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Treatment Patterns and Clinical Characteristics of Patients with Advanced Basal Cell Carcinoma in the Community Oncology Setting


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Advanced basal cell carcinoma (aBCC) includes metastatic and locally advanced BCC that is inoperable (or with surgery contraindicated). We describe patient characteristics and treatment history for aBCC cases from community oncology. Nine cases of aBCC were found within the ACORN Data Warehouse, a community oncology database of >180,000 cancer patients. Data were summarized descriptively. Three illustrative case histories are presented. Patients were predominantly Caucasian (8/9), male (6/9), and over 60 (6/9). Four had metastatic disease; five had aBCC without metastasis. Five had a history of treatment for early stage BCC, including surgery (5/5), radiation (1/5), and none had chemotherapy. Those with history of early stage BCC had periods of apparent lack of follow-up and treatment. One had chemotherapy for aBCC (platinum based with radiation) and eight had radiation without chemotherapy. Patients had multiple comorbid serious medical conditions. Six were deceased, but only one was documented to have aBCC as cause of death. Advanced BCC is rare in community oncology settings. There appear to be gaps in the care and follow-up of patients with initial early stage BCC. More data and larger samples are needed from multi-specialty databases such as dermatology and head and neck surgery.
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Journal of Cancer Therapy, 2013, 4, 24-31 Published Online July 2013 (
Treatment Patterns and Clinical Characteristics of
Patients with Advanced Basal Cell Carcinoma in the
Community Oncology Setting*
Mark S. Walker1#, Lee S. Schwartzberg2, Diana M. Chen3, D. Devi Ramanan3, Arthur C. Houts1,
Carolina Reyes3
1ACORN Research, LLC, Memphis, USA; 2The West Clinic, Memphis, USA; 3Genentech, Inc., South San Francisco, USA.
Received May 15th, 2013; revised June 18th, 2013; accepted June 25th, 2013
Copyright © 2013 Mark S. Walker et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Advanced basal cell carcinoma (aBCC) includes metastatic and locally advanced BCC that is inoperable (or with sur-
gery contraindicated). We describe patient characteristics and treatment history for aBCC cases from community on-
cology. Nine cases of aBCC were found within the ACORN Data Warehouse, a community oncology database of
>180,000 cancer patients. Data were summarized descriptively. Three illustrative case histories are presented. Patients
were predominantly Caucasian (8/9), male (6/9), and over 60 (6/9). Four had metastatic disease; five had aBCC without
metastasis. Five had a history of treatment for early stage BCC, including surgery (5/5), radiation (1/5), and none had
chemotherapy. Those with history of early stage BCC had periods of apparent lack of follow-up and treatment. One had
chemotherapy for aBCC (platinum based with radiation) and eight had radiation without chemotherapy. Patients had
multiple comorbid serious medical conditions. Six were deceased, but only one was documented to have aBCC as cause
of death. Advanced BCC is rare in community oncology settings. There appear to be gaps in the care and follow-up of
patients with initial early stage BCC. More data and larger samples are needed from multi-specialty databases such as
dermatology and head and neck surgery.
Keywords: Advanced Basal Cell Carcinoma; Community Oncology; Treatment Patterns; Observational Study; Long
Term Follow Up
1. Introduction
Basal cell carcinoma (BCC) accounts for approximately
80% of nonmelanoma skin cancers [1]. Based on limited
evidence from 2006, the incidence of basal cell and squa-
mous cell skin cancer may be as high as 3.5 million cases
annually [2]. The incidence is difficult to estimate because
skin cancers are typically not tracked by cancer registries
Basal cell carcinoma metastasizes only rarely, with es-
timates of about 0.1% of cases [3]. Median survival in
metastatic basal cell carcinoma is reported to be about 8 -
14 months [4-7]. The biological characteristics of BCCs
that may predispose some of these cancers to behave ag-
gressively or become metastatic are not well understood,
[8] and recent investigations failed to identify immuno-
histochemical markers that distinguished metastatic and
nonmetastatic BCCs [9]. Although a limited number of
cases have been reported in the literature, [10] metastatic
BCC is most often treated with combination chemother-
apy; however, there have been no clinical trials evaluat-
ing chemotherapy [11,12]. Newer targeted therapies bas-
ed on inhibition of the hedgehog pathway have shown
promise in early trials [13,14]. On January 30, 2012, vis-
modegib was approved for the treatment of adults with
metastatic basal cell carcinoma, or locally advanced BCC
that has recurred following surgery or who are not can-
didates for surgery, and who are not candidates for radia-
tion [15].
