Basal Cell Carcinoma 101 - Appalachian Spring Dermatology

The Most Common Skin Cancer

Basal cell carcinoma (BCC) is the most common type of skin cancer. 1 in 5 Americans will have one in their lifetime. It is the most common of all cancers. Like the other types of skin cancer, BCC is named for the type of cells that go awry. BCC originates in the basal cells, the layer of cells that are at the base of the epidermis. The good news is the BCC pretty much never spreads to other parts of the body or affects your lifespan. These growths just grow where they are. They can be quite invasive and “eat away” at the spot, so it is important that they be removed promptly and entirely.

Sun damage in the past is the cause of almost all basal cell carcinomas. That is why they occur most frequently on exposed parts of the body — the face, ears, neck, scalp, shoulders, and back. Some BCCs occur in areas of trauma as well such as in the smallpox vaccination scar.

What to Look For

BCCs are usually pink or red. Less common types are scar-like or brown pigmented. BCC is easily missed in its early superficial stage and type. Dr. Rosenberger often points out that a patch of rash, pimple, or wound that does not go away in 3 months is suspicious.

The Five Warning Signs of Basal Cell Carcinoma according to the Skin Cancer Foundation

-An Open Sore that bleeds, oozes or crusts and remains open for two to three months. A persistent, non-healing sore can be an early sign.

-A Reddish Patch or irritated area, frequently occurring on the chest, shoulders, arms, or legs. Sometimes the patch crusts. It may also itch or hurt. At other times, it persists with no noticeable discomfort.

– A Shiny Bump or nodule, that is pearly or translucent and is often pink, red, or white. The bump can also be tan, black, or brown, especially in dark-haired people, and can be confused with a mole.

-A Pink Growth with a slightly elevated rolled border and a crusted indentation in the center. As the growth slowly enlarges, tiny blood vessels may develop on the surface.

-A Scar-like Area which is white, yellow, or waxy, and often has poorly defined borders. The skin itself appears shiny and taut. Although a less frequent sign, it can indicate the presence of an aggressive tumor.

Basal Cell Carcinoma – Treatment Options

If skin cancer is suspected, a biopsy must be taken and examined microscopically. If the diagnosis is confirmed, there are many treatment options from which to choose. Fortunately, there are several effective ways to eradicate Basal Cell Carcinoma. The choice of treatment is based on the type, size, location, and depth of penetration of the tumor, as well as the patient’s age and general state of health. Treatment can almost always be performed on an outpatient basis. A local anesthetic is used during most procedures. Pain or discomfort is usually minimal with most techniques, and there is rarely much pain afterward.

Topical Medications A topical medication, is approved for the treatment of superficial basal cell carcinoma (sBCC). These creams work to help trigger your immune system to fight off the tumor. These medications can be expensive and require use multiple times a week for about one to three months. The lesions can be ulcerated open sores and tender during the treatment process. This method can have excellent cosmetic outcomes, but requires patient compliance with both application of the medicine and the side effects of open healing lesions. This method is best used on large superficial lesions and lesions where cosmesis is a primary issue; however this is only effective for some very superficial lesions. Dr Rosenberger can prescribe these medications.

Curettage and Electrodesiccation The growth is scraped off with a curette and the tumor site desiccated or burned. This method works because the tumor cells are not well adhered to the surrounding skin. This is not the most exact method of removal, because the margins of the removed tissue are not examined to determine that the entire tumor has been removed. However, this is an effective method for superficial and nodular lesions on the body. This method is less often used on the face because it does not leave the most cosmetically elegant scar. This method results in a pink or white circular scar somewhat larger than the original lesion. Dr. Rosenberger performs this technique in her office under local anesthesia.

Excisional Surgery Along with the above procedure, this is one of the most common treatments for BCCs and SCCs. Using a scalpel, the physician removes the entire growth along with a surrounding border of apparently normal skin as a safety margin. The incision is closed, and the growth is sent to the laboratory to verify that all cancerous cells have been removed and that the margins are clear. This method is used for morpheaform or sclerotic type basal cell carcinomas on the body as well as for lesions on the face. This method most often results in a sutured wound with a straight line scar. The patient will need to return for suture removal. Dr. Rosenberger performs this technique in her office under local anesthesia.

