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Queirolo P, Cinquini M, Argenziano G, Bassetto F, Bossi P, Boutros A, Clemente C, de Giorgi V, Del Vecchio M, Patuzzo R, Peris K, Quaglino P, Reali A, Zalaudek I, Spagnolo F. Guidelines for the diagnosis and treatment of basal cell carcinoma: a GRADE approach for evidence evaluation and recommendations by the Italian Association of Medical Oncology. ESMO Open 2023; 8:102037. [PMID: 37879235 PMCID: PMC10598491 DOI: 10.1016/j.esmoop.2023.102037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/20/2023] [Indexed: 10/27/2023] Open
Abstract
Basal cell carcinoma (BCC) is the most common form of cancer, with a high impact on the public health burden and social costs. Despite the overall prognosis for patients with BCC being excellent, if lesions are allowed to progress, or in a small subset of cases harboring an intrinsically aggressive biological behavior, it can result in local spread and significant morbidity, and conventional treatments (surgery and radiotherapy) may be challenging. When a BCC is not amenable to either surgery or radiotherapy with a reasonable curative intent, or when metastatic spread occurs, systemic treatments with Hedgehog inhibitors are available. These guidelines were developed, applying the GRADE approach, on behalf of the Italian Association of Medical Oncologists (AIOM) to assist clinicians in treating patients with BCC. They contain recommendations with regard to the diagnosis, treatment and follow-up, from primitive tumors to those locally advanced or metastatic, addressing the aspects of BCC management considered as priorities by a panel of experts selected by AIOM and other national scientific societies. The use of these guidelines in everyday clinical practice should improve patient care.
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Affiliation(s)
- P Queirolo
- Division of Melanoma, Sarcomas and Rare Tumors, European Institute of Oncology, Milan
| | - M Cinquini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan
| | - G Argenziano
- Dermatology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples
| | - F Bassetto
- Clinic of Plastic Surgery, Department of Neuroscience, Padua University Hospital, Padua
| | - P Bossi
- Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University of Brescia, ASST-Spedali Civili, Brescia
| | - A Boutros
- Department of Internal Medicine and Medical Specialties, School of Medicine, University of Genoa, Genoa
| | - C Clemente
- UO SMEL-2, Surgical Pathology, Department of Pathology and Laboratory Medicine, IRCCS-Policlinico San Donato, Milan
| | - V de Giorgi
- Dermatology Unit, Azienda USL Toscana Centro, Florence; Section of Dermatology, Department of Health Sciences, University of Florence, Florence
| | - M Del Vecchio
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan
| | - R Patuzzo
- Fondazione IRCCS Istituto Nazionale Dei Tumori, Melanoma and Sarcoma Unit, Milan
| | - K Peris
- Dermatology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome; Dermatology, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - P Quaglino
- Department of Medical Sciences, Clinic of Dermatology, University of Turin, Turin
| | - A Reali
- Radiation Oncology Department, Michele e Pietro Ferrero Hospital, Verduno
| | - I Zalaudek
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste
| | - F Spagnolo
- Oncologia Medica 2, IRCCS Ospedale Policlinico San Martino, Genoa; Department of Integrated Surgical and Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy.
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Vacchelli E, Galluzzi L, Eggermont A, Fridman WH, Galon J, Sautès-Fridman C, Tartour E, Zitvogel L, Kroemer G. Trial watch: FDA-approved Toll-like receptor agonists for cancer therapy. Oncoimmunology 2021; 1:894-907. [PMID: 23162757 PMCID: PMC3489745 DOI: 10.4161/onci.20931] [Citation(s) in RCA: 168] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Toll-like receptors (TLRs) have first been characterized for their capacity to detect conserved microbial components like lipopolysaccharide (LPS) and double-stranded RNA, resulting in the elicitation of potent (innate) immune responses against invading pathogens. More recently, TLRs have also been shown to promote the activation of the cognate immune system against cancer cells. Today, only three TLR agonists are approved by FDA for use in humans: the bacillus Calmette-Guérin (BCG), monophosphoryl lipid A (MPL) and imiquimod. BCG (an attenuated strain of Mycobacterium bovis) is mainly used as a vaccine against tuberculosis, but also for the immunotherapy of in situ bladder carcinoma. MPL (derived from the LPS of Salmonella minnesota) is included in the formulation of Cervarix®, a vaccine against human papillomavirus-16 and -18. Imiquimod (a synthetic imidazoquinoline) is routinely employed for actinic keratosis, superficial basal cell carcinoma, and external genital warts (condylomata acuminata). In this Trial Watch, we will summarize the results of recently completed clinical trials and discuss the progress of ongoing studies that have evaluated/are evaluating FDA-approved TLR agonists as off-label medications for cancer therapy.