*Funding Source: The study reported in this paper was funded by
Genentech, Inc., South San Francisco, CA, USA.
Conflict of Interest Statement: LSS is on the speakers’ bureau for
Genentech. DMC and CR are currently employed by Genentech, and
DDR was previously employed by Genentech. MSW and ACH report
that they have no conflicts to disclose.
Prior Presentation: Poster presentation at the 70th Annual Meeting o
the American Academy of Dermatology.
#Corresponding author.
Copyright © 2013 SciRes. JCT
Treatment Patterns and Clinical Characteristics of Patients with Advanced
Basal Cell Carcinoma in the Community Oncology Setting 25
Nonmetastatic BCC may be treated with electrodessi-
cation and curettage [16], surgical excision, or with Mohs
micrographic surgery [17,18]. Patients with lesions that
are not surgically accessible, or who have recurrent le-
sions, may be treated with radiation therapy [19,20]. Pa-
tients with locally advanced or otherwise inoperable ba-
sal cell carcinoma may be viewed as higher risk, and can-
didates for chemotherapeutic intervention [21].
The incidence of metastatic BCC is very low. The rate
of advanced or inoperable BCC is also rare but accurate
incidence rates are not available. Most nonmelanoma
skin cancers are treated outside medical oncology prac-
tices, a limitation of this analysis. As a result, patient sam-
ples available within typical community oncology prac-
tices are very small, and understanding of treatment pat-
terns and outcomes in this population is correspondingly
limited [22].
This study was a retrospective investigation to exam-
ine the patient characteristics, treatment patterns, and dis-
ease course of patients with advanced basal cell carcino-
ma (aBCC) treated in the community oncology setting.
2. Patients and Methods
2.1. Patients
Patients were eligible for this investigation if they were
found during review to have had aBCC at any point from
January 1, 2004 to November 1, 2010. Advanced BCC
was defined as meeting either of two criterion based de-
finitions: 1) locally advanced (i.e., American Joint Com-
mittee on Cancer [AJCC] Stage III) BCC [23] where per
the medical record the patient was declared inoperable or
where surgery was declared to be contraindicated, with
receipt of radiation therapy unless radiation was contra-
indicated; or 2) metastatic BCC.
To be included, the patient had to be 18 years old or
older and have received treatment at a community onco-
logy practice affiliated with ACORN Research, LLC
(Memphis, TN). Potentially eligible patients were identi-
fied through electronic search of patients with a diagno-
sis of BCC (ICD-9 173.xx) within the ACORN Data
Warehouse, a repository containing records for 180,000
patients from 10 participating community practices in 10
states (CO, DE, GA, MD, MI, MS, MT, NC, OH, TN).
Final eligibility was established through medical record
review by experienced clinical research nurses who ap-
plied the aforementioned inclusion criteria defining aBCC
case status.
2.2. Study Design
This study was a non-interventional study involving ret-
rospective review of existing data collected as part of
routine care. No direct patient contact occurred as part of
this retrospective study.
The primary objective of this study was to describe the
patients and treatment patterns observed from oncology
medical records of aBCC patients treated in the commu-
nity oncology setting. Given the low prevalence of aBCC,
results were expected to be limited to a small number of
patients. Reporting was therefore planned to include il-
lustrative cases of three case types: 1) aBCC patient with
history in the medical record of previous early stage dis-
ease prior to advanced disease; 2) aBCC patient without
metastasis; 3) aBCC patient with metastasis. All study
procedures were approved by IntegReview Institutional
Review Board (Austin, TX).
2.3. Study Measures
Basic demographic characteristics were collected, inclu-
ding age at initial diagnosis of BCC, sex, and race. Dis-
ease characteristics included date and AJCC stage of ini-
tial BCC diagnosis, status as metastatic vs. nonmetastatic,
location and size of lesions, and sites of metastasis among
metastatic patients. Assessment of treatment patterns in-
cluded history and dates of surgical treatments, radiation
therapy, and chemotherapy prior to diagnosis of advan-
ced disease and after diagnosis of aBCC. For chemothe-
rapy treatment of aBCC, name of drug, dose and sched-
ule were recorded. The specialty of providers was col-
lected where available to infer whether patients recei-
ved Mohs micrographic surgery, surgical excision, or ra-
diation therapy. Comorbid conditions and performance
status were also collected. The comorbid conditions that
were documented included those assessed as part of the
standard Charlson Comorbidity Index [24]. In addition,
dates of each disease progression, date of death, and
cause of death were assessed.
