

Author Affiliations

¹Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
²Women’s College Research Institute, Toronto, Ontario, Canada
³Skin Investigation Network of Canada (SkIN Canada), Toronto, Ontario, Canada
⁴Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
⁵Brunswick Dermatology Center, Fredericton, New Brunswick, Canada
⁶Probity Medical Research, Waterloo, Ontario, Canada
⁷SKiN Centre for Dermatology, Peterborough, Ontario, Canada
⁸Department of Medicine, Queens University, Kingston, Ontario, Canada
⁹Norwich Medical School, University of East Anglia, Norwich, United Kingdom
¹⁰Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
¹¹Division of Dermatology, The Ottawa Hospital, Ottawa, Ontario, Canada
¹²Innovaderm Research, Montreal, Quebec, Canada
¹³Save Your Skin Foundation, Penticton, British Columbia, Canada
¹⁴Peak Medical Specialty Clinic, Okotoks, Alberta, Canada
¹⁵Division of Dermatology, University of Calgary, Calgary, Alberta, Canada
¹⁶Department of Dermatology and Skin Science, University of British Columbia, Surrey, British Columbia, Canada
¹⁷Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
¹⁸K Papp Clinical Research, Waterloo, Ontario, Canada

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Key Points

Question What are the national clinical practice guideline recommendations for dermatologic follow-up of patients with squamous cell carcinoma (SCC) and basal cell carcinoma (BCC)?

Findings In this systematic review of 14 clinical practice guidelines, there was little consensus on the recommended follow-up frequency and duration for patients treated for SCC or BCC. Guidelines also differed in the criteria used to classify tumor risk and scored poorly in quality domains assessing applicability and patient involvement.

Meaning Follow-up recommendations for BCC and SCC are highly variable; findings highlight the need for randomized clinical trials comparing patient-relevant outcomes for different follow-up regimens.

Abstract

Importance Patients treated for cutaneous squamous cell carcinoma (SCC) and basal cell carcinoma (BCC), collectively called keratinocyte carcinoma (KC), are at risk for recurrence, metastasis, and additional primary cutaneous malignant neoplasms. It is unclear how often patients should be seen for follow-up skin examination after initial treatment of KC.

Objective To summarize the recommendations and evaluate the methodological quality of clinical practice guidelines for dermatologic follow-up of patients with BCC and invasive SCC.

Evidence Review PubMed, MEDLINE, and Embase were searched for relevant articles published from January 2010 to March 2022. Search terms included guideline, squamous cell carcinoma, and basal cell carcinoma. National or international guidelines containing recommendations for follow-up frequency after a diagnosis of localized cutaneous KC were included. Quality was assessed using the 6 domains of the Appraisal of Guidelines Research and Evaluation II (AGREE II) tool: (1) scope and purpose; (2) stakeholder development; (3) rigor of development; (4) clarity of presentation; (5) applicability; and (6) editorial independence. The Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) was used to guide study reporting.

Findings Among the 14 guidelines meeting eligibility criteria, there was little consensus on the appropriate follow-up frequency after initial KC treatment. Overall duration of follow-up ranged from a single posttreatment visit to lifelong surveillance. Most guidelines stratified their recommendations by recurrence risk. For low-risk BCC and guidelines that did not stratify by risk, follow-up recommendations ranged from every 6 to 12 months. For high-risk BCC, 1 guideline suggested follow-up every 3 months, while 4 recommended every 6 months. For low-risk SCC, 5 guidelines recommended annual follow-up; 3 guidelines, every 6 months; and 1 guideline, every 3 months. For high-risk SCC, recommendations included a range of follow-up frequencies, spanning every 3 months (n = 5 guidelines), 4 months (n = 1), 6 months (n = 6), or annually (n = 4). One guideline did not use risk stratification and recommended annual screening. The highest scoring AGREE II domain was “scope and purpose,” which assessed the guideline’s overall objectives, and the lowest scoring was “applicability,” which assessed barriers and facilitators to implementation.

Conclusions and Relevance The findings of this systemic review highlight variations in follow-up recommendations for patients after initial treatment for KC. Randomized clinical trials are needed to define an optimal follow-up regimen.

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Article Information

Accepted for Publication: August 31, 2022.

