In this video blog, Rebecca Hartman, MD, discusses highlights from her lecture, When To Put Down the Scalpel: Non-Surgical Therapies for Skin Cancer, on July 26, 2024, during the inaugural Elevate-Derm Alliance Summer Conference at the Westin Copley Place in Boston, Massachusetts.

In this video

Dr. Hartman frames non-surgical therapy around "the right treatment for the right patient." Topical therapies are best reserved for superficial cancers — squamous cell carcinoma in situ (SCCIS) and superficial basal cell carcinomas — in patients who agree to de-escalate care and can reliably follow up. She avoids these agents on the eyelid, where they can be toxic to the eye, and in hair-bearing scalp areas. For most patients meeting criteria, a trial of topical therapy is her go-to: it works about 80% of the time, reduces the need for surgery, and can help "clean" an area of field damage where it's hard to know where the lesion starts and stops.

For SCCIS, 5-FU is her preferred treatment, used twice daily for four to six weeks — though she notes this is off-label, as 5-FU is only FDA-approved for superficial basal cell. She turns to it especially when surgery would create a large, morbid defect and when the Mohs appropriate use criteria suggest de-escalating. Active surveillance she reserves for older patients with limited life expectancy, significant comorbidities, and small (under 1 cm), non-aggressive basal cells in non-critical locations. For patients getting "sick of surgery" with numerous NMSCs — five or six a year — she'll consider nicotinamide to reduce their surgical burden.

  • Reserve topical therapy for superficial cancers — SCCIS and superficial BCC — in patients who want to de-escalate; it works about 80% of the time and reduces the need for surgery.
  • 5-FU twice daily for four to six weeks is her preferred (off-label) treatment for SCCIS; it's only FDA-approved for superficial BCC.
  • Avoid topicals on the eyelid (eye toxicity) and hair-bearing scalp; topicals also help clean areas of field damage where lesion borders are unclear.
  • Consider active surveillance for older patients with limited life expectancy and comorbidities who have small (<1 cm), non-aggressive basal cells in non-critical locations.
  • Reliability matters — for both topicals and surveillance, patients must return for follow-up; "if this is the only chance to see them, you should just cut it out."
  • Consider nicotinamide for patients with numerous NMSCs (five or six a year) who want to reduce their surgical burden.