2.4. Procedures
Screening procedures used to identify possible cases in-
cluded identification of cases with ICD-9 diagnosis codes
for non-melanoma skin cancer (173.xx) and the use of
words or phrases (“BCC,” “basal cell”) indicative of ba-
sal cell carcinoma in searchable text within medical re-
cords. Screening required direct examination of each me-
dical record, with electronic search within the record for
text references to BCC, and review of the context of
those references. Pathology records were also reviewed
where available. The screening process ruled out cases of
early stage BCC and references to personal or family
history of BCC without any reference to the criteria that
defined aBCC. These screening procedures resulted in
identification of patients who met the aforementioned
definition of aBCC used in this study.
Copyright © 2013 SciRes. JCT
Treatment Patterns and Clinical Characteristics of Patients with Advanced
Basal Cell Carcinoma in the Community Oncology Setting
2.5. Statistical Methods
Statistical reporting was entirely descriptive, and inclu-
ded percentages, means, and standard deviations to des-
cribe the patient and disease-related characteristics.
3. Results
An initial screening list of over 1000 cases was created
using ICD-9 codes and text references suggesting BCC.
Following manual review of 1020 cases, nine patients
with aBCC were identified within the ACORN Data Ware-
house, and this represents the final study sample. Figure
1 presents a diagram showing reasons for screen failure.
As shown, most cases were screen failures because of a
personal history of BCC without evidence of locally ad-
vanced disease.
Table 1 shows demographic characteristics of the nine
patients with aBCC. Average age at initial diagnosis of
BCC was 61 years with a 2:1 ratio of males to females.
Most patients were Caucasian, but race was not known
for one patient. Text search of the record was used to
identify indications of performance status impairment;
however, formal performance status ratings were gener-
ally not available. None of the patients were impaired at
the time of their aBCC diagnosis.
Table 2 shows disease and clinical characteristics for
the nine patients with aBCC. Four of the nine patients
were initially diagnosed with disease that was already
locally advanced or metastatic, and had no history of
prior treatment for BCC. The remaining five were diag-
nosed at an earlier stage, but specific stage was recorded
in the medical records for only two of these patients (one
each at AJCC stage I and II) [23]. The mean interval be-
tween the first record of BCC to diagnosis of aBCC in
these patients was 6.9 years, with a range of less than one
year (two patients) to more than 13 years (two patients).
Four patients were classified as aBCC due to metas-
tatic disease, and the other five had locally advanced but
nonmetastatic disease. Only two of the five locally ad-
vanced, nonmetastatic patients had a prior history of
early stage disease. In contrast, three of the four metas-
tatic patients were originally diagnosed and treated with
early stage disease. Histopathological types were not
available for one of the metastatic and one of the nonme-
tastatic aBCC cases. Otherwise, the most common types
were infiltrating (3/9) and nodular (2/9).
Two-thirds of the patients had at least one significant
comorbidity. Diabetes was the most prevalent, observed
in three patients. This was followed in prevalence by
chronic obstructive pulmonary disease, renal disease, and
stomach ulcer with two patients each. Four patients had
other cancers, including one bladder cancer, one colo-
rectal cancer, and two patients with lung cancer. These
1020 screened as
potentially eligible
Personal history; not
advanced or no specific
information: 686
Not >18 years: 2
Family history; no
personal history: 175
Locally advanced but
operable: 146
1018 remain
843 remain
11 remain
157 remain
9 accrued
documentation for
accrual: 2
Figure 1. Basal cell carcinoma. Diagram of screening and
Table 1. Demographic characteristics of advanced basal cell
carcinoma patients (aBCC).
Demographic characteristics N (%)
Age in years; Mean (SD); Range 61.10 (13.33); 39 - 78
Male 6 (66.7%)
Female 3 (33.3%)
Caucasian 8 (88.9%)
Unknown/Not documented 1 (11.1%)
Performance status
Impaired* 0 (0%)
Not indicated as impaired 9 (100%)
*ECOG 2+ or text indication of impairment equivalent to ECOG 2+.
