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 & Electrodesiccation (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

What are the risks of performing a C&E?

How long will the procedure take?

Will I require additional treatment after a C&E?

How do I care for the wound after a C&E?

How long does it take to heal from a C&E?

Will I have to come back at a later time for a follow-up visit?

Will the procedure be covered by insurance and what, if any, out-of-pocket expenses will there be?

Click here to download and print a PDF of these questions.

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.

What are the risks of cryosurgery?

How long will the procedure take?

What are the side effects of cryosurgery and how will they be managed?

Will I require additional treatment after cryosurgery?

How do I care for the wound after cryosurgery?

How long does it take to heal from cryosurgery?

Will I have to come back at a later time for a follow-up visit?

Will the procedure be covered by insurance and what, if any, out-of-pocket expenses will there be?

Click here to download and print a PDF of these questions.

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.

What are the risks for using a topical medication?

How long will I need to use a topical treatment?

Will I have to come back at a later time for a follow-up care visit?

Will the topical medication be covered by insurance and, what, if any, out-of-pocket expenses will there be?

 

Click here to download and print a PDF of these questions.

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.

Will this surgery be performed in the clinic, at a same-day surgery center, or at a hospital?

How long will the procedure take?

Who will perform the surgery?

Should I have someone drive me?

What side effects may occur and how will they be managed?

Will I be left with a scar?

Will I require plastic surgery? If so, will that be done simultaneously/on the same day?

What will my recovery process look like?

Will I be limited in what activities I can perform?

Do you anticipate that I will be cancer-free after surgery?

Will the surgery be covered by insurance and, what, if any, out-of-pocket expenses will there be?

Click here to download and print a PDF of these questions.

Do you think you got all of the cancer out?

Did you have to repair the wound (with a skin graft or flap)? What do I need to know about that?

(If applicable) Will the plastic surgery that was performed be successful?

How do I reduce scarring?

What medications can I take for pain? What kind of stitches do I have? Do you need to take them out?

What kind of symptoms do I need to look for if my surgical site is not healing properly?

What kind of activity limitations will I have? For how long?

Are any additional pathology tests being conducted? If so, when will we have those results?

Will I have to come back at a later time for a follow-up?

Click here to download and print a PDF of these questions.

Are we confident that all of the cancer is out with a sufficient “margin” of clear skin around it?

If not, are you going to perform another surgery? Are there any other procedures that I need?

Has my cancer spread?

What additional treatment, if any, will I need?

If I need to see any additional specialists, whom do you recommend?

Click here to download and print a PDF of these questions.

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.

Why do you believe radiation is a possible treatment option?

How many treatments will I receive?

Should I have someone drive me to treatments?

What side effects may occur and how will they be managed?

What kind of activity limitations will I have? For how long?

Will the treatments affect my ability to work?

What is my prognosis?

What type of follow-up will I need?

Do I need regular scans?

Should I get a second opinion?

Will the treatments be covered by insurance and what, if any, out-of-pocket expenses will there be?

Should I consider enrolling in a clinical trial? Why or why not?

Click here to download and print a PDF of these questions.

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.

What are the risks for using light therapy?

How long will the procedure take?

How many treatments will I need?

How do I care for the area of the skin that is exposed to light therapy?

Will I have to come back at a later time for a follow-up visit?

Will the procedure be covered by insurance and what, if any, out-of-pocket expenses will there be?

Click here to download and print a PDF of these questions.

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

Oral Medications

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.

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.

Intravenous Medication

Cemiplimab (Libtayo®) is an immunotherapy, a treatment that helps your body’s immune system fight cancer. Cemiplimab is FDA approved for treatment of advanced BCC in patients who were previously treated with a hedgehog inhibitor or who were not appropriate candidates for a hedgehog inhibitor. Cemiplimab belongs to a class of drugs called programmed cell death protein 1 (PD-1) inhibitors. PD-1 inhibitors reactivate part of the immune system (the T-cell system) that has been suppressed by cancer cells. When this T-cell system is reactivated, it can then do its job and seek out and kill cancer cells.

In clinical trials, in patients with locally advanced BCC, cemiplimab shrank tumors in 23% while 6% had tumors that disappeared completely. The response lasted 6 months or longer in 79% of the these patients who responded to cemiplimab. For patients with metastatic BCC (meaning it had spread to the lymph nodes or distant regions) cemiplimab shrank tumors in 21% of patients, and all of those patients had responses that lasted at least 6 months.

In these studies, the most common side effects associated with cemiplimab were tiredness, musculoskeletal pain, diarrhea, rash, itching, and upper respiratory infection. Cemiplimab can cause side effects that are typically seen with PD-1 inhibitors, which are mostly related to the immune system being activated. These side effects included lung problems, intestinal problems, liver problems, hormonal issues, kidney problems, and skin issues such as rash, blistering, and sores in the mouth.

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). Additional studies of immuno-oncology therapies are ongoing for BCC; other studies 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.

Why do you believe systemic therapy is a possible treatment option?

How many treatments will I receive?

Should I have someone drive me to treatments?

What side effects may occur and how will they be managed?

What kind of activity limitations will I have? For how long?

Will the treatments affect my ability to work?

Can I take vitamins, supplements, herbs, medicinal marijuana, etc. while on this treatment? Why or why not?

What is my prognosis?

What type of follow-up will I need?

Do I need regular scans?

Should I get a second opinion?

Should I consider enrolling in a clinical trial? Why or why not?

Click here to download and print a PDF of these questions.

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

Register with EmergingMed so you know all your options and can make informed decisions about your care.  All information is kept in the strictest confidence.

Review clinical trial options with this convenient, personalized, and private service.

After Treatment Ends and Follow-Up Care

You may have had one or a combination of treatments detailed on this page, but now that treatment has ended you may find yourself asking, “now what?”

What type of follow-up care will I need?

What are the chances of my skin cancer returning or of developing skin cancer elsewhere on my body?

What can I do to decrease my risk for future skin cancers?

How can I increase my chances of detecting any future skin cancers?

Do you recommend any groups or organizations for emotional support for both myself and my family?

What is the risk of my family members developing skin cancer?

Click here to download and print a PDF of these questions.

*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.]