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PAPERS: Fiona Bath-Hextall, Jan Bong, William Perkins, and Hywel Williams Interventions for basal cell carcinoma of the skin: systematic review BMJ 2004; 329: 705 [Abstract] [Full text]

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Mohs micrographic surgery: the best intervention for basal cell carcinoma of the skin

Joseph Alcalay   (17 September 2004)

Misleading headline

David A Fitzgerald   (30 September 2004)

“Coordination of research”

Kamal M El-Ali   (4 October 2004)

Curettage and Cautery of Basal Cell Carcinomas

Charles P Dupont, Ireland   (15 October 2004)

Systematic reviews require input from specialists with a range of clinical interests

Lesley E. Rhodes, Richard W. Groves   (27 October 2004)

Mohs micrographic surgery: the best intervention for basal cell carcinoma of the skin 17 September 2004
Joseph Alcalay, Dermatologist, Mohs surgeon, Secretary of the European society for micrographic surgery Assuta Medical Center , Tel Aviv Israel Send response to journal: Re: Mohs micrographic surgery: the best intervention for basal cell carcinoma of the skin	Sir I have read with great interest the article by Bath-Hextal et al and would like to mention that Mohs micrographic surgery have been used as the best intervention for BCC in the last 30 Years in the USA and other countries(1). This method of surgery has been performed mainly for BCC of the face and and gives the patient maximal cure and maximal preservation of healthy tissue.This modality has been used also for other types of non- melanoma and melanoma skin cancers.Mohs surgery is also the treatment of choice for recurrent BCC (2).Mohs surgery is performed by a dermatologist who serves as the surgeon the pathologist and the reconstructive surgeon at the same time. Ref. 1.Lang PG Jr. The role of Mohs' micrographic surgery in the management of skin cancer and a perspective on the management of the surgical defect. Clin Plast Surg. 2004 Jan;31(1):5-31. 2.Rowe DE, Carroll RJ, Day CL Jr. Related Articles, Links Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol. 1989 Apr;15(4):424-31. Competing interests: None declared
Misleading headline 30 September 2004
David A Fitzgerald, Consultant Dermatologist Dermatology Centre, Hope Hospital, Salford. M6 8HD Send response to journal: Re: Misleading headline	The headline given to this paper in 'This week in the BMJ' was a misleading misrepresentation of the authors' conclusions. The authors conclude that inadequate research is available on treatment choice for basal cell carcinoma (BCC) but that on this limited evidence surgery and radiotherapy seem to be the most effective treatments. The authors emphasize the lack of evidence for different treatments, not evidence of lack of efficacy. Most effective is not equivalent to most appropriate. BCCs are a very heterogeneous group of tumours and factors such as tumour site, general health and particularly patient preference are important in determining optimum treatment in each individual case. To state that 'BCC should be excised' is an oversimplification and likely to mislead readers. Competing interests: None declared
“Coordination of research” 4 October 2004
Kamal M El-Ali, SHO Interested in plastic surgery Currently between jobs Send response to journal: Re: “Coordination of research”	This article has highlighted that despite genuine efforts, many of the conducted trials (on the most common cancer in humans!) were in general of poor quality. Does the profession bare some responsibility in this? If these trials were better coordinated could they have been be of a better quality? The answer most probably would be yes. Every profession has at least one annual meeting through their society or association, so why not use part of these meetings to discuss the quality of research among the profession? The experts in the field (with members’ contribution) can highlight important areas which need further research and types of studies needed. Candidates who would like to do research can then select from these studies (which from the start have the support and blessing of the profession) rather than just conducting trials which might be of a limited benefits. The advantages of this practice seem obvious for all involved. The criticism might be that this can create a big brother type of research monitoring, and people might feel some how obliged to take studies rather than conduct their own. If the profession develops the right mechanism to avoid these pitfalls, coordination of research can only be a step forward, which will save much precious time, efforts and resources and ultimately improve the quality of research. Competing interests: None declared
Curettage and Cautery of Basal Cell Carcinomas 15 October 2004