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Affiliation(s)
- Erika Vacchelli
- INSERM, U848; Villejuif, France ; Institut Gustave Roussy; Villejuif, France ; Université Paris-Sud/Paris XI; Paris, France
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Li M, Zhang X, Duan X, Cao X, Zhao H. A meta‐analysis of treatment effects of imiquimod for basal cell carcinoma. J Cosmet Dermatol 2019; 19:218-225. [PMID: 31692232 DOI: 10.1111/jocd.13119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/01/2019] [Accepted: 08/05/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Meng‐Ya Li
- Sinocelltech Ltd Beijing China
- Hebei General Hospital Shijiazhuang China
| | | | - Xin‐Bo Duan
- Department of Oncology Hebei General Hospital Shijiazhuang China
| | - Xiao‐Ci Cao
- Department of Oncology Hebei General Hospital Shijiazhuang China
| | - Hai‐Jing Zhao
- Department of Technology and Education Hebei General Hospital Shijiazhuang China
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Jia HX, He YL. Efficacy and safety of imiquimod 5% cream for basal cell carcinoma: a meta-analysis of randomized controlled trial. J DERMATOL TREAT 2019; 31:831-838. [PMID: 31294669 DOI: 10.1080/09546634.2019.1638883] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Hong-Xia Jia
- Department of Dermatology, Beijing Chao-Yang Hospital, Beijing, China
| | - Yan-Ling He
- Department of Dermatology, Beijing Chao-Yang Hospital, Beijing, China
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Kamath P, Darwin E, Arora H, Nouri K. A Review on Imiquimod Therapy and Discussion on Optimal Management of Basal Cell Carcinomas. Clin Drug Investig 2018; 38:883-899. [PMID: 30128748 DOI: 10.1007/s40261-018-0681-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Basal cell carcinoma (BCC) is the most common type of skin cancer with an increasing incidence. However, it is still poorly researched compared to many other human diseases. Today, cutaneous neoplasms are a frequent, major problem faced by medical professionals. BCC tumors can cause extensive cosmetic distress as well as disfigurement to patients especially when on the face. Treatment options include surgery, systemic agents, and topical agents. Over the past few decades more studies have been performed to evaluate the utility of topical imiquimod therapy for treatment of BCC. Imiquimod is a toll-like receptor that modifies the immune response via the up-regulation of cytokines and has the capacity to improve a person's immune response. Multiple clinical studies have demonstrated the ability of topical imiquimod to diminish or even eradicate basal cell carcinoma. Given this variety of treatment options and the need for noninvasive options, this review is focused on summarizing the existing information available on the use of imiquimod for BCC and comparing it to other treatment modalities. While excision is the first line treatment and often has greater success with regards to clearance, imiquimod has been shown to be an efficacious treatment modality for BCC. Imiquimod therapy has been shown to be a less invasive and cheaper option than many other treatment modalities. It may be used as either monotherapy or in combination with other treatments, though occlusion has not been shown to be helpful. Several dosing regimens have been studied in the literature. Dosing should take into account factors such as the type of BCC, location, and physician/patient comfort with the regimen. Variability in response to treatment with imiquimod amongst studies suggests that response to treatment may depend on location of lesion, thus more research must be done in this area.
