Effectiveness of Photodynamic Therapy in Treating Non-Melanoma Skin Cancer: A Systematic Review

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Executive summary
As the incidence of non-melanoma skin cancer (NMSCs) particularly basal cell carcinomas
(BCCs) pose mortality risk and has detrimental effect on quality of life of an individual, the wide
application of photodynamic therapy (PDT) in the field of dermatology has emerged. This systematic
review aimed to investigate and compare the efficacy of PDT compared to traditional treatment
methods in the treatment of NMSCs. By searching for papers in CINAHL, PubMed and MEDLINE
database, total five articles were selected for the review. The quality assessment of the paper was
done using the JBI-QARI tool. The three themes emerging from the review included excellent
cosmetic outcomes following PDT, risk of recurrence with PDT and adverse effects associated with
PDT. The overall conclusion from the paper was that PDT is superior to surgical interventions in
terms of cosmetic outcomes. However, evidence related to recurrence of the lesion following PDT
was a concern. As the research papers mostly used systematic review and meta-analysis, the results
gave the implication to conduct further research related to the three outcomes so that more clarity is
achieved and oncology staffs get better idea regarding the way to deal with challenges associated
with the implementation of PDT.

Table of Contents
INTRODUCTION...........................................................................................................................3
Introduction:................................................................................................................................3
Background:.................................................................................................................................4
Aim and objectives:.....................................................................................................................6
METHODOLOGY:.........................................................................................................................7
Inclusion criteria:.........................................................................................................................7
Search strategy:................................................................................................................................9
Assessment of methodological quality:.....................................................................................11
Data collection:..........................................................................................................................12
Data synthesis:...........................................................................................................................12
RESULTS:.....................................................................................................................................12
Description of studies:...............................................................................................................14
Methodological quality:.............................................................................................................14
Findings for the review:.............................................................................................................15
DISCUSSION:...............................................................................................................................20
CONCLUSION:............................................................................................................................23
Implications for practice:...........................................................................................................23
Implications for future research:................................................................................................24

INTRODUCTION
Introduction:
Due to the life time sun exposure, the incidence of skin cancer is increasing in ageing
population. It is a significant burden for elderly population considering its morbidity, mortality and
related cost (Torre et al., 2012). Although skin cancer are classified into two categories such as
cutaneous melanoma and non-melanoma skin cancers (NMSC), many types of tumors come under
the broader category of NMSC. It accounts for 80% of all cancers and it has the highest incidence
compared to other types of cancer (Garcovich et al., 2017). The most common treatment option for
non-melanoma skin cancer includes surgery. This involves different kind of surgeries such as
micrographic surgery, laser therapy and cryotherapy. However, the challenge associated with surgical
methods for elderly is that the invasive method poses many dilemmas for the elderly population. With
the increase in incidence of NMSC, the cost associated with treatment is also increasing (Stewart et
al., 2014). Hence, it is imperative to find out effective treatment options that reduce cost based
dilemma as well as other physical complications for elderly. New research evidence shows the
effectiveness of non-surgical treatment options of photodynamic therapy (PDT) in treating the
condition (Cohen & Lee, 2016). There is a need to explore how far PDT is effective in treating
NMSC compared to other methods.
This systematic review aims to address the research question ‘Can photodynamic therapy
offer an effective treatment for non-melanoma skin cancer compared to traditional treatment methods
for ageing Australians?’.

Background:
NMSC is the most common form of human tumour categorized into two categories namely
the basal cell carcinomas (BCCs) and the squamouus cell carcinomas (SCC). The diagnosis of NMSC
particularly SSCs increases mortality risk and lead to many detrimental effect on an individual’s
quality of life (Gaulin, Sebaratnam & Fernández‐Peñas, 2015). The diagnosis of NMSC has
significant effect on the quality of life of Australians because of effects of treatment, cost related
burden for patients, cosmetic burden and functional limitations. Functional limitation occurs because
of symptoms like bleeding pain and pruritus. In addition, daily activity is disrupted because of
surgery and recurrence of symptoms (Gaulin, Sebaratnam & Fernández‐Peñas, 2015). Allthese
burden implies that with the increase in incidence of NMSC, it leads to additional cost burden and
burden to the health care system too because of repeated visits to the health care setting and the needs
to undergo surgical or physical treatments.
The pressure on primary care is increasing because of high incidence of chronic disease and
the ageing population. The increase in incidence skin cancer suggest the need to pay attention to skin
cancer management and prevention strategies so that number of invasive procedure is reduced and
sustainable outcomes for ageing population is achieved. Review of recent report and statistics reveal
that Australia is a country with highest incidence of skin cancer. According to the AIHW report,
NMSC is the most common cancer diagnosed in Australia and in 2016, about 13, 28- cases of
melanoma was diagnosed in Australia. From the incidence rate of 27 cases per 100, 000, the
incidence rate of melanoma has increased to 49 cases per 100, 000 in 2016. The rate of
hospitalization for skin cancer is also on the rise evidenced by 23, 437 melanoma related
hospitalization in 2013-2014. The substantial expenditure on skin cancer is understood from payment
of $9.4 million Medicare benefit claim for melanoma (Australian Institute of Health and Welfare,
2016). The estimate for the future is that two in every three Australians will be diagnosed with skin

