Establish intent of treatment

• Curative (most keratinocyte cancer will be cured with simple excision or radiation therapy)
• Palliative

Surgery involves excision with an adequate margin of skin and subcutaneous tissue – usually fat. Margin-control surgery may be considered for some patients. Curettage and diathermy may be an option for some keratinocyte cancers. Referral to a specialist plastic surgeon may be required.

Definitive radiation therapy should be recommended for patients who have declined or have contraindications for conventional surgery, and for cases of persistent, recurrent or advanced keratinocyte cancer where adjuvant radiation can complement surgery to improve control rates.

Adjuvant radiation therapy should be recommended for patients with incompletely excised keratinocyte cancer where re-excision would result in significant morbidity, patients with locally advanced or node-positive disease or patients with neurotropic or recurrent lesions.

Other therapies for SCC in situ and early-stage keratinocyte cancer when surgery is not suitable include curettage and electrocautery, cryotherapy, 5-fluorouracil or imiquimod cream, photodynamic therapy and oral acitretin.

Palliative care

Early referral to palliative care can improve quality of life and in some cases survival. Referral should be based on need, not prognosis. For more, visit the Palliative Care Australia website.

Communication

The lead clinician and team’s responsibilities include:

• discussing treatment options with the patient and/or carer including the intent of treatment as well as risks and benefits
• discussing advance care planning with the patient and/or carer where appropriate
• communicating the treatment plan to the patient’s GP
• helping patients to find appropriate support for exercise programs where appropriate to improve treatment outcomes.

Checklist

Timeframe

Surgery: Patients will usually be having active treatment within a 3 month period.

Radiation therapy: Adjuvant radiation therapy should start as soon as possible once surgical wounds have healed, usually within 4–6 weeks of surgery.

Other therapies: Treatment should start as soon as diagnosis and staging has occurred and the treatment modality becomes available, ideally within 4 weeks of the MDM.