Basal Cell Carcinoma

Treatment and Diagnosis :

If you have a change on the skin, the doctor must find out whether it is due to cancer or to some other cause. Your doctor removes all or part of the area that does not look normal. The sample goes to a lab. A pathologist checks the sample under a microscope. This is a biopsy. A biopsy is the only sure way to diagnose skin cancer.

You may have the biopsy in a doctor's office or as an outpatient in a clinic or hospital. Where it is done depends on the size and place of the abnormal area on your skin. You probably will have local anesthesia.

There are four common types of skin biopsies:

• Punch biopsy: The doctor uses a sharp, hollow tool to remove a circle of tissue from the abnormal area.
• Incisional biopsy: The doctor uses a scalpel to remove part of the growth.
• Excisional biopsy: The doctor uses a scalpel to remove the entire growth and some tissue around it.
• Shave biopsy: The doctor uses a thin, sharp blade to shave off the abnormal growth.

Staging

If the biopsy shows that you have cancer, your doctor needs to know the extent (stage) of the disease. In very few cases, the doctor may check your lymph nodes to stage the cancer.

The stage is based on:

• The size of the growth
• How deeply it has grown beneath the top layer of skin
• Whether it has spread to nearby lymph nodes or to other parts of the body

These are the stages of skin cancer:

• Stage 0: The cancer involves only the top layer of skin. It is carcinoma in situ.
• Stage I: The growth is 2 centimeters wide (three-quarters of an inch) or smaller.
• Stage II: The growth is larger than 2 centimeters wide (three-quarters of an inch).
• Stage III: The cancer has spread below the skin to cartilage, muscle, bone, or to nearby lymph nodes. It has not spread to other places in the body.
• Stage IV: The cancer has spread to other places in the body

Treatment

• Getting a Second Opinion
• Treatment Methods
• Surgery
• Topical Chemotherapy
• Photodynamic Therapy
• Radiation Therapy

Sometimes all of the cancer is removed during the biopsy. In such cases, no more treatment is needed. If you do need more treatment, your doctor will describe your options.

Treatment for skin cancer depends on the type and stage of the disease, the size and place of the growth, and your general health and medical history. In most cases, the aim of treatment is to remove or destroy the cancer completely.

It often helps to make a list of questions before an appointment. To help remember what the doctor says, you may take notes or ask whether you may use a tape recorder. You may also want to have a family member or friend with you when you talk to the doctor -- to take part in the discussion, to take notes, or just to listen.

Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat skin cancer include dermatologists, surgeons, and radiation oncologists.

Getting a Second Opinion

Before you have treatment, you might want a second opinion about the diagnosis and treatment plan. Many insurance companies cover a second opinion if you or your doctor requests it. It may take some time and effort to gather medical records and arrange to see another doctor. Usually it is not a problem to take several weeks to get a second opinion. In most cases, the delay will not make treatment less effective. To make sure, you should discuss this delay with your doctor. Sometimes people with skin cancer need treatment right away.

There are a number of ways to find a doctor for a second opinion:

• Your doctor may refer you to one or more specialists. At cancer centers, several specialists often work together as a team.
• A local or state medical society, a nearby hospital, or a medical school can usually provide the names of specialists.

Treatment Methods

Your doctor can describe your treatment choices and what to expect. You and your doctor can work together to develop a treatment plan that meets your needs.

Surgery is the usual treatment for people with skin cancer. In some cases, the doctor may suggest topical chemotherapy, photodynamic therapy, or radiation therapy.

Because skin cancer treatment may damage healthy cells and tissues, unwanted side effects sometimes occur. Side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each person.

Before treatment starts, your doctor will tell you about possible side effects and suggest ways to help you manage them.

Many skin cancers can be removed quickly and easily. Even so, you may need supportive care to control pain and other symptoms, to relieve the side effects of treatment, and to ease emotional concerns.

You may want to talk to your doctor about taking part in a clinical trial, a research study of new ways to treat cancer or prevent it from coming back. The section on "The Promise of Cancer Research" has more information about clinical trials.