Copyright © 2013 SciRes. JCT
Treatment Patterns and Clinical Characteristics of Patients with Advanced
Basal Cell Carcinoma in the Community Oncology Setting 27
Table 2. Disease and clinical characteristics of advanced ba-
sal cell carcinoma patients (aBCC).
Disease and clinical characteristic N (%)
Stage at initial presentation
Early stage BCC 5 (55.6%)
Locally advanced or metastatic (aBCC) 4 (44.4%)
aBCC Status and Histopathology Type
Metastatic 4 (44.4%)
No subtype reported 1
Infiltrating 2
Poorly differentiated BCC 1
Locally Advanced, not metastatic 5 (55.6%)
No subtype reported 1
Positive for BCC no other reported 1
Nodular 2
Infiltrating 1
Years from initial BCC to aBCC;
Mean (SD); Range* 6.9 (6.7); 0.8 - 14.8
Comorbidities within aBCC sample
Number of patients with at least 1 comorbidity 6 (66.7%)
Chronic obstructive pulmonary disease 2 (22.2%)
Congestive heart failure 1 (11.1%)
Diabetes 3 (33.3%)
Peripheral vascular disease 1 (11.1%)
Renal disease 2 (22.2%)
Stomach ulcer 2 (22.2%)
*Among five patients diagnosed initially with early stage BCC.
four patients included three who did not have a record of
any other specific comorbidity. Taken together, the co-
morbid disease and other cancer burden reflect a patient
sample with very serious health problems, apart from
Table 3 shows the modalities of treatment for the
subset of five patients who had records of early stage
disease and for the entire sample of nine patients treated
during the course of aBCC. Among the five patients who
were treated during early stage disease, none received
chemotherapy, one received radiation therapy, and all
five had surgery. Documentation in the oncology medical
record did not specify whether any of these were Mohs
surgery. All five of these patients necessarily experi-
enced progression to aBCC, since inclusion criteria re-
quired this. Only one of the nine patients with aBCC re-
Table 3. Treatment modalities during early stage disease
and during advanced basal cell carcinoma.
Type of treatment Early stage disease
(N = 5) aBCC (N = 9)
Chemotherapy, n (%) 0 (0%) 1 (11.1%)
Radiation treatment, n (%) 1 (20.0%) 9 (100%)
Surgical treatment, n (%) 5 (100%) --
Note: Only 5 patients had treatment of Early Stage Disease and all progres-
sed to advanced basal cell carcinoma (aBCC).
ceived chemotherapy. That patient was treated with che-
moradiation, including cisplatin and paclitaxel weekly for
eight weeks, with a single dose of carboplatin at the end.
After 21 month follow-up, this patient did not have dis-
ease progression following the chemoradiation treatment.
Among the eight patients who did not have chemother-
apy, four developed disease progression. As shown in
Table 3, all nine aBCC patients received radiation ther-
apy in the aBCC setting, including the afore-mentioned
chemoradiation treatment. Some patients received se-
quential radiation therapy to different lesions. Two pa-
tients received radiation therapy that was described as
palliative, and one of these received only palliative radia-
tion therapy in the aBCC setting.
Illustrated in Table 4 is a mortality table for all nine
patients. Death status was determined from the clinical
record and with Social Security Death Index. Three of
the nine were still living at the close of the study. Among
the six who were deceased, only one had a cause of death
likely attributable to BCC. Two patients died due to lung
cancer or likely due to lung cancer. Three patients had
cause of death that was unknown or unstated in the avai-
lable records.
Case Examples
History of Previous Early Stage Disease Prior to aBCC
(ID #8). This patient was a white male diagnosed with a
right temporal BCC in 2008 at the age of 63. The patient
was reported in the medical record to have had chronic
obstructive pulmonary disease and a history of renal dis-
ease. His ECOG performance status was reported as 0.
The size and AJCC staging of the initial BCC lesion was
not reported in the available medical record. This lesion
was resected, and the patient received radiation therapy.
