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OK. The following randomised trial demonstrates what I suggest, that the
cosmetic outcome with radiotherapy deteriorates with time.

.Evaluation of cosmetic results of a randomized trial comparing surgery and
radiotherapy in the treatment of basal cell carcinoma of the face.

Petit JY, Avril MF, Margulis A, Chassagne D, Gerbaulet A, Duvillard P,
Auperin A, Rietjens M.

Plastic Surgery Department, European Institute of Oncology, Milan, Italy.
jypetit@ieo.cilea.it

Basal cell carcinoma is the most frequent cutaneous carcinoma, and it is
characterized by its local spreading and an exceptional tendency to
metastasize. Radical excision or destruction ensures the highest chance of
cure. The most frequent site of this tumor is the face, where radical
excision is limited by the proximity of essential anatomic structures. The
main difficulty is to avoid mutilation and to provide good cosmetic results
despite the vicinity of the eyes, the nose, and the mouth. Surgery and
radiotherapy are known to provide similar chances of cure, but results
concerning cosmetic sequelae are controversial, depending sometimes on the
specialty of the physician in charge of the treatment. A randomized trial
was performed at the Gustave-Roussy Institute to compare basal cell
carcinomas of the face treated either by surgery or by radiotherapy. In
summary, a significant advantage was observed in favor of surgery, as has
been published elsewhere. Looking at the details of the cosmetic results, we
analyzed the specific methodology of the cosmetic evaluation set up to
eradicate the usual bias owing to subjective judgments. We looked also to
the evolution of the cosmetic results with time. A panel of five judges
performed repeated evaluations during the follow-up, and standardized
photographs were taken at each visit and rated later by three nonmedical
judges. In total, 174 patients were treated by surgery and 173 by
radiotherapy; the choice of the treatment was allocated by randomization.
Postoperative complications were higher in the radiotherapy group. The final
cosmetic results after 4 years of follow-up were rated significantly better
with surgery than with radiotherapy (good in 87 percent versus 69 percent
according to the patient, 79 percent versus 40 percent according to the
dermatologist, and respectively for each of the observers). Evolution of the
ratings during the follow-up demonstrated an improvement of the cosmesis
after surgery and stable or deteriorated results after radiotherapy. The
same trend was observed regardless of the site of the tumor on the face,
except for the nose, where the difference--still in favor of the
surgery--was not significant. Concordance of all assessments in our study
was the main guarantee of reliability of our methodology for cosmetic
evaluation.

     Another for good luck.    The face heals very well and scars tend to
disappear with time.   There can be no question that the changes I described
increase with time after radiotheapy.

     Br J Cancer. 1997;76(1):100-6.  Related Articles, Links

Comment in:
 a.. Br J Cancer. 1998 Nov;78(9):1257.

Basal cell carcinoma of the face: surgery or radiotherapy? Results of a
randomized study.

Avril MF, Auperin A, Margulis A, Gerbaulet A, Duvillard P, Benhamou E,
Guillaume JC, Chalon R, Petit JY, Sancho-Garnier H, Prade M, Bouzy J,
Chassagne D.

Service de dermatologie, Institut Gustave Roussy, Villejuif, France.

Basal cell carcinomas (BCCs) are very frequent cutaneous cancers, often
located on the face. Cure rates with surgery and radiotherapy are high, but
these treatments have never been compared prospectively. A randomized trial
was initiated in 1982 to compare surgery and radiotherapy in the treatment
of primary BCC of the face measuring less than 4 cm. The primary end point
was the failure rate (persistent or recurrent disease) after 4 years of
follow-up. The secondary end point was the cosmetic results assessed by the
patient, the dermatologist and three persons not involved in the trial. In
the course of the trial, 347 patients were treated. Of the 174 patients in
the surgery group, 71% had local anaesthesia and 91% frozen section
examination. Of the 173 patients in the radiotherapy group, 55% were treated
with interstitial brachytherapy, 33% with contactherapy and 12% with
conventional radiotherapy. The 4-year actuarial failure rate (95% CI) was
0.7% (0.1-3.9%) in the surgery group compared with 7.5% (4.2-13.1%) in the
radiotherapy group (log-rank P = 0.003). The cosmetic results assessed by
four of the five judges were significantly better after surgery than after
radiotherapy. Eighty-seven per cent of the surgery-treated patients and 69%
of the radiation-treated patients considered the cosmetic result as good (P
< 0.01). Thus, in the treatment of BCC of the face of less than 4 cm in
diameter, surgery should be preferred to radiotherapy.

Peter Moran

We do all the team political correctness stuff in BC.
It doesn't cut into clinical time, just breakfast and lunch and
supper............