nonmelanoma skin cancers include basal cell carcinoma ( bcc ) , squamous cell carcinoma , and more uncommon entities such as merkel cell carcinoma [ 1 , 2 ] . bcc can be treated with many modalities such as surgical excision , topical immunomodulations , mohs micrographic surgery , photodynamic therapy , and x - ray therapy . x - ray therapy is an effective treatment and results in good function and cosmesis , why it could be considered as a first option in many cases such as high risk bcc ; diameter > 2  cm , location on nose , lips , and ears , and rapid growth [ 2 , 3 ] . x - ray therapy has been limited because of legal regulations and the high equipment and running cost of radiation devices , which discourage clinics from establishing the treatment .   unlike many other medical conditions , approximately 80% of bccs occur in the head and neck and may cause disfiguring skin changes with impact on the patient 's body image and health - related quality - of - life ( hrqol ) . two studies have used the dermatology life quality index ( dlqi ) to assess hrqol in patients with bcc who have been treated with cryotherapy , curretage , excision , and mohs for bcc surgery [ 5 , 6 ] , but no reports are available on hrqol in patients with bcc treated by x - ray . the aim of the present study was to quantify the hrqol in patients treated by x - ray for bcc . the study population consisted of 25 patients with bcc treated by x - ray ( 40  gy , kv 40 ( median ) in 10 fractions over two weeks ) and 25 healthy controls without skin diseases matched by gender and age ( table 1 ) . the patients were enrolled consecutively for this descriptive study .   to assess the specific impact of x - ray therapy , the validated short , self - administered questionnaire dlqi was used [ 57 ] . the dlqi consists of 10 questions relating to  the last week  answered on a scale from 0 ( not at all ) , through 1 ( a little ) , 2 ( a lot ) , to 3 ( very much ) , with a maximum possible score of 30 . the dlqi can be analysed under six headings , which include : ( 1 ) symptoms and feelings , ( 2 ) daily activities , ( 3 ) leisure , ( 4 ) work and school , ( 5 ) personal relations , and ( 6 ) treatment ( table 2 ) . the questionnaires were completed immediately before x - ray therapy , and again two weeks and three months after treatment . a two - week follow - up was chosen because major skin reactions due to the x - ray are expected at this time , and the three - month follow - up was chosen because healing is expected to be completed at this time [ 3 , 5 , 6 ] . data included demographic and clinical information . to evaluate the skin reactions three months after x the study protocol was approved by the danish data protection agency ( cvr - nr . 11 - 88 - 37 - 29 ) and the scientific ethical committee for copenhagen county ( kf 01 271885 ) and was conducted in accordance with the declaration of helsinki v. all participants gave written informed consent . data were analysed in spss version 19.0 for windows ( spss , inc . , chicago , il , usa ) . the comparison of the patients with bcc and the healthy controls was performed using the mann - whitney u - test . the different effects of the x - ray therapy on dlqi at the different times were analysed using the wilcoxon two - sample test . twenty - five patients with bcc ( 16 male , 9 female , mean age 70 , range 4495 ) and 25 healthy controls matched by gender and age participated in the study . twenty - one ( 84% ) of the bccs were located on the head or neck , 3 ( 12% ) on the trunk , and 1 ( 4% ) on a leg . the lesion diameters at baseline were 760  mm ( mean 25.9  mm ) and had been present for a mean of 27 months ( range 684 months ) before x - ray treatment . the bcc diagnoses had in all cases been ascertained by a dermatologist ( n = 25 ) and confirmed by a pathologist . at baseline three ( 12% ) eight ( 32% ) patients had ulcerations immediately after the x - ray and 21 ( 84% ) patients subsequently developed radiotherapy induced ulcerations , which had healed three months later . three months after x - ray therapy nine patients had no skin reactions ( grade 0 , rtog / eortc late morbidity scoring scheme ) , 12 had slight atrophy , pigmentation change , and/or some hair loss ( grade 1 ) , five had patch atrophy , moderate telangiectasia , and/or total hair loss ( grade 2 ) , none had marked atrophy and gross telangiectasia ( grade 3 ) , none had ulcerations ( grade 4 ) . despite these changes we found a significant decrease in the overall dlqi scores from baseline to three months after x - ray therapy ( p = 0.024 ) and from two weeks to three months after x - ray therapy ( p = 0.002 ) . scores in the subcategory  symptoms and feelings  significantly decreased from two weeks to three months after x - ray therapy ( p = 0.004 ) . generally the scores in each of the subcategories and the overall scores of dlqi were very low ( table 2 ) . the patients had a significantly higher dqli score before and two weeks after x - ray therapy compared to the matched healthy controls ( p = 0.007 ; p = 0.001 ) ( table 3 ) . three months after x - ray therapy the dlqi was similar for patients with bcc and healthy controls ( p = 1.000 ) . this study demonstrated a significant effect on patients ' hrqol from baseline to three months after therapy ( table 2 ) . hrqol is considered an important outcome in cancer research , and is associated with sequela such as depression , anxiety , and vulnerability . although bcc is not life - threatening , it may affect hrqol , because bcc often results in skin changes and ulcerations after x - ray therapy and may result in recognition of illness ( figure 1 ) [ 5 , 6 ] .   