{"entity":{"id":"avril-surgery-versus-radiotherapy-bcc","kind":"trial","name":"Surgery against radiotherapy for basal cell carcinoma of the face","aka":["Avril trial","Institut Gustave Roussy basal cell carcinoma trial"],"tldr":"The only randomised trial ever run of surgery against radiotherapy for the commonest skin cancer found surgery better on both counts: fewer cancers came back and the face looked better afterwards. Radiotherapy is used when an operation is not possible, not because it is equal.","summary":"This is the trial that decides the order of the two curative treatments for basal cell carcinoma, and it has never been repeated. Beginning in 1982, the Institut Gustave Roussy randomised 347 patients with a primary facial basal cell carcinoma of less than 4 cm to surgery or radiotherapy. In the surgery arm 71 per cent had local anaesthesia and 91 per cent had frozen section examination of the margin. The radiotherapy arm reflects French practice of the period: 55 per cent interstitial brachytherapy, 33 per cent contact therapy and 12 per cent conventional external beam.\n\nThe four-year actuarial failure rate, counting persistent as well as recurrent disease, was 0.7 per cent after surgery (95 per cent confidence interval 0.1 to 3.9) against 7.5 per cent after radiotherapy (4.2 to 13.1), log-rank p=0.003.\n\nThe cosmetic comparison was done carefully, with five judges including three people not involved in the trial rating standardised photographs. Four of the five rated surgery significantly better. Eighty-seven per cent of the surgical patients and 69 per cent of the irradiated patients called the cosmetic result good (p<0.01); by the dermatologist's rating it was 79 against 40 per cent. A later analysis of the same cohort showed why the gap widens: appearance improves in the years after surgery and stays the same or deteriorates after radiotherapy, because radiation changes the skin permanently. The exception was the nose, where the difference still favoured surgery but was not significant.\n\nRadiotherapy remains the right treatment for people in whom an operation would be mutilating or is refused, for those too frail for surgery, and after incomplete excision where re-operation is not possible. This trial is why it is second and not first.","status":"positive","asOf":"2026-09-25","links":[{"label":"Randomised comparison (British Journal of Cancer 1997)","url":"https://doi.org/10.1038/bjc.1997.343"},{"label":"Randomised comparison on PubMed","url":"https://pubmed.ncbi.nlm.nih.gov/9218740/"},{"label":"Cosmetic analysis (Plastic and Reconstructive Surgery 2000)","url":"https://doi.org/10.1097/00006534-200006000-00039"}],"tags":[],"related":[],"cancers":["basal-cell-carcinoma","skin-cancer"],"sections":[],"technologies":["brachytherapy","electron-beam-therapy-systems","imrt-igrt"],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":["radiotherapy-for-skin-cancer","surgical-margins-keratinocyte-cancer"],"trials":["mohs-versus-excision-facial-bcc","trog-05-01"],"people":[],"bottlenecks":[],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"phase":"3","setting":"Primary basal cell carcinoma of the face measuring less than 4 cm: surgery, with frozen section examination in 91 per cent, against radiotherapy given as interstitial brachytherapy in 55 per cent, contact therapy in 33 per cent and conventional external beam in 12 per cent, with the failure rate at four years as the primary endpoint and cosmetic result as the secondary endpoint","sponsor":"Institut Gustave Roussy, France","result":"Four-year failure rate 0.7 per cent after surgery against 7.5 per cent after radiotherapy (p=0.003), with a good cosmetic result in 87 against 69 per cent by the patient's judgement and 79 against 40 per cent by the dermatologist's.","yearReported":1997,"enrolled":347,"enrolledBasis":"randomised","enrolledNote":"347 patients were randomised from 1982, 174 to surgery and 173 to radiotherapy; the trial began two decades before trial registration existed and has no registry record.","outcomes":[{"endpoint":"Actuarial failure rate at 4 years","primary":true,"unit":"%","arms":[{"name":"Surgery","n":174,"value":0.7,"note":"95 per cent confidence interval 0.1 to 3.9"},{"name":"Radiotherapy","n":173,"value":7.5,"note":"95 per cent confidence interval 4.2 to 13.1"}],"p":"0.003","source":"https://doi.org/10.1038/bjc.1997.343"},{"endpoint":"Good cosmetic result, patient's assessment at 4 years","unit":"%","arms":[{"name":"Surgery","value":87},{"name":"Radiotherapy","value":69}],"p":"<0.01","source":"https://doi.org/10.1038/bjc.1997.343"},{"endpoint":"Good cosmetic result, dermatologist's assessment at 4 years","unit":"%","arms":[{"name":"Surgery","value":79},{"name":"Radiotherapy","value":40}],"source":"https://doi.org/10.1097/00006534-200006000-00039"}],"replication":"No randomised trial has compared surgery with modern radiotherapy for basal cell carcinoma since. The radiotherapy techniques in this trial, particularly contact therapy, are not the techniques used today, which is the strongest argument against reading the 7.5 per cent as a current figure."},"route":"/trials/avril-surgery-versus-radiotherapy-bcc/","neighbours":{"cancer":[{"id":"basal-cell-carcinoma","kind":"cancer","name":"Basal cell carcinoma","route":"/cancers/basal-cell-carcinoma/"},{"id":"skin-cancer","kind":"cancer","name":"Skin cancer (all types)","route":"/cancers/skin-cancer/"}],"technology":[{"id":"brachytherapy","kind":"technology","name":"Brachytherapy","route":"/technologies/brachytherapy/"},{"id":"electron-beam-therapy-systems","kind":"technology","name":"Electron beam therapy systems (linac electrons, total skin electron units, mobile electron IORT)","route":"/technologies/electron-beam-therapy-systems/"},{"id":"imrt-igrt","kind":"technology","name":"IMRT / IGRT (modern external beam)","route":"/technologies/imrt-igrt/"}],"term":[{"id":"radiotherapy-for-skin-cancer","kind":"term","name":"Radiotherapy for skin cancer","route":"/terms/radiotherapy-for-skin-cancer/"},{"id":"surgical-margins-keratinocyte-cancer","kind":"term","name":"The margin in skin cancer surgery","route":"/terms/surgical-margins-keratinocyte-cancer/"}],"trial":[{"id":"mohs-versus-excision-facial-bcc","kind":"trial","name":"Mohs surgery against ordinary excision for facial basal cell carcinoma (Nijmegen trial)","route":"/trials/mohs-versus-excision-facial-bcc/"},{"id":"trog-05-01","kind":"trial","name":"TROG 05.01 (chemotherapy added to radiotherapy after surgery for high-risk skin squamous cell carcinoma)","route":"/trials/trog-05-01/"}]}}