TREATING BASAL CELL CARCINOMA:
TREATMENT OPTIONS

Once you have gone over the pathology report and staging information with your doctor, it’s time to plan the treatment strategy. In this section, we discuss the different types of therapy that are available for basal cell carcinoma (BCC) and their advantages and disadvantages.*

 

Surface/Destructive Therapy

These are treatments that are applied directly to your skin to treat BCC.

Curettage & Electrodessication (C & E)

In this procedure, the doctor scrapes the cancer from your skin (curettage). Then s/he applies heat to destroy any remaining cancer cells (electrodessication), which also stops any bleeding.

Advantages:

  • It’s quick, often completed in one office visit
  • It does not require stitches (or a follow-up appointment to remove them)
  • It’s a non-invasive option for people who don’t want or can’t tolerate a more-invasive procedure
  • For high-risk groups who may have numerous BCCs, C & E allows rapid treatment of multiple cancers at the same time. It’s just important to check the pathology to make sure there are no high-risk features

Disadvantages:

  • It does not work well on areas that have hair
  • It may not heal as well as an excision, so it probably should not be used on an area where you are concerned about the appearance
  • If the tumor is deeper than they expected, it may still need to be surgically removed
  • It is not as effective as surgery

Cryosurgery

This procedure involves applying a cold substance, such as liquid nitrogen, to the tumor and freezing it off. It may be considered for low-risk BCC when more effective therapies are either not advised or impractical. It can also be considered in individuals with conditions that cause them to form large numbers of tumors.

Topical Medication Treatments

Two medications are used in low-risk BCCs or when a patient has a large number of small BCCs within a region.

Imiquimod (Aldara®)

This drug modulates the immune system and has been approved by the US Food and Drug Administration (FDA) for treatment of superficial BCC on the trunk, neck, and extremities. It is usually applied once a day or every other day for six weeks or longer.

5-Fluorouracil (5-FU)

This is a chemotherapeutic medication that is usually applied twice daily for three to six weeks.

 

Both imiquimod and 5-FU act to destroy cancer cells, so you will most likely feel effects where they have been applied. These include skin redness, swelling, sores, crusting, itching, and tingling.

Surgery

There are two general types of surgery for BCC:

Wide Local Excision

A dermatologist (or specialized surgeon) cuts out the cancer and an area around the tumor. Removing an extra part of skin (a wide margin) assures that s/he got all the cancer. If there is a big enough margin of normal skin around the cancer cells, your treatment is complete. If not, your doctor may need to go back and take more.

Mohs Micrographic Surgery (MMS)

Mohs (rhymes with nose) surgery is recommended for BCC that is likely to recur (come back) or is in an area where you don’t want to remove a lot of skin (such as the face, neck, or hand). Mohs surgery is not appropriate for all BCC, and your BCC must meet certain criteria, such as size or location on the central face, for Mohs surgery to be considered appropriate and to be covered by insurance.

In Mohs (also called microscopic controlled excision) surgery, you are awake while the surgeon removes the smallest amount of tissue needed to treat the cancer.  Often this procedure can be done in the medical office but sometimes needs to be performed at a surgical center. It is done at a hospital only rarely, when surgery will be extensive.

The surgeon removes the skin cancer that can be seen. Then a thin layer of surrounding skin is cut away and examined under a microscope. If cancer cells are found in that additional layer, the process will be repeated until no cancer cells can be seen. The surgeon will then decide the best way to treat the wound.

Radiation Therapy

Radiation therapy is used if you can’t receive surgery or if you really don’t want it. Or in some cases, radiation is given for people who have aggressive BCC as a follow-up treatment to surgery to help destroy any remaining cancer cells so that the cancer does not come back (adjuvant therapy). The radiation therapy is given at a hospital or treatment center over a period of several weeks. Radiation is typically only used in people 60 years of age or older.

Light (Photodynamic) Therapy

This treatment uses light-activated radiotherapy. It’s a two-part process: A solution (called a photosensitizer) that makes your skin sensitive to light is applied to the cancer and a portion of surrounding skin. After one or more hours, a colored or white light will be aimed at the BCC to kill the cancer cells. You may need a single treatment or multiple treatments.

This method works well for small, well-defined nodular BCCs. Potential side effects include being sensitive to the sun (requiring you to avoid the sun and use photoprotection for 48 hours) as well as redness, swelling, tenderness, and sometimes crusting or erosions.

 

Laser therapy, with a pulse dye laser, is not recommended for treatment of BCC.

Key terms:

Adjuvant therapy: Additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back. For squamous cell skin cancer, the primary treatment is usually surgery.  Adjuvant therapy may include chemotherapy, radiation therapy, hormone therapy, targeted therapy, biological therapy, or immunotherapy.