The original pathology was not available, and no histo-
logical information was reported in the record. The pa-
tient then presented 10 months after initial presentation
with swelling in his right neck. A biopsy was performed
of the parotid and jugular lymph nodes and was consis-
tent with metastatic BCC, infiltrating type. The parotid
lymph node metastasis was reported as 2 cm. The size of
Copyright © 2013 SciRes. JCT
Treatment Patterns and Clinical Characteristics of Patients with Advanced
Basal Cell Carcinoma in the Community Oncology Setting
the jugular lymph lesion was not reported. The patient
had gross resection of the parotid lymph node and two
jugular chain nodes. He also received chemoradiation
with chemotherapy consisting of cisplatin/paclitaxel for
an eight week period beginning at month 11. He received
carboplatin/paclitaxel for the last treatment. A computer-
ized tomographic (CT) scan was performed at month 14,
and compared with a CT scan done at month 9, prior to
the chemoradiation. The scan findings were “unremark-
able” and “normal”. There was no evidence of patholo-
gically enlarged adenopathy in the neck. The scan re-
port did not reference any evidence of disease. A follow-
up progress note cited “no evidence of recurrence … [the
patient] having had gross resection of the disease in the
parotid region and having completed definitive chemora-
diation to the parotid lymph node region and neck.” The
patient was last seen at month 34 and was stable. There
was no record of the patient’s death.
Advanced Basal Cell Carcinoma without Metastasis
(ID #1). The patient was a white female, first diagnosed
with BCC in 1990 at the age of 64. Her medical oncol-
ogy chart begins in 2001, when she was diagnosed with
early stage colon cancer. The patient had a history of con-
gestive heart failure and diabetes. Although the patient’s
oncology chart begins in 2001, there was no mention of
her history of BCC at this point. Instead, the first note
related to BCC was a pathology report dated in 2005.
This pathology report mentioned BCC recurrence of the
right scalp, extending to margins of resection. There were
no additional histopathology findings in the report. The
medical oncologist’s notes did not address the BCC until
about month 6 after the pathology note, when the medi-
cal record stated that the patient had a 15-year history of
right scalp BCC with five resections, according to the pa-
tient, and recurrences. The dates of the resections were
not reported, and the specialties of the providers who
performed the resections were also not reported. This
BCC, which had grown to 12 × 18 cm, was considered
locally advanced BCC. The medical oncologist stated in
this note that the lesion was now too large to be resected
with local anesthesia, and that the patient was unable to
have general anesthesia due to her heart disease. She was
a candidate for radiotherapy, which she received to her
right scalp for five weeks beginning month 7. The patient
did not receive any chemotherapy for her BCC. At the
patient’s follow-up visit at month 9, about one month fol-
lowing the completion of radiotherapy, the medical on-
cologist stated that the lesion was healing nicely and in-
structed her to follow-up with her dermatologist. The pa-
tient continued to be followed for her colon cancer with-
out any further mention of the BCC. The patient was last
seen in 2008, at month 33, and this note addressed her
colon cancer only. There was no record of death in the
patient’s oncology chart, but she died at month 53 ac-
cording to the Social Security Death Index, at about age
83. No information regarding cause of death was avail-
Advanced Basal Cell Carcinoma with Metastasis (ID
#9). This was a male patient, race unspecified, who was
diagnosed with metastatic BCC of the left ear extending
to the left temporal bone in 2009 at the age of 75. The
patient was reported in the medical record to have chro-
nic obstructive pulmonary disease, a history of renal dis-
ease, and ulcer disease. The patient’s history also includ-
ed a possible cardiovascular accident. No histopathology
was available. The patient’s initial BCC was AJCC stage
IV according to the chart record, and the patient received
radiation therapy, ending at about month 3 after initial di-
agnosis. The duration of the radiation therapy was not re-
ported. No chemotherapy was given. The patient did well
until about month 6 when a follow-up magnetic reso-
nance imaging (MRI) study showed metastases of the C4
and T1 vertebral bodies. A biopsy of the T1 lesion re-
vealed metastatic, poorly differentiated BCC. No treat-
ment was given at this time. A bone scan at month 8 re-
vealed metastatic tumor in three portions of the skull, the
cervical spine and upper thoracic spine. The patient then
received three weeks of radiation therapy to his spine.
The medical oncologist considered chemotherapy but de-
cided against this due to the patient’s lack of symptoms.
The patient had a follow-up MRI at month 12 that reveal-
ed a tumor in the lateral wall of the left orbit. He received
radiation therapy to this area, ending at month 13. The
last note in the chart was dated at month 14 when the pa-
tient was instructed to have a follow-up MRI in two
months. The medical oncologist discussed the possibility
of chemotherapy if the patient developed systemic dis-
ease not amenable to palliative radiation therapy. There
were no other notes in the chart. The chart did not docu-
ment a cause of death, but the patient was reported by
Social Security Death Index to have died at about month
4. Discussion
Advanced basal cell carcinoma is rare and information
about its treatment in the community setting is limited.
