John R. Tkach, M.D.
300 North Willson, Suite 203B
Bozeman, MT 59715
(406) 587-5442

Basal Cell Carcinoma (Skin Cancer)

Patient Information Sheet

Basal Cell Skin Cancer is a form of cancer. That's the bad news. The good news is this. If you have to get a cancer, Basal Cell Skin Cancer is the best one to get. Over 90% of Basal Cell Skin Cancers can be cured with relatively simple office surgery. Although it can spread to distant areas of the body, this is very rare. It can become locally very destructive if not treated.

Basal cell cancer is the most common cancer in the U.S. The Skin cancer Foundation estimates that there will be 750,000 cases of basal cell cancer in the U.S. this year. It has become so common that there is no longer a requirement to report it to the tumor registry.

Normally, the skin grows from a row of cells called the basal layer of the epidermis. They move outward, undergo some chemical changes, die, and form a protective outer layer of dead skin. This is gradually worn away in such a manner that we do not notice it. It takes about 1 month for a basal cell to move from the basal layer to the outer layer and be shed.

Normal Skin

Normal Skin (Above)

In Basal Cell Skin Cancer, the basal cells have been damaged by the sun or other unknown factors and become malignant. They produce an enzyme called collagenase. Collagenase dissolves the main stuff that makes up the lower portion of the skin, the dermis. This allows the basal cells to invade inward deeply into the skin.

Normal Skin

Basal Cell Skin Cancer (Above)

Sometimes Basal Cell Skin Cancer will begin as an innocent little pimple with a black head that can be squeezed out but does not heal up as a pimple would. About 50% to 70% of patients describe them this way to me. Sometimes people who have a Basal Cell Skin Cancer are totally unaware of the problem, and the doctor discovers it on a routine examination. After about 4 months Basal Cell Skin Cancer may start to ulcerate and bleed. It bleeds especially after being rubbed with a washcloth. Usually, they become fairly obvious within 6 to 12 months, although I have seen some people who have had them 5 years or more. If left untreated, Basal Cell Skin Cancer destroys the surrounding tissue and can produce terribly disfiguring results. In very rare cases when patients refused treatment, Basal Cell Skin Cancer has been known to invade vital structures such as the brain or carotid artery and cause death. But that is very rare. In over 90% of cases, Basal Cell Skin Cancer is relatively easy to treat. The sooner it is treated, the better the result.

Treatment Options

I want to stress that Basal Cell Skin Cancer is a cancer. It must be treated. It is especially bad to let it go untreated on the eyelid, near the eyes, and on the nose.

  1. No treatment- this is a mistake.
  2. Excision and suture- most of the time this is the best approach. There are exceptions. Excisional surgery gives about a 98% cure rate.
  3. Tangential excision followed by electrodesiccation and curettage- For some areas such as the nose, excision and suturing is very difficult. Tangential excision followed by curettage can give cure rates of about 95% almost as good as excision and suturing and produce very little scar. This used to be the most common form of treatment. I no longer recommend it. I think people better results with other surgical forms of treatment.
  4. Radiation treatment- cure rates with x-ray and electron beam are very good 87% to 92% or better. For some forms of Basal Cell Skin Cancer such as the difficult morpheaform Basal Cell Skin Cancer, x-ray may work better than some other options.
  5. Liquid Nitrogen- the cure rates are significantly less perhaps 70% with liquid nitrogen, so I do not favor it.
  6. Topical 5-fluorouracil cream- is less effective than surgery, but occasionally works well for very superficial Basal Cell Skin Cancer.
  7. Topical Aldara (imiquimod) cream- The reliability of this as a primary treatment has not been established, but it is an appealing approach. It is thought to stimulate the immune system to fight off the cancer, but it may also push the cancer cells into programmed cell death (apoptosis). About 20% of people lack a genetic requirement such as a "Toll 7" receptor. It does not work for them.
  8. Mohs Micrographic Surgery- This is a microscopically, precisely controlled way to remove large and difficult skin cancers. Over the past 20 years, I have seen this specialty grow and in some cases has cured Basal Cell Skin Cancers that seemed hopeless. In many situations, it is the best treatment.
    The surgeon removes the cancer. He/she marks the outer margins in such a way that 99% to 100 % of the margins can be seen under the microscope. If there is a little cancer left in one spot, the surgeon can remove just that smaller area instead of making a much larger excision. Mohs surgeons call their technique "tissue sparing."
    In Montana, our most highly trained and experienced Mohs surgeons are in Billings at the Billings Clinic. I have been referring patients there 20 years.

Follow Up Visits

While the probability of cure from simple office surgery is very high, it is not 100%. Therefore follow up visits to check for recurrence of cancer are essential. The initial follow up visit is in 3-4 months. If the scar looks OK, follow up visits are then once a year. These visits may seem like a waste of time and money to you, but I assure you they are absolutely necessary.

I no longer do surgery. In my experience from about 1973-1981, out of hundreds of Basal Cell Skin Cancers that I removed, only about 5 returned. These were mostly on the nose, and all returned within 4 months. Thus, in my series of patients, the first follow up visit is the most important. If you make it past 3-4 months without a recurrence, the chances are high that the Basal Cell Skin Cancer was cured. If we look at thousands of patients of hundreds of doctors (reports of large series), the first 2 years are the important time span. In such series, 75% of recurrences occur in the first 2 years. After the first occurrence of basal cell cancer, there is 35% probability of getting a second basal cell cancer (not necessarily in the same spot) within five years. Of these, 27% are discovered by the patient and 73% by the doctor. It's just hard to see some areas yourself. Also, sometimes basal cell cancer looks so innocent, it is hard to recognize. So, you can see that the follow up visits are very important.

I suspect that a Basal Cell Skin Cancer recurring after seeming to be gone is usually actually a new cancer not a recurrence. Some people just seem to have certain areas that are prone to Basal Cell Skin Cancer. This is another reason follow up visits are important.

Prevention: The most important and effective thing you can do is to protect your skin from the sun by leaving protective clothing, avoiding sunburns, and by using sunscreen. One of the nicest sunscreens I have found is Neutrogena Ultra Sheer Dry-Touch SPF 100.

Learn more about skin cancer on the Skin Cancer Foundation web site.

The information provided in these patient information sheets is offered for general informational and educational purposes only; it is not offered as and does not constitute medical advice. In no way are any of the materials presented meant to be a substitute for professional medical care or attention by a qualified practitioner, nor should they be construed as such.

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