Basal cell carcinoma (BCC) is a common form of skin cancer. Exposure to ultraviolet radiation and ionizing radiation increases the risk of developing BCC. People with certain genetic conditions, like Gorlin Syndrome, are also at increased risk for BCC.
BCC is less likely to metastasize than other types of skin cancer and generally has a good prognosis. Primary treatment of BCC involves surgical removal with appropriate margins. Radiation therapy may also be considered as a primary treatment option or as an adjuvant treatment for some patients. Options for radiation therapy include image-guided radiation therapy (used with intensity-modulated radiation therapy, proton beam radiotherapy, or 3D conformal radiation) and isotype-based brachytherapy.
In today's side-by-side comparison, we look at the latest clinical practice guidelines from the American Academy of Dermatology (AAD), the American Society for Radiation Oncology (ASTRO), the National Comprehensive Cancer Network (NCCN), and the Consensus of Physician Experts (CPE) on BCC.
The focus of this article is radiation therapies for BCC. We encourage you to review the full guidelines found at the links below for more helpful information on this topic.
Guidelines for Comparison
| Item | Guidelines of Care for the Management of Basal Cell Carcinoma | Definitive and Postoperative Radiation Therapy for Basal and Squamous Cell Cancers of the Skin | Basal Cell Skin Cancer | Clinical Practice Guidelines for the Management of Basal Cell Carcinoma in Gorlin Syndrome |
|---|---|---|---|---|
| Authoring Society | American Academy of Dermatology | American Society for Radiation Oncology | National Comprehensive Cancer Network | Consensus of Physician Experts |
| Publication Date | March 2018 | December 2019 | September 2025 | October 2025 |
| Graded Recommendations | Yes | Yes | Yes | Yes |
| Links | Summary / Full Text | Summary / Full Text | Full Text | Summary / Full Text |
Key Takeaways
While all four of these articles address treatment for BCC the scope of the recommendations are quite different. The NCCN article is the most comprehensive of the four offering guidance in both diagnosis and management of BCC. The ASTRO guideline makes recommendations only for radiation therapy for both BCC and squamous cell carcinoma (SCC). The AAD guideline is meant to support dermatologists providing office-based treatment for BCC and only offers basic guidance for more advanced and/or metastatic disease. The CPE article is the most specific, addressing management of BCC only in patients with Gorlin Syndrome.
Patient Selection for Radiation Therapy (RT)
- AAD recommends considering other therapy options for patients with low-risk tumors who can not have surgery or prefer not to have surgery. This includes topical and radiation therapies.
- AAD and ASTRO recommend adjuvant radiation therapy for metastatic disease that is limited to the regional lymph node basin.
- ASTRO and NCCN recommend definitive radiation therapy for patients who are not undergoing surgery for BCC either because they are unable to or prefer not to have surgery. In addition, RT is conditionally recommended for areas where surgery could affect function or cosmetic outcome.
- CPE only addressed patients with Gorlin syndrome. Radiation therapy should only be used as salvage therapy or as palliative therapy for older patients in this population.
Dosing
- Dosing and fractionation of RT is beyond the scope of the AAD and CPE guidelines.
- ASTRO gives specific recommendations for dosing and fractionation of radiation therapy.
- NCCN defers dosing to the ASTRO guideline but does provide some general guidance on dosing and fractionation.
Postoperative Radiation Therapy (PORT)
- PORT was not specifically addressed by the AAD or CPE guidelines.
- ASTRO and NCCN recommend radiation therapy for patients with gross perineural tumor spread.
- ASTRO also conditionally recommends PORT for the following:
- Close or positive margins that cannot be corrected with further surgery
- Recurrence after prior margin-negative resection
- Locally advanced or neglected tumors involving bone on muscle infiltration.
Image-Guided Radiation Therapy (IGRT)
- The NCCN recommends IGRT for intensity-modulated radiation therapy, proton beam radiation therapy, and 3D conformal radiation therapy.
- Similarly, ASTRO comments on the importance of IGRT for accurate delivery of RT.
- The NCCN recommends treatments be delivered by a trained radiation oncologist with support from radiation physics.
- THe AAD and CPE guidelines did not address IGRT.
Brachytherapy
- AAD recommends considering other therapies to include brachytherapy for low-risk tumors when surgery is not an option due to feasibility or patient preference.
- AAD and NCCN were unable to recommend routine electronic surface brachytherapy due to insufficient evidence.
- AAD also reported insufficient evidence to recommend laser surface brachytherapy.
- Both ASTRO and NCCN state that isotype-based brachytherapy may effectively treat BCCs.
- NCCN makes additional recommendations for shielding, use of surface applicators, interstitial brachytherapy, and when to start adjuvant radiation.
- CPE does not address brachytherapy.
Contraindication for Radiation Therapy
- AAD recommends systemic therapy for patients with contraindications to radiation therapy but does not provide any recommendations regarding contraindications for RT.
- ASTRO and NCCN do not recommend RT for patients with certain genetic conditions which predispose them to BCC or radiosensitivity, Gorlin syndrome being one such condition.
- CPE only addressed Gorlin syndrome which is an absolute contraindication for RT in pediatric patients and relative contraindication in adults.