We were able to identify only nine such cases in a com-
munity oncology data warehouse of 180,000 patients. Six
of those nine were deceased. Precise causes of death
among the six deceased patients were not well documen-
ted; in only one case of the six was there any reference to
BCC as the cause of death. Two-thirds of the patients
were over 60 years old and had a variety of other medical
conditions, including other cancers, indicating generally
poor health. Selection of cases from medical oncology
Copyright © 2013 SciRes. JCT
Treatment Patterns and Clinical Characteristics of Patients with Advanced
Basal Cell Carcinoma in the Community Oncology Setting
Copyright © 2013 SciRes. JCT
practices may have biased the sample toward patients
with other cancers, however.
Five of the nine patients had a history of BCC prior to
developing aBCC, and the oncology medical records often
lacked detail regarding the history of treatment of the
early stage disease. AJCC staging for BCC is not rou-
tinely used in other specialties such as dermatology. There
is a lack of universal staging criteria and accordingly this
contributes to the challenges in identifying aBCC cases.
Information regarding location and size of lesions at ini-
tial presentation was incomplete and reasons for lack of
follow-up were often unclear. The extent to which the
lack of information in the oncology record was due to the
patient or physician is also unclear. For example, in the
case study illustration of aBCC that was not metastatic
(ID #1), the patient had a long history of BCC prior to
aBCC. Even though the patient reported a history of five
previous BCC resections to the scalp, it appears that in-
formation on the recurrent BCC on the scalp had not been
captured over the course of a four-year period when he
was being followed in medical oncology for colon cancer.
In another case (ID #4 in Table 4), a patient had a 15-
year history of BCC that included two resections, one
due to recurrence, but at the time the patient was seen for
advanced disease, the patient had neglected or was un-
aware of a second recurrence for over two years. In yet
another case (ID #3), a patient observed a lesion on his
face growing to a size of 3 × 5 cm over a period of 8
years, yet the patient sought treatment only after the le-
sion began to itch.
It is unclear why patients may wait long periods of
time before seeking the attention of medical profession-
als, or why when care is sought that recurrent disease is
missed. It is possible that given the multiple medical
conditions of these patients, that patients and physicians
do not place a high degree of attention to skin cancer.
Efforts to educate the public about the dangers of skin
cancer have been fairly recent, and it is possible that
there are cohort effects in that those who develop aBCC
have never received such education. The treatment course
in aBCC needs to be examined in larger data sets that
include multiple specialties that treat BCC to better un-
derstand this patient population and the evolution of their
BCC care over the long term.
This study was limited by the small number of patients
identified. There simply may be a small proportion of all
aBCC patients who are treated in community oncology
practices as opposed to other settings. An additional li-
mitation was that medical records available were limited
to those within the medical oncology practice. As a result,
detailed records regarding earlier treatment, including
surgery, were lacking. Further, because patients were se-
lected from among those seen in medical oncology prac-
tices, there may have been a bias toward selection of
cases with other cancers. Although such a selection bias
may have been present, it is also important to note that
our sample was demographically similar to another larger
community oncology sample in being predominantly
male, over 60 years old, and with significant comorbidi-
ties [22].
Although we identified these cases from a repository
of 180,000 patients, there is clearly a need to have richer
sources of information about aBCC. This may be achie-
vable with larger samples where both claims data and
Table 4. Mortality table for nine aBCC patients.
ID aBCC status Age at initial dx Sex Deceased Cause of death Other disease burden Years to end of
1 LA 64 F Y Unknown Colon cancer, CHF, diabetes 4.48
2 LA 71 M Y Lung cancer Lung cancer 3.22
3 LA 61 M Y Not stated Bladder cancer 0.97
4 LA 50 F Y Implied BCC High blood pressure 2.49
5 LA 39 F N -- Diabetes, ulcer disease 0.5
6 Met 47 M Y Possibly lung cancer Lung cancer, metastatic 7.5
7 Met 78 M N -- Diabetes, peripheral vascular
disease, history of CABG 2.96
8 Met 63 M N -- COPD, history of renal disease 2.04
9 Met 75 M Y Unknown COPD, history of renal disease,
ulcer disease 1.46
Note. Three patients remained alive at the time of record inspection. Years to end of observation = total time under observation from aBCC diagnosis until
death or censoring. Abbreviations used: LA (Locally advanced), Met (Metastatic), CHF (congestive heart failure), CABG (coronary artery bypass graft), COPD
chronic obstructive pulmonary disease), Dx (diagnosis), N (No), Y (Yes). (
Treatment Patterns and Clinical Characteristics of Patients with Advanced
Basal Cell Carcinoma in the Community Oncology Setting
detailed medical histories can be combined to identify
cases from multiple treatment settings.
