Basal Cell Carcinoma Basics, From Diagnosis to Treatment

Basal cell carcinoma, or BCC, is the most common form of skin cancer globally, but it is also highly curable. This guide is designed to provide newly diagnosed patients with the necessary information to partner with their oncologist and make informed treatment decisions.

Overview of Basal Cell Carcinoma

Basal cell carcinoma originates in the basal cells, which line the deepest layer of the epidermis, the outer layer of the skin. It is overwhelmingly caused by long term exposure to ultraviolet (UV) radiation from the sun or tanning beds.

“Chronic sun exposure, if you’ve had lots of sunburns previously, a prior history of another skin cancer or if you have light skin, blue eyes or are immunocompromised, those are all risk factors for having these types of skin cancers,” explained Dr. Barbara Ma, assistant professor of medicine at Weill Cornell Medicine, in a previous interview with CURE.

While BCC can appear anywhere on the body, it is most often found on sun-exposed areas such as the head, neck, arms and legs. BCC grows slowly and rarely spreads to other parts of the body, which is why cure rates are exceptionally high when detected early. Patients are often diagnosed with BCC in their forties or fifties, though risk increases with age.

Diagnosis: What the Journey Looks Like

A diagnosis typically begins when a patient or a doctor notices a suspicious lesion during a clinical skin examination. BCC often presents as a persistent sore that does not heal, a reddish patch, a shiny or pearly bump, or a waxy scar-like area.

The definitive step for diagnosis is a biopsy, where a small sample of the suspicious tissue is removed and examined under a microscope by a pathologist. The biopsy confirms the presence of basal cell carcinoma and helps classify the subtype (e.g., nodular, superficial or infiltrative), which guides the treatment plan. Your oncologist will use this information to determine if the cancer is high risk or low risk based on size, location, and microscopic features.

Treatment Options

The choice of treatment depends heavily on the tumor's size, depth, location and the patient’s overall health. The primary goal is the complete removal or destruction of the cancer with the best possible cosmetic outcome.

1. Surgical Excision: This is a common and highly effective procedure where the entire tumor and a small margin of surrounding healthy tissue are cut out and stitched closed. The sample is sent to a lab to ensure the borders, or margins, are clear of cancer cells.
2. Mohs Micrographic Surgery: This specialized surgical technique is often used for tumors located in cosmetically sensitive areas like the nose, eyelids, lips or ears, as well as for large or recurrent tumors. The surgeon removes the tumor layer by layer and immediately examines the tissue under a microscope until all cancer cells are gone. This method spares the maximum amount of healthy tissue.
3. Curettage and Electrodesiccation: This technique is often used for small, superficial BCCs on the trunk or limbs. The doctor scrapes the cancer off using a sharp instrument (curette), followed by burning the area with an electric needle (desiccation) to destroy remaining cells and stop bleeding.
4. Topical Therapies: For very superficial BCCs, non-surgical options like topical chemotherapy (such as fluorouracil) or immune response modifiers (such as imiquimod cream) may be applied directly to the skin. These treatments induce an inflammatory response that kills the cancer cells.
5. Radiation Therapy: This treatment uses high energy X-rays to kill cancer cells. It is typically reserved for patients who are not candidates for surgery due to age, poor health, or if the tumor is in an area difficult to operate on.

Side Effects and Recovery

Each treatment option carries potential side effects. It is important to discuss these fully with your care team before starting.

• Surgical Procedures (Excision, Mohs): The most common side effect is the formation of a scar. Scars are generally minimized by the surgeon but their appearance depends on the size and location of the removal. Other risks include temporary pain, swelling, bleeding and infection at the surgical site.
• Topical Creams (Fluorouracil, Imiquimod): These treatments intentionally cause intense localized skin reactions that may last for several weeks. Patients should expect significant redness, inflammation, erosion and crusting in the treated area. This reaction is a sign the treatment is working.
• Radiation Therapy: Side effects are localized to the treated area. They can include skin redness and irritation similar to a severe sunburn, long term changes in skin color and texture, and potential hair loss in the treated field. Patients may also experience general fatigue during the course of treatment.

Conclusion and Next Steps

The outlook for basal cell carcinoma is excellent, with cure rates approaching 99% for early-stage disease. While this diagnosis can be unsettling, having an informed discussion with your care team is the best step forward.

When meeting with your oncologist, consider asking the following questions to drive a personalized conversation:

1. Based on the biopsy, what is the specific subtype of my BCC, and is it considered high or low risk?
2. Which treatment option — Mohs, excision, or a non-surgical approach — offers the highest cure rate for my specific tumor?
3. What are the estimated downtime and recovery period, and what are the best strategies to manage scarring or the skin reaction from treatment?
4. Once this BCC is treated, what is my follow-up schedule for regular skin examinations, and what signs should I watch for in the future?

Reference

1. “Educated Patient® Skin Cancer Summit Basal Cell Carcinoma/Squamous Cell Carcinoma Presentation: June 18, 2022,” CURE; https://www.curetoday.com/view/educated-patient-skin-cancer-summit-basal-cell-carcinoma-squamous-cell-carcinoma-presentation-june-18-2022

This guide is designed to be a starting point. Your personal experience will be unique. By using this information as a foundation for your discussions, you can partner with your oncologist to make the best decisions for your health.

Editor's note: This article is for informational purposes only and is not a substitute for professional medical advice. Please contact your healthcare team with any questions or concerns.

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