Dear Sir,

This article gives an excellent overview of BCC management but a number of points need to be raised: Mohs micrographic surgery (MMS), a technique developed by Frederic Mohs a general surgeon in the 1930’s is currently limited in the UK, a fact that is recognised by the British Society of Dermatological Surgery and British Association of Dermatologists in their 2011 report 1. The authors state that this is the treatment of choice for lesions of the central face, high risk and recurrent lesions however, issues of access to MMS need to be addressed. Currently in the UK it is anticipated that most Moh’s surgeons on average undertake 3 – 5 cases a weeks1 with access to Mohs currently limited to specialist regional units. Given that 75,000 of the UK population develop BCC’s, one must consider whether training programmes should be widened to include specialities such as Plastic, Oculoplastic and ENT surgery who are commonly involved in post-Mohreconstruction of complex defects. Whilst fellowships in Mohs micrographic surgery are available, these tend to be for the minority and geared to dermatology trainees, improving exposure to this important technique at an early stage may prove pivotal in increasing public access to MMS and allowing simultaneous excisional and reconstructive surgery at the same site. Perhaps the time has come to consider MMS as an interface specialty in itself, taking note from the success of other areas such as hand and breast surgery in bringing together clinicians from different specialist training pathways to provide a common resource in treating patients.
With regards to the mentioned use of photodynamic therapy (PDT), current guidance is that it should not be used for infiltrative or recurrent lesions 2. Guidance on both BCC management and PDT from the British association of Dermatologist suggests its use in patients with primary superficial BCC’s and low-risk nodular BCC’s though in the later situation it is less efficacious than surgery 2,3. Another factor in using PDT that was not mentioned in it that it can be a time consuming process requiring the application of the photosensitising agent for a number of hours before treatment.
Whilst this article presented an excellent overview of common modalities employed in treating basal cell carcinomas, more novel techniques such as vismodegib, the hedgehog signalling pathway inhibitor, were not considered. Approved by the US FDA in January 2012, phase II data has shown promising results in treating patients with both locally-advanced (43% response) and metastatic (30% response) basal cell carcinoma4. However, significant adverse events were noted, of which seven were patient deaths. Furthermore, the cost of implementing vismodegib at an estimated $7,500 (£4700) or $75,000 (£47,000) for a ten-month course (Genentech, Roche Group, USA) may well be prohibitive in allowing widespread use5. Regardless, these areas remain important avenues for exploration, particularly in the specific target group with inoperable disease or those for whom surgery is inappropriate due to the anticipated surgical disfigurement or low cure rate.

Yours Sincerely
Mr Kavan S Johal+, Mr Saif Ramman+, Mr Chidi Ekwobi*

+Core Trainees in Plastic Surgery, *Specialist Registrar (SpR) in Plastic Surgery

References
1. BSDS Mohs Setting Standards Working Group. British Association of Dermatologists working party report on setting standards for Mohs Micrographic Surgery Services. Recommendations of The British Society for Dermatological Surgery and British Association of Dermatologists. November 2011 (final revision 4a AC).
2. Telfer NR, Colver GB, Morton CA; British Association of Dermatologists. Guidelines for the management of basal cell carcinoma. Br J Dermatol. 2008 Jul;159(1):35-48.
3. Morton CA, McKenna KE, Rhodes LE; British Association of Dermatologists. Therapy Guidelines and Audit Subcommittee and the British Photodermatology Group. Guidelines for topical photodynamic therapy: update. Br J Dermatol. 2008 Dec;159(6):1245-66.
4. Sekulic A, Migden MR, Oro AE, Dirix L, Lewis KD, Hainsworth JD, Solomon JA, Yoo S, Arron ST, Friedlander PA, Marmur E, Rudin CM, Chang AL, Low JA, Mackey HM, Yauch RL, Graham RA, Reddy JC, Hauschild A. Efficacy and safety of vismodegib in advanced basal-cell carcinoma. N Engl J Med. 2012 Jun 7;366(23):2171-9.

Competing interests: None declared