As new treatments become available in the emerging
era of targeted therapies, it is important to understand the
history and patterns of treatment in such poorly described
cancers as advanced BCC so that both patients and pro-
viders can fully appreciate the impact of future treat-
5. Acknowledgements
ACORN wishes to express its appreciation for the par-
ticipation of the practices and patients whose data were
used in this study. The authors also acknowledge the con-
tribution of Jiandong Kerr, MS, ACORN Research, who
performed the statistical analyses for this paper. Mr. Kerr
has no pertinent conflicts of interest to disclose.
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Full-text available
Mutations in hedgehog pathway genes, primarily genes encoding patched homologue 1 (PTCH1) and smoothened homologue (SMO), occur in basal-cell carcinoma. In a phase 1 clinical trial, we assessed the safety and pharmacokinetics of GDC-0449, a small-molecule inhibitor of SMO, and responses of metastatic or locally advanced basal-cell carcinoma to the drug. We selected 33 patients with metastatic or locally advanced basal-cell carcinoma to receive oral GDC-0449 at one of three doses; 17 patients received 150 mg per day, 15 patients received 270 mg per day, and 1 patient received 540 mg per day. We assessed tumor responses with the use of Response Evaluation Criteria in Solid Tumors (RECIST), physical examination, or both. Molecular aspects of the tumors were examined. The median duration of the study treatment was 9.8 months. Of the 33 patients, 18 had an objective response to GDC-0449, according to assessment on imaging (7 patients), physical examination (10 patients), or both (1 patient). Of the patients who had a response, 2 had a complete response and 16 had a partial response. The other 15 patients had either stable disease (11 patients) or progressive disease (4 patients). Eight grade 3 adverse events that were deemed to be possibly related to the study drug were reported in six patients, including four with fatigue, two with hyponatremia, one with muscle spasm, and one with atrial fibrillation. One grade 4 event, asymptomatic hyponatremia, was judged to be unrelated to GDC-0449. One patient withdrew from the study because of adverse events. We found evidence of hedgehog signaling in tumors that responded to the treatment. GDC-0449, an orally active small molecule that targets the hedgehog pathway, appears to have antitumor activity in locally advanced or metastatic basal-cell carcinoma. ( number, NCT00607724.)
The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.
Basal cell carcinoma (BCC) is the most common cutaneous skin malignancy. BCC generally has a clinical course characterized by slow growth, minimal soft tissue invasiveness, and a high cure rate. Occasionally, however, BCC behaves aggressively with deep invasion, recurrence, and potential regional and distant metastasis. Several factors, including tumor size, duration, histology, and perineural spread, have been postulated as markers of the aggressive BCC phenotype. It is undetermined whether intrinsic biological factors within certain subsets of BCC predispose these tumors toward an inherently aggressive behavior, or whether any BCC with inadequate early management may assume this phenotype. Review of the pertinent literature on this topic suggests that both intrinsic biological factors and extrinsic management factors play a role in the development and progression of aggressive BCC.
The Hedgehog (Hh) signaling pathway is critical for cell growth and differentiation during embryogenesis and early development. While it is mostly quiescent in adults, inappropriate reactivation of the Hh pathway has been shown to be involved in the development of cancer. A number of tumor types rely on overexpression of Hh ligands to activate the pathway in a paracrine manner from the tumor to the surrounding stroma. Alternatively, Hh ligands may act on cancer stem cells in some hematopoietic cancers, such as chronic myelogenous leukemia. However, the role of the Hh pathway is best established in tumors, such as basal cell carcinoma and medulloblastoma, where the pathway is activated via mutations. Understanding the contribution of Hh signaling in these various tumor types will be critical to the development and use of agents targeting this pathway in the clinic. We review here the activity of clinical inhibitors of the Hh pathway, including GDC-0449, a small molecule inhibitor of Smoothened (SMO).