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Affiliation(s)
- Preetha Kamath
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave., RMSB 2023, Miami, FL, 33136, USA.
| | - Evan Darwin
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave., RMSB 2023, Miami, FL, 33136, USA
| | - Harleen Arora
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave., RMSB 2023, Miami, FL, 33136, USA
| | - Keyvan Nouri
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave., RMSB 2023, Miami, FL, 33136, USA
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Karabulut GO, Kaynak P, Ozturker C, Fazil K, Ocak OB, Taskapılı M. Imiquimod 5% cream for the treatment of large nodular basal cell carcinoma at the medial canthal area. Indian J Ophthalmol 2017; 65:48-51. [PMID: 28300740 PMCID: PMC5369293 DOI: 10.4103/ijo.ijo_958_16] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Context (Background): Imiquimod (IMQ) 5% cream is an immunomodulatory and antitumorigenic agent, which was used as a topical treatment regimen, who had periocular basal cell carcinoma (BCC). Aim: This study aims to present three cases with large BCC at the medial canthal area treated with IMQ 5% cream. Materials and Methods: IMQ 5% cream was used in three patients with ages 45, 49, and 73 who preferred medical treatment over surgery. Following incisional biopsy IMQ cream was used once a day, 5 times a week and the patients were followed up weekly during 12 week treatment period and monthly after the clearance of the lesion. Results: Erythema and erosion on the surface of the lesion, injection of conjunctiva, burning and itching sensation, epiphora and punctate keratitis were seen in all patients during the treatment period. The ophthalmic side effects could be managed by topical lubricating eye drops and the inflammatory reactions resolved within 1 month after cessation of therapy. The patients were followed up for at least 3 years without tumor recurrence and the biopsies taken from the suspected area were found to be tumor free. Conclusion: Surgical excision of carcinoma of the eyelid at medial canthal area can be difficult without causing damage to the lacrimal system and reconstruction of the defect may need grafts or flaps. IMQ may provide an alternative therapy to surgery in certain cases.
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Affiliation(s)
- Gamze Ozturk Karabulut
- Department of Ophthalmic and Plastic Surgery, Istanbul Beyoglu Eye Research and Training Hospital, Galata, 34421 Istanbul, Turkey
| | - Pelin Kaynak
- Department of Ophthalmic and Plastic Surgery, Istanbul Beyoglu Eye Research and Training Hospital, Galata, 34421 Istanbul, Turkey
| | - Can Ozturker
- Department of Ophthalmic and Plastic Surgery, Istanbul Beyoglu Eye Research and Training Hospital, Galata, 34421 Istanbul, Turkey
| | - Korhan Fazil
- Department of Ophthalmic and Plastic Surgery, Istanbul Beyoglu Eye Research and Training Hospital, Galata, 34421 Istanbul, Turkey
| | - Osman Bulut Ocak
- Department of Ophthalmology, Istanbul Beyoglu Eye Research and Training Hospital, Galata, 34421 Istanbul, Turkey
| | - Muhittin Taskapılı
- Department of Ophthalmology, Istanbul Beyoglu Eye Research and Training Hospital, Galata, 34421 Istanbul, Turkey
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Husein-ElAhmed H, Fernandez-Pugnaire MA. Dermatoscopy-guided therapy of pigmented basal cell carcinoma with imiquimod. An Bras Dermatol 2017; 91:764-769. [PMID: 28099598 PMCID: PMC5193187 DOI: 10.1590/abd1806-4841.20165255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 11/17/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND: Dermatoscopy is a non-invasive diagnostic tool used to examine skin lesions with an optical magnification. It has been suggested as a useful tool for monitoring therapeutic response in lentigo maligna patients treated with imiquimod. OBJECTIVE: To examine the accuracy of dermatoscopy as a tool to monitor the therapeutic response of pigmented basal cell carcinoma treated with imiquimod. METHOD: The authors designed a prospective study. Patients with pigmented basal cell carcinoma were included and data regarding the dermatoscopy features were collected following the Menzies criteria, prior to initiating the imiquimod treatment. Subsequent dermatoscopic evaluations were performed at weeks 4 and 8, following imiquimod discontinuation. RESULTS: Twenty lesions were included. The most common pigmented dermatoscopy features were large blue-grey ovoid nests (80%), followed by blue-grey globules (50%) and leaf-like areas (30%). No spoke wheel areas were observed. In 17 out of 20 patients, a response was noted during the first evaluation at 4 weeks, while the clearance was noted at the second check-up after 8 weeks. In two patients, the clearance was found at the initial evaluation at 4 weeks, while in one patient, the response remained unchanged. Blue-grey globules were the fastest to exhibit clearance (50% at week 4), followed by leaf-like areas (15%) and large blue-grey ovoid nests (6.25%). CONCLUSION: According to our results, dermatoscopic evaluation enhances the accuracy in the assessment of the clinical response to imiquimod in pigmented basal cell carcinoma.
