Basal Cell Carcinoma (BCC)

BCC is the most common of all skin cancers, and is caused by uncontrolled growth of cells in the basal cell layer of the epidermis (the outer layer of the skin). BCC varies in appearance but can look like an open sore, pink or red spots/growths, shiny or waxy looking bumps, or even scars. This type of cancer is almost exclusively caused by excessive and cumulative sun exposure.
Basal cell skin cancer most commonly occurs in areas that are regularly exposed to the sun, particularly the face.

The good news? BCC almost never metastasizes beyond the its original tumor site. However, untreated or inadequately treated tumors will become larger in diameter and more invasive, leading to damage of surrounding tissue and disfigurement.

Skin cancer is the most frequently diagnosed cancer in the U.S. – more common than almost all of the other major cancers combined. In specific, BCC is the most common of the different skin cancers with 4 million new cases diagnosed each year.

BCC DIAGNOSIS
Following a thorough examination with a dermatology provider, the diagnosis of BCC is confirmed with a biopsy. A biopsy is obtained by numbing the skin with local anesthetic and then removing a small piece of the tumor and submitting it to a lab where it is examined under a microscope. It is absolutely necessary to take a biopsy to make the diagnosis and determine the depth of invasion, so we can make the best choice of treatment options.

BCC TREATMENT
The choice of BCC treatment is based on several factors, including the type, location, size and depth of the tumor. We also take into account the patient’s age, their other medical problems, and the potential cosmetic results of the procedure. Almost all of the treatments can be performed on an outpatient basis in our office. Most of our surgical treatments require the use of a local anesthetic. Pain or discomfort during the procedure is minimal and we will make every effort to insure you are comfortable. Pain after the procedure is very rare and is typically quite mild.

Electrodessication and Curettage
This treatment is reserved for tumors that are very small or superficial. After injecting local anesthetic, the tumor is scraped away with a curette, an instrument with a sharp, ring-shaped tip. After scraping, the site is dessicated (burned) with an electrocautery needle. The cure rate from this procedure is above 95%. The wound takes 3-4 weeks to completely heal and will leave behind a scar the size of the tumor. This procedure is less appropriate for invasive BCC, tumors in high-risk sites, or areas where a scar would be cosmetically undesirable.

Excisional Surgery
After injecting local anesthesia, the provider uses a scalpel to remove the entire tumor along with a narrow border of normal looking skin as a safety margin. The skin is then closed with stitches and the specimen is sent to the laboratory to verify that all cancer cells have been removed. Cure rates from this procedure is above 95%. If all of the cells have not been removed, it may be necessary to perform a second procedure to get clear margins.

Radiation
This outpatient procedure is delivered by a radiation oncologist in an outpatient facility. X-ray beams are directed at the tumor to destroy the cancerous cells. This procedure does not require any cutting or anesthetic. Total destruction of the tumor usually requires 20-30 treatments over the course of a few weeks. This treatment is ideal for tumors in areas where it would be difficult to do surgery, and also for elderly patients or those in poor health. Cure rates for radiation are approximately 90%.

Mohs’ Micrographic Surgery
This highly specialized surgical technique is reserved for the most serious tumors in specific areas on the face. The procedure requires the surgeon to remove a thin layer of tissue containing the tumor. While the patient waits, the tissue is sectioned, frozen and examined by the surgeon under a microscope. If cancer is present in any of the examined sections, the procedure is repeated until the examined areas are cancer free. Once the cancer has been completely removed, the surgeon will close the skin with stitches. The cure rate with Mohs’ surgery is greater than 99%, but the procedure should be reserved for only the most serios cancers in areas that are difficult to treat by other methods.

Topical Medications
There are two creams that are FDA approved for the treatment of BCC – imiquimod and 5-Fluorouracil (5-FU).

Imiquimod is FDA approved for the treatment of superficial BCCs, with cure rates between 80 and 90%. The cream is applied to the tumor 5 times per week for at least 6 weeks. This innovative treatment works by stimulating the patient’s immune system to produce interferon, a chemical that destroys the cancer.

5-Fluorouracil has be used for many years as chemotherapy for internal cancers. A cream version of this medication has been approved by the FDA for superficial BCC, with cure rates that are similar to imiquimod. The medication is applied to the tumor twice daily for 3-6 weeks. Side effects from patient to patient, but some degree of redness, irritation and inflammation will occur.

IMPORTANT NOTE!
Only excisions and Mohs’ surgery will produce pathological specimens that can be checked for clear margins. The other treatments listed above do not produce a specimen and there is no way to know for sure how completely the tumor was removed. It is very important that all skin cancer patients be monitored regularly for recurrences and new cancers.

Oral Medication for Advanced Basal Cell Carcinoma
Erivedge (vismodegib), is an oral medication approved by the FDA in 2012 for locally advanced cases of BCC. This is the only oral medication approved for BC and works by blocking the “hedgehog” signaling pathway, a key step in developing BCC. Erivedge is only used for very serious BCC where the nature of the cancer limits other treatment options. It has a risk of birth defects and should not be used by women who are pregnant or may become pregnant.

Odomzo (sonidegib) is the second “hedgehog” inhibitor approved by the FDA in 2015 for patients with locally advanced BCC, specifically those patient whose tumors have recurred following surgery or radiation, or who are not candidates for surgery or radiation. Like Erivedge, this medical has a risk of birth defects.

Currently research is underway to identify new oral therapies for the treatment of locally advanced and metastatic BCC.

HOW TO AVOID BCC
Most skin cancers, including BCC, are curable when detected and treated early. However, it is best to prevent them in the first place and limit risk of developing more cancers in the future. At Paladin Dermatology, we recommend the following sun safety habits:

  • Avoid direct sun exposure and seek the shade, especially between 10:00am and 4:00pm.
  • Do not allow your skin to get red or burned in the sun.
  • Avoid tanning in the sun and never use UV tanning beds.
  • Cover up with clothing, including a broad-brimmed hat and UV blocking sunglasses.
  • Use a broad spectrum (UVA and UVB) sunscreen with an SPF of 15 or higher every day. For extended exposure, use a water-resistant sunscreen with a SPF of 30 or higher. Make sure to reapply sunscreen every 2 hours, and immediately after swimming or with excessive sweating.
  • Apply 1 ounce (two tablespoons) of sunscreen to your entire body 30 minutes before going outside.
  • Keep newborns out of the sun. Sunscreen should be used on babies over the age of 6 months.
  • Examine your skin head-to-toe every month.
  • See us annually for a professional skin exam, and every 6 months if you’ve previously had a skin cancer.