Energy-Based and Ablative Destructive Therapies Versus Surgical Excision for Primary Basal Cell Carcinoma: A Systematic Review and Meta-Analysis

Abstract

Background: Surgical excision is the reference treatment for basal cell carcinoma (BCC), but energy-based and ablative therapies, including photodynamic therapy, radiotherapy and brachytherapy, laser ablation, electrochemotherapy and curettage-based destruction, are increasingly used.

Objective: To quantify the loss of tumour control and the cosmetic gain of these therapies relative to excision.

Methods: PubMed/MEDLINE, Scopus, Europe PMC and ClinicalTrials.gov were searched from inception for randomised and non-randomised controlled studies comparing these therapies with excision for primary BCC. The primary outcome was treatment failure. Risk ratios (RR) were pooled with Mantel–Haenszel random-effects models, and certainty was graded with GRADE.

Results: Fourteen studies (11 randomised) were included; 12 studies with 1,737 lesions or patients informed the primary outcome. In randomised trials, failure was more frequent after ablative therapy (RR 5.34, 95% CI 2.76 to 10.33; I²=23.3%; moderate certainty). Across all studies the RR was 3.26 (95% CI 1.47 to 7.23; prediction interval 0.27 to 40.00), an absolute excess of 7.6 failures per 100 tumours; heterogeneity (I²=60.3%) was explained by study design. Early failure and late recurrence also increased. Good or excellent cosmesis was more frequent after photodynamic therapy in two trials (RR 1.87, 95% CI 1.54 to 2.26; low certainty), but not after radiotherapy or cryosurgery.

Conclusion: Energy-based and ablative therapies increased the risk of treatment failure five-fold in randomised trials, while photodynamic therapy improved cosmesis. Excision should remain first-line when tumour control is the priority; non-surgical options suit selected thin, low-risk tumours or patients unfit for surgery, with imaging-supported selection and surveillance.