Published Online: November 2, 2022. doi:10.1001/jamadermatol.2022.4590

Corresponding Author: An-Wen Chan, MD, DPhil, Division of Dermatology, Women’s College Hospital, 76 Grenville St, Toronto, ON, Canada, M5S 1B2 (anwen.chan@utoronto.ca).

Author Contributions: Drs Mirali and Chan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Tang, Drucker, Turchin, Levell, Beecker, Bissonnette, Catherall, Lapointe McKenzie, Hawkins, Papp, Chan.

Acquisition, analysis, or interpretation of data: Mirali, Tang, Drucker, Gooderham, Hong, Kalia, Chan.

Drafting of the manuscript: Mirali, Tang, Catherall, Lapointe McKenzie.

Critical revision of the manuscript for important intellectual content: Tang, Drucker, Turchin, Gooderham, Levell, Beecker, Bissonnette, Hawkins, Hong, Kalia, Papp, Chan.

Statistical analysis: Tang, Chan.

Obtained funding: Drucker.

Administrative, technical, or material support: Tang, Kalia.

Supervision: Drucker, Turchin, Beecker, Hawkins, Kalia, Chan.

Conflict of Interest Disclosures: Dr Mirali reported receiving nonfinancial support from Skin Investigation Network of Canada (SkIN Canada) during the conduct of the study and serving as an Editorial Trainee for the British Journal of Dermatology outside the submitted work. Dr Drucker reported receiving grants from Canadian Institutes of Health Research during the conduct of the study; and compensation from the British Journal of Dermatology (reviewer and Section Editor), American Academy of Dermatology (guidelines writer), and National Eczema Association (grant reviewer) outside the submitted work. Dr Gooderham reported receiving grants (research investigator) and personal fees (speaker, advisory board) from Amgen, AbbVie, Arcutis, Bristol Myers Squibb, Boehringer Ingelheim, Eli Lilly, Galderma, Bausch Health, Janssen, LEO Pharma, Novartis, Pfizer, Regeneron, Sanofi Genzyme, and UCB; grants (research investigator, adviser) from Aslan; and grants (research investigator) from AnaptysBio, Dermira, Incyte, Meiji, Moonlake, Merck, and Reistone outside the submitted work. Dr Levell reported being a past chair of the UK Therapy and Guideline Committee up to July 2022, which has published national guidelines on the topic under review. Dr Hawkins reported receiving grants from L’Oréal and personal fees from AbbVie, LEO Pharma, Sanofi, and Lilly outside the submitted work. Dr Hong reported honoraria and clinical trials from AbbVie, Amgen, Arcutis, Eli Lilly, Boehringer Ingelheim, Bristol Myers Squibb, Dermavant, Galderma, GlaxoSmithKline, Incyte, Janssen, LEO Pharma, Novartis, Pfizer, Regeneron, Sanofi, and UCB outside the submitted work. Dr Kalia reported serving as Sun Awareness Working Group, Canadian Dermatology Association National Chair outside the submitted work. Dr Papp reported receiving grants and personal fees paid to institution from AbbVie, Akros, Amgen, Bausch Health, Boehringer Ingelheim, Celgene, Coherus, Dermavant, Galderma, Kyowa Hakko Kirin, LEO Pharma, Sanofi Genzyme, Sun Pharma, Takeda, UCB, Merck (MSD), Janssen, Novartis, Pfizer, and Eli Lilly; grants paid to institution from Anacor, Arcutis, Avillion, Bristol Myers Squibb, Can-Fite Biopharma, Dermira, Dow Pharma, Evelo, Gilead, GlaxoSmithKline, Incyte, Regeneron, and Roche; and personal fees paid to institution from Acelyrin, Aralez Pharmaceuticals, Celltrion, Dice Pharmaceuticals, Forbion, Meiji Seika Pharma, Mitsubishi Pharma, Reistone, Sandoz, vTv Therapeutics, and Xencor outside the submitted work. No other disclosures were reported.

Funding/Support: This work was conducted by members of the Skin Investigation Network of Canada (SkIN Canada), which provided in-kind support.

Role of the Funder/Sponsor: Members of the Skin Investigation Network of Canada (SkIN Canada) were involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Arani Muthurajah, HBSc, for her assistance with screening articles. She was compensated for these contributions.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.