Comparison of Recommendations
| Type | ADD | ASTRO | NCCN | CPE |
|---|---|---|---|---|
| Patient Selection for Radiotherapy | If surgical therapy is not feasible or preferred, topical therapy (eg, imiquimod or 5-FU), MAL- or ALA-PDT, and radiation therapy (eg, superficial radiation therapy, brachytherapy, external electron beam, and other traditional radiotherapy forms for BCC) can be considered when tumors are low risk, with the understanding that the cure rate may be lower. When metastatic disease is limited to the regional lymph node basin, surgery and/or radiation therapy remain the most appropriate treatment, when possible. | In patients with BCC and cSCC who cannot undergo or decline surgical resection, definitive RT is recommended as a curative treatment modality. In patients with BCC and cSCC in anatomic locations where surgery can compromise function or cosmesis, definitive RT is conditionally recommended as a curative treatment modality. For patients with cSCC or BCC that metastasized to clinically apparent regional lymph nodes, therapeutic lymphadenectomy followed by adjuvant RT is recommended, with the exception of patients who have a single, small (<3 cm) cervical lymph node harboring carcinoma, without extracapsular extension. For patients with cSCC or BCC that metastasized to clinically apparent regional lymph nodes, definitive RT is only recommended for patients who are medically inoperable or surgically unresectable. | Refers to the ASTRO guideline for information on when to use radiation therapy and recommended dose. | Among adults with Gorlin Syndrome, RT is relatively contraindicated and should only be used as a salvage therapy or for palliation for high-risk lesions in older patients when other treatments are contraindicated or infeasible. |
| Dosing | Not Addressed. | For patients with BCC or cSCC undergoing adjuvant RT after therapeutic lymphadenectomy, a dose of 6000-6600 cGy (conventional fractionation [180-200 cGy/fx]) is recommended. In patients with BCC and cSCC receiving RT in the definitive setting, the following dose-fractionation schemes are recommended:Conventional (180-200 cGy/fx): BED10 70-93.5Hypofractionation (210-500 cGy/fx): BED10 56-88 Implementation remark: Conventional fractionation is delivered 5 days per week Hypofractionation is delivered daily or 2-4 times per week. In patients with BCC and cSCC receiving RT in the postoperative setting, the following dose-fractionation schemes are recommended:Conventional (180-200 cGy/fx): BED10 59.5-79.2Hypofractionation (210-500 cGy/fx): BED10 56-70.2 Implementation remark: Conventional fractionation is delivered 5 days per week Hypofractionation is delivered daily or 2-4 times per week. | Radiation may be divided into smaller doses given over a longer period of time to improve cosmetic results and is recommended for areas with poor vascularization and cartilaginous areas. Brachytherapy: Longer courses of FT may be considered for sensitive areas.A higher total dose may be considered for patients who are immunocompromisedA lower dose may be used for small low-risk tumors.Twice daily radiation treatments may be considered for interstitial brachytherapy. | Not Addressed. |
| Postoperative Radiation Therapy (PORT) | Not Addressed. | PORT is recommended for gross perineural spread that is clinically or radiologically apparent. PORT is conditionally recommended in patients with BCC with close or positive margins that cannot be corrected with further surgery (secondary to morbidity or adverse cosmetic outcome). PORT is conditionally recommended in patients with BCC in the setting of recurrence after a prior margin-negative resection. PORT is conditionally recommended in patients with BCC with locally advanced or neglected tumors involving bone or infiltrating into muscle. | Clinical or radiographic perineural tumor spread (PNTS) should receive comprehensive coverage. | Not Addressed. |
| Image-Guided Radiation Therapy (IGRT) | Not Addressed. | Supporting Text: Image-guided RT is instrumental for accurate delivery of photon-based RT when treating regional lymphatics and nerve tracks in the head and neck. For local treatment of skin targets, the task force emphasizes the importance of regular and frequent visual confirmation of surface coverage by the treating radiation oncologist (ie, biweekly “see-on-table” verification). Daily imaging is neither necessary nor useful when treating with electron beam, ELS, or skin surface brachytherapy. | When using intensity-modulated radiation therapy (IMRT), proton beam radiotherapy, or 3D conformal radiation image-guided radiation therapy (IGRT) should be utilized. IGRT is not needed for other types of radiation therapy. Consider a bolus over the primary tumor. Dosimeters should be used to verify the dose given. A radiation oncologist with radiation physics support should give treatments. | Not Addressed. |
| Brachytherapy | There is insufficient evidence to recommend the routine use of laser or electronic surface brachytherapy in the treatment of BCC. | Supporting text: Multiple RT modalities can be used to appropriately treat BCC and cSCC. Megavoltage (MV) electrons, brachytherapy (low-dose-rate and high-dose-rate [HDR]), kilovoltage, and MV photons have been successfully used to treat BCC and cSCC. | Isotope-based brachytherapy may be effective for BCCs of the head and neck. There is insufficient information to recommend routine electronic surface brachytherapy. Shielding may be considered. Adjuvant radiation should usually start 4-8 weeks after surgery. Surface applicators should only be used for tumors of less than 5mm depth. Interstitial brachytherapy or EBRT should be considered for tumors greater than 5mm depth. May referral patients for brachytherapy to centers with expertise in this type of therapy. | Not Addressed. |
| Contraindications to RT | If surgery and radiation therapy are contraindicated or inappropriate for the treatment of locally advanced BCC, or if residual tumor persists following surgery and/or radiation therapy and further surgery and radiation therapy are contraindicated or inappropriate, systemic therapy with a smoothened inhibitor should be considered. | Definitive RT for BCC and cSCC is conditionally not recommended in patients with genetic diseases predisposing to heightened radiosensitivity. | Contraindicated for patients with genetic conditions that increase the risk of skin cancer. Relative contraindication for patients with connective tissue disorders. Radiation should not routinely be given in the same area again for disease recurrence. | RT for BCC in GS is absolutely contraindicated in the pediatric population. Among adults, RT is relatively contraindicated and should only be used as a salvage therapy or for palliation for high-risk lesions in older patients when other treatments are contraindicated or infeasible. |
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