The skin overlying the nose cartilage is a particularly frequent localization of skin carcinoma (about 25% of all carcinomas occurring on the head and neck). It is therefore of great practical interest to identify the best therapy, able to combine effectiveness with a good cosmetic and functional result. To verify both the therapeutic effectiveness of dermatologic radiotherapy and its 'toxicity' in the treatment of a large number of skin carcinomas overlying the cartilage of the nose. A retrospective study was done on 671 basal and squamous cell carcinomas treated by kilovoltage radiotherapy in the period 1972-2007. The mean follow-up time was 38.016 months (range, 1-351 months). The 5-year cure rate was 88.09%. Cosmetic results were evaluated as 'good' or 'acceptable' in 96.84% of the treated lesions in complete remission. So far, no complication or sequelae to the radiologic treatment have been observed. Dermatologic radiotherapy showed to be a safe, effective and non-invasive method, superior, on the basis of the literature data, to any other available therapeutic modality in the management of basal and squamous cell skin carcinomas localized over the nasal cartilages.
Metastatic basal cell carcinoma was found in 12 patients at the University of Wisconsin Mohs Surgery Clinic during the period 1936 to 1989. All patients were white men. The time of onset of the primary tumor ranged from childhood to 71 years. Eleven patients had previous treatment for basal cell carcinoma; two patients had received x-ray radiation to the face for teenage acne. The locations of the primary basal cell carcinomas were the face (n = 10), back (n = 1), and arm (n = 1). The primary tumors ranged from 3.6 x 3.0 to 20.0 x 7.0 cm. The interval from onset to the first sign of metastases ranged from 7 to 34 years. In all cases, the primary tumor was histologically identical to the metastatic lesion. Perineural extension of the basal cell carcinoma in the primary lesion was found in five cases. Regional lymph nodes were the most frequent site of metastasis. Treatment consisted of a combination of surgery, radiation, and chemotherapy. Only two patients survived more than 5 years after surgical treatment. One patient has survived 25 years and is still alive.
A case of long-term survival with metastatic basal cell carcinoma to regional lymph nodes is presented. The literature has been briefly reviewed. When a metastatic basal cell carcinoma is discovered, the average survival is only 8 to 10 months. The patient in this case report has been followed for 10 years from the initial metastatic discovery and 7 years from the last metastatic surgery by one of the authors. There has been no evidence of recurrent disease. The topic of metastatic basal cell carcinoma is detailed in this report.
A total of 339 consecutively treated, biopsy proven squamous and basal cell carcinomas of the skin treated from January 1966 to December 1986 were retrospectively analyzed to determine the patterns of local recurrence. There were 242 basal cell carcinomas, 92 squamous cell carcinomas, and 5 variants of squamous cell carcinoma in various locations. Radiotherapy was the initial treatment modality in 212 patients and 127 were treated after failing initial surgical excision. Lymph nodes were involved in patients (.4%) with basal cell carcinoma, patients (15%) with initially treated squamous cell carcinoma, and (39%) with recurrent squamous cell lesions. Distant metastasis was found in one patient. Superficial X rays were given to 187 patients, electrons to 57 patients, megavoltage photons to 15, and a combination of modalities to the remainder. Overall local tumor control was achieved in 292 of 339 patients (86%), 220 of 242 (91%) with basal cell and 73 of 97 (75%) with squamous cell carcinoma. Tumor control was closely related to the size of the primary lesion. For lesions < 1 cm tumor control was 97% ( ) for basal cell and 91% ( ) for squamous cell carcinoma. For 1 to 5 cm, tumor control was 87% ( ) for basal cell and 76% ( ) for squamous cell carcinoma and for lesions greater than 5 cm, the tumor control was 87% (13 of 15) and 56% ( ), respectively. Tumor control was related to the modality used to treat the patient in spite of stratification of primary lesion size. For superficial X rays, tumor control was 98% ( ) for lesions < 1 cm, 93% ( ) for lesions 1–5 cm and 100% ( ) for lesions greater than 5 cm. For electrons tumor control was 88% ( ), 72% ( ), and 78% ( ), respectively. For mixed beams tumor control was 90% ( ), 76% ( ), and 64% ( ), respectively, and for ⁶⁰Co-4 MV X rays, tumor control was 100% ( ), 67% ( ), and 33% ( ), respectively.