Mohs Micrographic Surgery The physician removes the visible tumor with a curette or scalpel and then removes very thin layers of the remaining surrounding skin one layer at a time. Each layer is checked under a microscope, and the procedure is repeated until the last layer viewed is cancer-free. It is often used for tumors that have recurred or are in hard-to-treat places such as the head, neck, hands, and feet. This procedure requires additional training and equipment and is not performed by most general dermatologists. This technique has the highest cure rate and can save the greatest amount of healthy tissue. Therefore, this method has the best chance of minimizing scarring as well. Dr. Rosenberger does not perform this procedure. However, she can refer you to a doctor who does perform this procedure.

Photodynamic Therapy (PDT) PDT can be especially useful for lesions on the face and scalp, and when patients have multiple BCCs. Currently, this is used only for superficial BCC in the US; however, testing on thicker and nodular lesions is underway in Europe. Topical 5-aminolevulinic acid (5-ALA) is applied to the lesions at the physician’s office. This solution is preferentially absorbed by the cancerous lesions, including those not visible with the naked eye. After one hour of incubation time, those medicated areas can be activated by light using intense pulsed light or blue light. This treatment selectively destroys BCCs while causing minimal damage to surrounding normal tissue. Some redness and swelling can result from this newer therapy. This therapy is being widely used and tested in Europe. While insurance companies may pay for this method (using destruction of malignant lesion code), they may not pay for the 5-ALA solution which has significant cost associated ($300-425 per application). Thus this method may result in some out-of-pocket cost. This method has been shown to have excellent long-term cosmesis, and treatment of the full face may reduce the risk of development of new lesions in the future. Dr. Rosenberger does offer this treatment method in her office.

Radiation X-ray beams are directed at the tumor. Total destruction usually requires several treatments a week for a few weeks. This is ideal for tumors that are hard to manage surgically and for elderly patients who are in poor health. This method is complicated by the side effects of radiation.

Eviredge and Odomzo. These are newer medications used to treat large, aggressive, or extremely rare metastatic basal cell carcinoma. Over 1 million Americans have basal cell carcinoma each year. Since 1894, there have been less than 500 reported cases of metastatic basal cell carcinoma, so the risk of a basal cell carcinoma spreading beyond the original location is extremely rare. Eviredge and Odomzo are capsules taken by the patient at home and are quite expensive. To learn more about these medications see www.eviredge.com. Or https://www.odomzo.com/.

Cemiplimab-rwlc (Libtayo®) – is the newest immunotherapy medication FDA approved to treat advanced BCC in 2021. It is only for advanced or metastatic growths that have not responded to Eviredge or Odomzo.

After you have been diagnosed and treated for basal cell carcinoma

What is my risk of the tumor recurring or spreading? The risk of non-melanoma skin cancer spreading or metastasizing to other parts of the body is low. Over 1 million Americans have basal cell carcinoma each year. Since 1894, there have been less than 500 reported cases of metastatic basal cell carcinoma, so the risk of a basal cell carcinoma spreading beyond the original location is extremely rare. However, the tumors can recur locally if not totally removed or a new lesion can occur adjacent to the previous one or in a new location.

What is my risk of developing another skin cancer in the future? One in five Americans develops skin cancer some time in their life. Once someone has one type of skin cancer, they have a further increased risk of developing both non-melanoma and melanoma skin cancer in the future.

What can I do to prevent new lesions now? It is important to continue aggressive sun protection and sun avoidance when possible. Dr. Rosenberger likes to see her skin cancer patients at three months, six months, and one-year intervals following diagnosis and treatment of skin cancer. At these visits, we will be looking for recurrence as well as monitoring for the development of new lesions.

Do my family members now have an increased risk of developing skin cancer? There are a few rare genetic syndromes where family members all develop high numbers of skin cancers. However, most non-melanoma skin cancers do not have increased for immediate family members by a direct specific gene. That being said we inherit many characteristics from our parents, including skin color, eye color, and hair color which may increase one’s propensity to develop skin cancer. Plus, the family that plays in the sun together gets skin cancer together. For instance…Dr. Rosenberger’s father has had basal cell carcinoma. Dr. Rosenberger inherited her fair skin and tendency to freckle from her father. Dr. Rosenberger spent time at the beach with her family. Dr. Rosenberger developed her first basal cell carcinoma at age 30.

To learn more about other types of skin cancers, read our posts about Melanoma and Squamous Cell Carcinoma.

Photo courtesy of Medicine.net

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