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Williams HC, Bath-Hextall F, Ozolins M, Armstrong SJ, Colver GB, Perkins W, Miller PS. Surgery Versus 5% Imiquimod for Nodular and Superficial Basal Cell Carcinoma: 5-Year Results of the SINS Randomized Controlled Trial. J Invest Dermatol 2017; 137:614-619. [DOI: 10.1016/j.jid.2016.10.019] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 09/27/2016] [Accepted: 10/06/2016] [Indexed: 01/21/2023]
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Matin N, Tabatabaie O, Mohammadinejad P, Rezaei N. Therapeutic targeting of Toll-like receptors in cutaneous disorders. Expert Opin Ther Targets 2015; 19:1651-63. [DOI: 10.1517/14728222.2015.1069275] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Zloty D, Guenther LC, Sapijaszko M, Barber K, Claveau J, Adamek T, Cancer JA. Non-melanoma Skin Cancer in Canada Chapter 4: Management of Basal Cell Carcinoma. J Cutan Med Surg 2015; 19:239-48. [DOI: 10.1177/1203475415586664] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Basal cell carcinoma (BCC) is the most common malignancy. Growth of BCCs leads to local destruction of neighbouring healthy skin and underlying tissue and can result in significant functional and cosmetic morbidity. Objective To provide guidance to Canadian health care practitioners regarding management of BCCs. Methods Literature searches and development of graded recommendations were carried out as discussed in the accompanying Introduction. Results Although BCCs rarely metastasize“ they can be aggressive and disfiguring. This chapter describes the natural history and prognosis of BCCs. Risk stratification is based on clinical features” including the site and size of the tumour“ its histologic subtype (nodular vs sclerosing)” and its history of recurrence. Conclusions Various options should be considered for BCC treatment” including cryosurgery” curettage” and topical or photodynamic approaches, as well as fixed-margin surgery and Mohs micrographic surgery. Stratification of recurrence risk for individual BCCs determines the most appropriate therapeutic course.
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Affiliation(s)
- David Zloty
- University of British Columbia, Vancouver, BC, Canada
| | | | | | - Kirk Barber
- Kirk Barber Research and University of Calgary, Calgary, AB, Canada
| | - Joël Claveau
- Clinique Dermatologique Joël Claveau, Québec, QC, Canada
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Surgical excision versus imiquimod 5% cream for nodular and superficial basal-cell carcinoma (SINS): a multicentre, non-inferiority, randomised controlled trial. Lancet Oncol 2013; 15:96-105. [PMID: 24332516 DOI: 10.1016/s1470-2045(13)70530-8] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Basal-cell carcinoma is the most common form of skin cancer and its incidence is increasing worldwide. We aimed to assess the effectiveness of imiquimod cream versus surgical excision in patients with low-risk basal-cell carcinoma. METHODS We did a multicentre, parallel-group, pragmatic, non-inferiority, randomised controlled trial at 12 centres in the UK, in which patients were recruited between June 19, 2003, and Feb 22, 2007, with 3 year follow-up from June 26, 2006, to May 26, 2010. Participants of any age were eligible if they had histologically confirmed primary nodular or superficial basal-cell carcinoma at low-risk sites. We excluded patients with morphoeic or recurrent basal-cell carcinoma and those with Gorlin syndrome. Participants were randomly assigned (1:1) via computer-generated blocked randomisation, stratified by centre and tumour type, to receive either imiquimod 5% cream once daily for 6 weeks (superficial) or 12 weeks (nodular), or surgical excision with a 4 mm margin. The randomisation sequence was concealed from study investigators. Because of the nature of the interventions, masking of participants was not possible and masking of outcome assessors was only partly possible. The trial statistician was masked to allocation until all analyses had been done. The primary outcome was the proportion of participants with clinical success, defined as absence of initial treatment failure or signs of recurrence at 3 years from start of treatment. We used a prespecified non-inferiority margin of a relative risk (RR) of 0.87. Analysis was by a modified intention-to-treat population and per protocol. This study is registered as an International Standard Randomised Controlled Trial (ISRCTN48755084), and with