TREATING BASAL CELL CARCINOMA:
TREATMENT OPTIONS

Curettage & Cautery (C&C)

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 & C 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 is not as effective as surgery
• 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 tumour is deeper than they expected, it may still need to be surgically removed

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 five times per week for a minimum of six weeks.

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.

Wide Local Excision

A dermatologist (or specialised surgeon) cuts out the cancer and an area around the tumour. 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.

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 centre 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 coloured 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 superficial 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 treatments are not recommended for treatment of BCC.

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 tumours in some patients. In fact, some patients with locally advanced BCC even see their tumours 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 diarrhoea (loose stools). In addition, there may also be some liver problems associated with these agents. The most critical side effect is foetal 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 foetal 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^®) LIBTAYO as monotherapy is indicated for the treatment of adult patients with locally advanced or metastatic basal cell carcinoma (laBCC or mBCC) who have progressed on or are intolerant to a hedgehog pathway inhibitor (HHI). 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 tumours in 23% while 6% had tumours 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 tumours 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, diarrhoea, 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 tumour 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.