Systemic Therapy

Two medications that are taken in a pill form approved by the FDA and are available for advanced BCC. Both of these drugs belong in a class of drugs called hedgehog inhibitors. For more about how hedgehog inhibitors work, see the Science Sidebar. These drugs are:

Vismodegib (Erivedge®) (vis-moe-deh-gib) is an inhibitor of smoothened (SMO) protein, part of the Hedgehog pathway. This therapy was approved by the FDA in 2012 for advanced BCC, including both locally advanced and metastatic disease.

Sonidegib (Odomzo®) (so-nī-deh-gib) is a prescription medication used to treat adults with locally advanced BCC that has come back following surgery or radiation or that cannot be treated with surgery or radiation. This drug was approved by the FDA in 2015. Sonidegib is not FDA approved for metastatic BCC.

 

More About Hedgehog Inhibitors

Vismodegib and sonidegib stop or slow down the spread of the cancer and shrink the tumors in some patients. In fact, some patients with locally advanced BCC even see their tumors disappear. These drugs are generally taken as long as they are working and the side effects are tolerable.

Hedgehog inhibitors have a number of side effects, including muscle spasms, weight loss, altered taste, fatigue, hair loss, nausea (being sick to stomach), and diarrhea (loose stools). In addition, there may also be some liver problems associated with these agents. The most critical side effect is fetal harm—When a baby is exposed to these drugs in utero, the drugs can cause the baby to die before it is born or cause severe birth defects. Therefore, both women with reproductive potential and men whose partners have reproductive potential should practice birth control while taking these medications if they are sexually active to avoid pregnancy and potential fetal harm.

The side effects of hedgehog inhibitors led to about 28% of subjects discontinuing therapy in these clinical trials, so the tolerability issue is a factor to consider. Be sure to have a conversation with your provider about the potential side effects prior to starting therapy. It helps if you know what to expect and there is a plan in place to communicate and manage these side effects proactively. See the Effects of hedgehog Inhibitors in the LIVING WITH BASAL CELL CARCINOMA section for more strategies to address potential side effects.

 

Investigational Agents

A number of trials are ongoing with multiple investigational agents and approaches for BCC. Some involve use of various hedgehog inhibitors to prevent BCC from coming back or to treat the tumor before surgery to make it more manageable during and after surgery (neoadjuvant therapy). Others are looking at the use of immuno-oncology therapies (such as PD-1 inhibitors) for BCC; still others are examining various therapy combinations to treat BCC.

Key terms:

Neoadjuvant describes a therapy given as a first step to shrink a tumor before the main therapy, which is usually surgery.

Science Sidebar

Sonic hedgehog? Am I in a movie?

In patients with BCC, a pathway involved with cellular signaling, the hedgehog pathway, is overactive, leading to unrestricted cellular proliferation/development of cancer. Some patients with genetic disorders leading to BCC have mutations in genes such as PTCH, which normally restricts the hedgehog pathway. That’s why patients with some genetic disorders develop so many BCCs–they don’t have a way to suppress that pathway. Hedgehog inhibitors slow down this overactive hedgehog pathway, thereby slowing or stopping the growth of BCCs.

But where does the term hedgehog come from? Turns out the hedgehog pathway is also involved with embryonic development. The name is used because one of the intercellular molecules involved in the pathway, a molecule called Hedgehog (Hg), is found in fruit flies. When fruit flies lack (or have a mutation in) the Hg gene, their larvae are affected. The larvae take on a different shape and are said to resemble hedgehogs, as shown below.

This fact is relevant. In humans, hedgehog inhibitors also have an effect on fetal development, which explains why both vismodegib and sonidegib carry a strong warning—called a Black Box warning in pharmaceutical lingo—about potential fetal harm.

More on Clinical Trials in BCC

Clinical trials are research studies that test how well new medical approaches work.  They have an important place in your care as researchers strive to improve current cancer treatments and search for new and better ones. Clinical trials are essential for learning about cancer and how to prevent or cure it.

Our most-effective cancer treatments would not be available without the clinical trial process. Unfortunately, many people with cancer are unaware of the option for a clinical trial or are unsure about the value of participation.

Your goal is to find the best treatment available whenever you make a treatment decision.  While there may be a good standard of care for you—care that experts believe is appropriate for your specific diagnosis and treatment history—sometimes the current standard of care is not as effective as you and your doctor would like. Other times, the standard of care works for a time but then stops working.  In still other instances, there is no standard of care for your situation.  At these times, participation in a clinical trial may be the best option for you.

The best time to search for clinical trials is every time you are faced with a treatment decision.  

Skin Cancer Clinical Trial Matching Service

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*Throughout these treatment sections, we make references to recommended treatment strategies. We consulted the American Academy of Dermatology (AAD) and the National Comprehensive Cancer Network (NCCN) guidelines on these topics. These professional groups are the foremost authorities on skin cancer management. To consult these guidelines, please see RESOURCES.

Hedgehog image from Joe Hanson, PhD, It’s okay to be smart. [permission pending.]