ClinicalTrials.gov, number NCT00066872. FINDINGS 501 participants were randomly assigned to the imiquimod group (n=254) or the surgical excision group (n=247). At year 3, 401 (80%) patients were included in the modified intention-to-treat group. At 3 years, 178 (84%) of 213 participants in the imiquimod group were treated successfully compared with 185 (98%) of 188 participants in the surgery group (RR 0.84, 98% CI 0.78-0.91; p<0.0001). No clear difference was noted between groups in patient-assessed cosmetic outcomes. The most common adverse events were itching (211 patients in the imiquimod group vs 129 in the surgery group) and weeping (160 vs 81). We recorded serious adverse events in 99 (40%) of 249 participants in the imiquimod group and 97 (42%) of 229 in the surgery group had serious adverse events, but none were regarded as related to treatment. 12 (5%) participants in the imiquimod group withdrew because of adverse events compared with four (2%) in the surgery group. INTERPRETATION Imiquimod was inferior to surgery according to our predefined non-inferiority criterion. Although excisional surgery remains the best treatment for low-risk basal-cell carcinoma, imiquimod cream might still be a useful treatment option for small low-risk superficial or nodular basal-cell carcinoma dependent on factors such as patient preference, size and site of the lesion, and whether the patient has more than one lesion. FUNDING Cancer Research UK.
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Tinelli M, Ozolins M, Bath-Hextall F, Williams HC. What determines patient preferences for treating low risk basal cell carcinoma when comparing surgery vs imiquimod? A discrete choice experiment survey from the SINS trial. BMC DERMATOLOGY 2012; 12:19. [PMID: 23035730 PMCID: PMC3532314 DOI: 10.1186/1471-5945-12-19] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 09/22/2012] [Indexed: 11/16/2022]
Abstract
Background The SINS trial (Controlled Clinical Trials ISRCTN48755084; Eudract No. 2004-004506-24) is a randomised controlled trial evaluating long term success of excisional surgery vs. imiquimod 5% cream for low risk nodular and superficial basal cell carcinoma (BCC). The trial included a discrete choice experiment questionnaire to explore patient preferences of a cream versus surgery for the treatment of their skin cancer. Methods The self-completed questionnaire was administered at baseline to 183 participants, measuring patients’ strength of preferences when choosing either alternative ‘surgery’ or ‘imiquimod cream’ instead of a fixed ‘current situation’ option (of surgical excision as standard practice in UK). The treatments were described according to: cost, chance of complete clearance, side effects and appearance. Participants had to choose between various scenarios. Analysis was performed using a mixed logit model, which took into account the impact of previous BCC treatment and sample preference variability. Results The analysis showed that respondents preferred ‘imiquimod cream’ to their ‘current situation’ or ‘surgery’, regardless of previous experience of BCC symptoms and treatment. Respondents were more likely to be worried about their cosmetic outcomes and side effects they might experience over and above their chance of clearance and cost. Those with no experience of surgery (compared with experience) valued more the choice of ‘imiquimod cream’ (£1013 vs £781). All treatment characteristics were significant determinants of treatment choice, and there was significant variability in the population preferences for all of them. Conclusions Patients with BCC valued more ‘imiquimod cream’ than alternative ‘surgery’ options, and all treatment characteristics were important for their choice of care. Understanding how people with a BCC value alternative interventions may better inform the development of health care interventions.
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Affiliation(s)
- Michela Tinelli
- Centre of Evidence Based Dermatology, University of Nottingham, A103, King's Meadow Campus, Lenton Lane, Nottingham, NG7 2NR, UK.
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Puig M, Tosh KW, Schramm LM, Grajkowska LT, Kirschman KD, Tami C, Beren J, Rabin RL, Verthelyi D. TLR9 and TLR7 agonists mediate distinct type I IFN responses in humans and nonhuman primates in vitro and in vivo. J Leukoc Biol 2011; 91:147-58. [DOI: 10.1189/jlb.0711371] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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