UK practice survey of NMSC radiotherapy
ForNMSC (BCC/SCC) for primary RT, across fitness strata
TL;DROf 63 UK respondents, most chose one of four daily schedules (18-20 Gy/1#, 35 Gy/5#, 45 Gy/10#, 55 Gy/20#). Non-standard schedules varied widely, with 24 different regimens proposed.
The actionable signal is the non-standard (less-than-daily) schedules for frail pts: 24 different regimens were proposed, and the authors' BED modelling flags 28 Gy/2# 6 weeks apart, 32.4 Gy/3# weekly and 36 Gy/4# weekly as carrying too much late-effect risk. The authors also say a 22 Gy single fraction should be dropped unless it corrects for stand-off.
For a frail elderly pt with NMSC who cannot manage daily visits, this questions the weekly 28 Gy/2#, 32.4 Gy/3# and 36 Gy/4# schedules on late-effect grounds. It does not inform the fit pt, where daily 35 Gy/5# to 55 Gy/20# matched the published series.
The actionable signal is the non-standard (less-than-daily) schedules for frail pts: 24 different regimens were proposed, and the authors' BED modelling flags 28 Gy/2# 6 weeks apart, 32.4 Gy/3# weekly and 36 Gy/4# weekly as carrying too much late-effect risk. The authors also say a 22 Gy single fraction should be dropped unless it corrects for stand-off.
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Anonymous online survey sent through the clinical heads of service and audit leads at 58 UK centres, open for 3 months. 43 complete and 20 partial responses.
UK clinical oncologists treating NMSC. Each scenario assumed tissue diagnosis and an MDT decision for primary RT, posed for a healthy 65yo, a relatively well 80yo, and an 85yo nursing home resident with early dementia.
Responses grouped as single fractions, 3-5 fx (27.5-35.0 Gy), 8-10 fx (32-45 Gy), 15-33 fx (45-66 Gy), non-standard alternate-day / twice-weekly / weekly, brachytherapy, and palliative. kV available to 81%. Electrons were favoured for larger lesions and younger pts.
Four schedules dominated: 18-20 Gy/1#, 35 Gy/5#, 45 Gy/10#, 55 Gy/20#. Non-standard practice was heterogeneous, with 24 different fractionations. kV use split by site: >80% for a 1.5-cm ala nasi BCC vs around 25% for a 2-cm helical SCC.
| Dose fractionation | Times suggested |
|---|---|
| 35 Gy/5# | 237 |
| 45 Gy/10# | 170 |
| 55 Gy/20# | 134 |
| 50 Gy/20# | 57 |
| 50 Gy/15# | 56 |
| 45 Gy/9# | 51 |
| 18 Gy/1# | 41 |
| 40 Gy/10# | 29 |
| 32 Gy/5# | 27 |
| 60 Gy/30# | 26 |
| 45 Gy/9# over 3 weeks | 24 |
| 40.5 Gy/9# | 22 |
| 27 Gy/3# over 2 weeks | 20 |
| 20 Gy/1# | 18 |
| 45 Gy/15# | 15 |
| 66 Gy/33# | 11 |
| 28 Gy/2# over 6 weeks | 11 |
| 38 Gy/6# over 6 weeks | 11 |
| Scenario | Finding |
|---|---|
| 1.5-cm ala nasi BCC | >80% kV photons, mostly 35 Gy/5# |
| 2-cm helical rim SCC | kV photons used by only around 25% |
| Inner canthus BCC | around 80% kV; stand-off correction by 74% |
| 4-cm dorsum hand SCC | around 70% favour ≥15 fractions; 7.7% declined any regimen |
| Shin carcinoma | around 20% refuse treatment, even in the infirm |
| 4-cm shin BCC, elderly infirm | 32% give 3-5 daily fx; 30% non-standard |
No prospective trials exist to compare against. The authors judge daily schedules consistent with retrospective hypofractionation series (44-45 Gy/10# or 35 Gy/5#), and single-fraction dosing consistent with data favouring 18 or 20 Gy over 22 Gy for cosmesis and necrosis.
Responses are stated preference for hypothetical stems, not audited delivered treatment. The BED comparison depends on assumed parameters (α/β 8.5 Gy tumour, 3 Gy late, Tk 28 days), and no fitness-stratified outcome data were collected.
Daily practice is broadly harmonized. The real gap is the frail-elderly non-standard regimens and graft recurrence volumes, where an almost even split between whole-graft and recurrence-plus-margin reflects missing data rather than a considered choice.
Scenario-based practice-pattern survey with no outcome endpoint; it reports clinician preference, and the authors' fractionation recommendations rest on retrospective series and BED modelling.
- Which non-standard fractionation is safest and most effective in frail elderly NMSC? recruiting Impact of Hypofractionated Radiotherapy Strategy After Surgery of Skin Carcinomas in Older Patients Phase NAn=303 · primary completion 2028-03 · ≥70y adjuvant 15# vs extreme hypofx vs surgery alone
- Whole graft vs recurrence-plus-margin volume for in-graft recurrence
- Does kV over ear cartilage carry excess late toxicity?
📚 Sources · 📄 1 paper
The longer read
The value of this survey is not that it shows UK skin RT is well aligned with the evidence. There is very little evidence to align with, and the authors themselves describe the published base as retrospective series and case reviews. What the survey does is mark where consensus has formed without trial data and where it has not. Daily schedules converge on a small set (35 Gy/5#, 45 Gy/10#, 55 Gy/20#, and 18-20 Gy single fraction), and those match the retrospective series the authors cite. This convergence is best read as inherited institutional practice that happens to agree with retrospective data, not as validation of any one schedule against another.
The heterogeneity that matters is in the frailest pts, where 24 different less-than-daily regimens were proposed. This is the clinical setting where follow-up is weakest: the authors acknowledge these pts are often not reviewed regularly after treatment, so local failures and late toxicity are under-ascertained. The authors' linear-quadratic comparison is the most useful analytic piece. It suggests the three most popular non-standard schedules are radiobiologically similar, and that 28 Gy/2# 6 weeks apart, 32.4 Gy/3# weekly and 36 Gy/4# weekly may carry excess late-effect risk. A reader should hold this loosely. The tumour α/β of 8.5 Gy, the kick-off time and the repopulation terms are borrowed estimates, and a time-correction term built on a 4-day doubling time is a model assumption, not a skin-cancer measurement. The direction of the warning is plausible. The ranking among the safer schedules is not well supported by this calculation.
The site-specific findings show clinicians weighing anatomy against what the literature says. Over 80% chose kV for a small ala nasi BCC, but only around 25% did so for a helical SCC, even though the cited retrospective data report good control and low late morbidity with kV at the ear. The authors offer vascular tolerance as a possible reason. A simpler one is that a single bad chondronecrosis case shapes an individual clinician's practice more than any series does. The refusal rates for the shin (around 20%) and the 7.7% who declined to treat the hand, despite the scenario stating the pt was unfit for surgery, show the same conservatism. In both cases brachytherapy, which the authors note has favourable data for the hand, was rarely chosen.
Methodologically, this is stated preference for hypothetical cases from 43 complete respondents, many of whom treat fewer than 5 skin cases a month, and it dates from 2014. It cannot show that any schedule controls disease better. Its lasting use is narrower: it supports dropping 22 Gy single fractions without stand-off correction, it gives grounds to question the most hypofractionated weekly regimens in pts who may live long enough to see late effects, and it identifies graft recurrence volumes and frail-elderly fractionation as the places where pooled local outcome data would change practice soonest.