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Presentation

Prevention and Active Surveillance Strategies for Keratinocyte Carcinoma

Description

The talk reviewed prevention and surveillance strategies for keratinocyte carcinoma through case-based examples. For a patient with extensive actinic keratoses and prior facial squamous cell carcinoma, the speaker favored short-course compounded 5-fluorouracil plus calcipotriol, noting strong evidence for reducing future facial/scalp squamous cell carcinomas, good patient preference despite brisk but brief inflammation, and limited evidence for forearm benefit. Other preventive options included non-ablative fractional laser and pulsed dye laser, both supported by retrospective studies suggesting about a 50% reduction in future keratinocyte carcinoma, though cost and lack of insurance coverage are barriers. For patients with multiple prior basal cell or squamous cell carcinomas, oral nicotinamide 500 mg twice daily was highlighted as a low-cost option with randomized trial evidence for reducing combined skin cancer outcomes, real-world data suggesting benefit when started early, and no clear increase in major adverse cardiac events. The talk then discussed less invasive management for low-risk tumors in frail or older patients, including shave saucerization that can sometimes fully remove a low-risk lesion, and active surveillance for carefully selected small, asymptomatic, low-risk basal cell carcinomas in favorable locations with close follow-up. The speaker emphasized shared decision-making, patient preference, tumor risk features, and that monitoring is reasonable in selected cases, especially when life expectancy is limited.

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Conclusions

Short-course compounded 5-fluorouracil plus calcipotriol appears to be an effective and patient-preferred topical chemoprevention strategy for reducing facial squamous cell carcinoma risk in actinically damaged skin.
Laser-based field treatments such as fractionated laser resurfacing, nonablative fractional laser, and pulse dye laser may lower subsequent keratinocyte carcinoma risk, but the evidence is mostly retrospective and the treatments are often not covered by insurance.
Oral nicotinamide 500 mg twice daily likely reduces future keratinocyte cancers while patients are taking it, with the greatest benefit when started early after the first skin cancer.
Available real-world data do not show an increased risk of major adverse cardiovascular events with nicotinamide use.
For carefully selected low-risk, asymptomatic basal cell carcinomas in patients with limited life expectancy or strong preferences to avoid surgery, active surveillance can be a reasonable management option.
Low-risk basal cell carcinomas often grow slowly, many partially biopsied lesions regress or remain stable, and metastasis or death from appropriately selected lesions appears very uncommon.
Shave saucerization or punch removal with narrow clinical margins can sometimes completely remove low-risk nonmelanoma skin cancers with low recurrence rates, making it a viable less-invasive option in selected cases.
If a low-risk lesion is clinically gone after biopsy despite positive histologic margins, close monitoring rather than immediate re-excision can be acceptable in selected patients who understand the tradeoffs.

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