cancer after they reach the age of 70 years (Skin and Cancer Foundation, 2017). Hence, with the day
by day increase in skin cancer incidence in Australia, there is a need to investigate better options that
reduce economic and social burden for elderly patients and maintain their quality of life too.
Several treatment modalities exist for treatment of different types of NMSC. The mainstay
treatment continues to be simple excision or Mohs micrographic surgery. However, PDT has now
emerged as alternative treatment option to achieve optimal cosmetic results for BCC and SCC
(Lucena et al., 2015). The PDT is centered around photo-oxidation principles and the key
components required for the therapy includes photo-sensitizer, oxygen and light. After application of
the photosensitizer in to target tissue, reactive oxygen species (ROS) are produced following a type II
photo-oxidation reaction. This reaction leads to destruction of cell membranes and organelles
resulting in cell death (Cohen & Lee, 2016). It gives the evidence regarding the popularity of PDT as
a treatment modality throughout Australia. The main justification given by the author for the
effectiveness of PDT in treating NMSC was its excellence clearance rate and cosmetic outcomes.
PDT is effective in correcting aberrantly expressed cancer-associated geners and inducing expression
of extracellular matrix in photoaged skins (Nguyen & Khachemoune, 2019). As reported by Cohen
and Lee (2016), many research studies have now revealed superior cosmetic outcomes compared to
surgical treatment. Hence, critical analysis and systematic review of these papers are essential to
understand how PDT is superior from traditional methods in treating patients with NMSC.
The significance and the need for conducting research on the topic of PDT and comparing it
with other intervention is also understood from the presence of unclear ideas regarding surgical
approach and PDT. For example, there is argument that surgical excision has superior outcomes
compared to other therapies because like cryotherapy, PDT and radiotherapy (Fahradyan et al., 2017).
PDT is found to be effective in treating superficial SCCs because of high safety profiled in elderly
and immune-depressed patient. However, there is evidence regarding early and late side effects due to

PDT. Borgia et al. (2018) argues that due to exposure to light source after the therapy, symptoms of
pain, burns, itching and pustular formation is found in patients. These are short terms complications
that translates to long term patient satisfaction. Hence, review of research paper and critical
comparison of two treatment option is critical to understand which treatment option is feasible and
safe for the elderly population.
Aim and objectives:
The main aim of the systematic review is to consider the effectiveness of PDT as an
alternative option in place of surgical intervention for elderly population. Invasive surgical
procedures are currently first line treatment options for BCCs and SCCs. However, this systematic
review aims to compare PDT with surgical techniques to understand whether elderly patients can
benefits from use of viable alternatives like surgical intervention or not. The key objectives of the
systematic review are as follows:
 To compare and contrast PDT and surgical interventions for treatment of NMSC in elderly
 To critically assess the viability of PDT as an alternative option for treatment of NMSC
 To evaluate the effectiveness of PDT in prevent skin lesions and the demand on primary
health care resources
The research question that guides the overall research are as follows:
Will the treatment of NMSC with PDT help to prevent and reduce number of skin lesions
requiring surgical excision and reduce the demand on primary health resources?

METHODOLOGY:
Inclusion criteria:
The systematic review has been guided by some inclusion and exclusion criteria. There are
different factors based on which inclusion and exclusion criteria are developed. The key inclusion
criteria for finding and extracting relevant papers for this systematic review are as follows:
Type of research design: As the main aim of this research is to compare PDT with surgical
interventions for treatment of NCSM, research papers with randomized controlled trials (RCTs) is the
most preferred option for this systematic review. However, other research papers such as systematic
literature reviews and other research design were also considered if relevant to the research question.
Sample type: Only those papers were considered which has the following list of participants for the
review:
 Elderly patients with BCCS or SCCs
 Patients with photodamaged skin
 Patients with diagnosis of either BCCs or SCCs
 Patient with actinic keratoses
 Patients with the intention to reduce pre-malignant skin lesions and skin cancers
 Patients expecting positive cosmetic outcome
 Patients with past history of skin cancer
Type of intervention: For the systematic review, the main intervention of interest includes PDT. It is a
modern and non-surgical treatment option that is used to treat precancerous skin lesions. While
searching for research articles, only those papers will be selected which examines and explores the
performance and outcome of PDT in preventing skin cancers. Therefore, the main intervention that
needs to be reviewed by each research papers includes PDT.