in the present study the overall dlqi score was between 0.41.5 and this represents a very small effect on patient 's hrqol according to finlay and khan ( tables 2 and 3 ) . the mean dlqi scores ( maximum 30 ) in a normal population range from 0 to 0.5 , which was the case in our controls as well . dlqi has been used in two other studies in relation to surgery for bcc ( table 4 ) [ 5 , 6 ] . both studies showed dlqi baseline 5.3  4.1 and 2.4  2.7 , and a significant decrease in dlqi three months after surgery ( 1.3  2.1 and 1.7  2.9 ) . the present study also showed a significant decrease in dlqi to normal level three months after treatment ( from 1.2 + 1.5 to 0.4  0.9 ) ( tables 2 and 3 ) . x - ray therapy itself had no effect on hrqol , which was less than for surgery ( table 4 ) . within the first month x - ray therapy acute reactions are common , which may be reflected in dlqi 's subcategory  symptoms and feelings . concern about the acute side effects of x - ray therapy seems not to be a problem after x - ray therapy , as the dlqi had the same levels as before x - ray and less than after surgery . the decline of the dlqi could be a result of confounders , but except for instructions in sun protection and care of ulcers , there was no difference between the healthy and the intervention group . patients with bbc located at visible areas such as face or neck may suffer more than patients with bcc on at trunk and legs . this is confirmed by a separate analyse of face elements showing a significant difference in dlqi from before to 2 weeks after treatment , different from the total material . a number of authors argue that dlqi may be too non - specific for this use [ 1214 ] . the items seem not to capture such issues as scarring , disfigurement , and worry about recurrence or new lesions , which are frequent problems for patients with bcc . the questionnaire appears more tailored for chronic , benign skin conditions such as psoriasis or eczema , while it emphasizes physical complaints such as itchiness and irritation . the change in dlqi scores in this study could indicate the need for a more disease - specific instrument . the facial skin cancer index , a new and as yet less commonly used questionnaire , may prove useful , but there is a need for translation and validation for use in non - english speaking countries [ 4 , 12 , 15 ] . the present study shows that for 14 out of 25 patients more than a year passed before the patients sought medical advice , and the same tendency is seen in other studies [ 5 , 16 ] . this could indicate that small lesions do not represent a major problem , which accords with what the dlqi scores indicate . in conclusion , the diagnosis , bcc , has a negative effect on patients ' hrqol , and cure by x - ray therapy brought hrqol levels back to those of healthy controls , despite minor skin manifestations .
background . 
 advanced basal cell carcinoma ( bcc ) is often treated by surgery or x - ray therapy . 
 the consequences of x - ray therapy on the patients ' health - related quality - of - life ( hrqol ) have so far not been described . objectives . to quantify quality of life in bcc patients before and after 
 x - ray therapy compared with matched healthy controls . 
 materials . 
 twenty - five patients ( mean age 69 ) with bcc completed the dermatology life quality index ( dlqi ) before and two weeks and three months after x - ray therapy and their results were compared with the dlqi scores for 25 matched controls . 
 results . compared to the healthy controls the patients ' dlqi score was significantly higher before and 2 weeks after x - ray therapy ( p = 0.005 ; p = 0.000 ) . 
 the patients ' dlqi score decreased significantly from baseline to three months after x - ray therapy ( p = 0.024 ) , when it became similar to that of the healthy controls ( p = 0.819 ) . 
 three months after x - ray therapy eight patients had no skin reactions , 11 had slight atrophy , pigmentation change , and/or some hair loss , four had patch atrophy , moderate telangiectasia , and/or total hair loss . conclusions . 
 bcc has a negative effect on patients ' quality of life . 
 the study shows that hrqol normalises shortly after x - ray therapy , despite minor skin manifestations .