The definitive treatment of primary keratinocyte cancer involves complete excision of the skin and subcutaneous tissue – usually fat. Margin-control surgery may be offered to some patients for removing keratinocyte cancers with a high risk of recurrence or metastasis, or to maximise skin preservation (e.g. around the lips, nose or eyes). Curettage and diathermy may be an option for some keratinocyte cancers. Referral to a specialist plastic surgeon may be required.

Most clinically favourable BCCs can be excised with a margin of 2–3 mm, with a very high chance of achieving complete excision and long-term control. While a margin of 0.5 mm may be adequate for a well-defined (nodular) BCC, an aggressive form of BCC would require a wider margin of 3–5 mm.

The recommended surgical margin of excision for SCC varies from 2 mm to 10 mm. For SCCs with poor prognostic features, even wider margins may be necessary (Cancer Council Australia Keratinocyte Cancers Guideline Working Party 2019). If there is any concern about margins, consider a discussion with a pathologist and referring for adjuvant radiotherapy if re-excision is not possible.

Timeframe for starting treatment

Patients will be prioritised depending on their particular tumour type and extent but will usually be having active treatment within a three-month period.

Training and experience required of the surgeon

Surgeons must have training and experience of this standard:

• Fellow of the Royal Australian College of Surgeons or Fellow of the Australasian College of Dermatologists (or equivalent) with adequate training and experience that enables institutional credentialing and agreed scope of practice in keratinocyte cancer
• adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

Documented evidence of the surgeon’s training and experience, including their specific (subspecialty) experience with keratinocyte cancer and procedures to be undertaken, should be available.

Health service characteristics

To provide safe and quality care for patients having surgery, health services should have adequate equipment and staff availability appropriate to the complexity of surgery being performed. Critical care support may be required.