Charles P Dupont, Consultant Dermatologist 18 Merlyn Road, Dublin 4, Ireland Send response to journal: Re: Curettage and Cautery of Basal Cell Carcinomas	Dear Sir/Madam Re: Interventions for Basal Cell Carcinoma of the skin: systematic review – Fiona Bath-Hextall, Jan Bong, William Perkins, Hywel Williams – BMJ 2004; 329;705 (25 September) I was sorry to see that this article stated that evidence for curettage and cautery of this tumour is inconclusive. Although recurrence may be more likely and certain types, sites and sizes of tumour are not suitable for this form of therapy it can be very effective with very low morbidity (2). As basal cell carcinoma rarely metastasises (1) and recurrence tends to be local is the latter all that important? Perhaps more attention should be paid to the immunological response to them as recent research has shown (3,4,5). References: 1.Why does basal cell carcinoma metastasise so rarely? Blewett RW Int J Dermatol 1980 19; 144-46 2. Curettage, electrosurgery and skin cancer Sheridan At Dawber PT Australasian Journal Derm 2000 41; 19-30 3. The Use of Toll-like receptor-7 agonist in the treatment of basal cell carcinoma: an overview Stockfleth E, Trefzer U, Garcia-Bartels C, Wegner T, Schmook T et al Br J Dermatol 2003 Nov; 149 Suppl 66: 53-6 4. Imiquimod in basal cell carcinoma: How does it work? Dummer R, Urosevic M, Kempf W, Hoeck K, Hafner J, Burg G. Br J Dermatol 2003 Nov; 149 Suppl 66: 57-8 5. Evaluation of superficial basal cell carcinomas after treatment with imiquimod 5% cream or vehicle for apoptosis and lymphocyte phenotyping Sullivan TP, Dearaujo T, Vincek V, Berman B Dermatol Surg. 2003 Dec: 29 (12): 1181-6 Yours faithfully, Dr. C. Dupont Consultant Dermatologist Competing interests: None declared
Systematic reviews require input from specialists with a range of clinical interests 27 October 2004
Lesley E. Rhodes, senior lecturer in dermatology University of Manchester, Hope Hospital, Manchester M6 8HD, Richard W. Groves Send response to journal: Re: Systematic reviews require input from specialists with a range of clinical interests	EDITOR - Bath-Hexall et al report a systematic review of interventions for basal cell carcinoma in the British Medical Journal1 with a fuller version on the Journal’s website.2 Basal cell carcinomas are extremely common and the incidence continues to rise. Evidence-based treatments are welcomed, to effectively manage this “epidemic”. Traditional management comprises surgery, radiotherapy, cryotherapy, and topical chemotherapy. In recent years, 2 new interventions have shown promise: the topical immunomodulator, imiquimod, and topical photodynamic therapy. All 4 authors of the recent systematic review were based at the same centre and all are actively involved in performing clinical research with imiquimod. Their review comprehensively covers randomised research with this agent and, even though only short term data is currently available, it is flagged prominently in the manuscript abstract. However, the review of the intervention of photodynamic therapy appears less thorough. We recently published a multicenter randomised study comparing topical methylaminolevulinate photodynamic therapy with standard excision surgery, with 2-year follow-up data.3 Comparable clinical clearance rates were found, with significantly better cosmesis and a trend for higher recurrence rates with photodynamic therapy. From Bath-Hexall’s website publication, it is clear that the authors were aware of our full manuscript, since our 7-page publication is cited (reference 34). However, in the manuscript text, reference 34 is dismissed with the sentence, “Four trials in abstract form are not discussed here.34-37” The intervention of photodynamic therapy is not mentioned at all in the Journal abstract, which is an important point of reference for busy clinicians who may have insufficient time to peruse the whole article. The Nottingham group have a great deal of experience in systematic reviews, and we suspect the omission of consideration of our data is an oversight. However, omission of published data, as well as subconscious bias e.g. in trial inclusion criteria, could be minimised by including researchers with a range of special interests in subsequent systematic review panels. Lesley Rhodes senior lecturer in dermatology University of Manchester, Hope Hospital, Manchester M6 8HD lesley.e.rhodes@manchester.ac.uk Richard W Groves professor of dermatology Imperial College of Science, Technology & Medicine, Chelsea & Westminster Hospital, London SW10 9NH Competing interests: LER and RWG received sponsorship from Photocure Ltd for performing a randomised trial comparing methylaminolevulinate photodynamic therapy against excision surgery in nodular basal cell carcinoma.