Surgery

Surgery to treat skin cancer may be done in one of several ways. The method your doctor uses depends on the size and place of the growth and other factors.

Your doctor can further describe these types of surgery:

• Excisional skin surgery is a common treatment to remove skin cancer. After numbing the area, the surgeon removes the growth with a scalpel. The surgeon also removes a border of skin around the growth. This skin is the margin. The margin is examined under a microscope to be certain that all the cancer cells have been removed. The size of the margin depends on the size of the growth.
• Mohs surgery (also called Mohs micrographic surgery) is often used for skin cancer. The area of the growth is numbed. A specially trained surgeon shaves away thin layers of the growth. Each layer is immediately examined under a microscope. The surgeon continues to shave away tissue until no cancer cells can be seen under the microscope. In this way, the surgeon can remove all the cancer and only a small bit of healthy tissue.
• Electrodesiccation and curettage is often used to remove small basal cell skin cancers. The doctor numbs the area to be treated. The cancer is removed with a sharp tool shaped like a spoon. This tool is a curette. An electric current is sent into the treated area to control bleeding and kill any cancer cells that may be left. Electrodesiccation and curettage is usually a fast and simple procedure.
• Cryosurgery is often used for people who are not able to have other types of surgery. It uses extreme cold to treat early stage or very thin skin cancer. Liquid nitrogen creates the cold. The doctor applies liquid nitrogen directly to the skin growth. This treatment may cause swelling. It also may damage nerves, which can cause a loss of feeling in the damaged area.
• Laser surgery uses a narrow beam of light to remove or destroy cancer cells. It is most often used for growths that are on the outer layer of skin only. The NCI fact sheet "Lasers in Cancer Treatment: Questions and Answers" has more information.
• Grafts are sometimes needed to close an opening in the skin left by surgery. The surgeon first numbs and then removes a patch of healthy skin from another part of the body, such as the upper thigh. The patch is then used to cover the area where skin cancer was removed. If you have a skin graft, you may have to take special care of the area until it heals.

The time it takes to heal after surgery is different for each person. You may be uncomfortable for the first few days. However, medicine can usually control the pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain relief.

Surgery nearly always leaves some type of scar. The size and color of the scar depend on the size of the cancer, the type of surgery, and how your skin heals.

For any type of surgery, including skin grafts or reconstructive surgery, it is important to follow your doctor's advice on bathing, shaving, exercise, or other activities.

Topical Chemotherapy

Chemotherapy uses anticancer drugs to kill skin cancer cells. When a drug is put directly on the skin, the treatment is topical chemotherapy. It is most often used when the skin cancer is too large for surgery. It is also used when the doctor keeps finding new cancers.

Most often, the drug comes in a cream or lotion. It is usually applied to the skin one or two times a day for several weeks. A drug called fluorouracil (5-FU) is used to treat basal cell and squamous cell cancers that are in the top layer of the skin only. A drug called imiquimod also is used to treat basal cell cancer only in the top layer of skin.

These drugs may cause your skin to turn red or swell. It also may itch, hurt, ooze, or develop a rash. It may be sore or sensitive to the sun. These skin changes usually go away after treatment is over. Topical chemotherapy usually does not leave a scar. If healthy skin becomes too red or raw when the skin cancer is treated, your doctor may stop treatment.

Photodynamic Therapy

Photodynamic therapy (PDT) uses a chemical along with a special light source, such as a laser light, to kill cancer cells. The chemical is a photosensitizing agent. A cream is applied to the skin or the chemical is injected. It stays in cancer cells longer than in normal cells. Several hours or days later, the special light is focused on the growth. The chemical becomes active and destroys nearby cancer cells.

PDT is used to treat cancer on or very near the surface of the skin.

The side effects of PDT are usually not serious. PDT may cause burning or stinging pain. It also may cause burns, swelling, or redness. It may scar healthy tissue near the growth. If you have PDT, you will need to avoid direct sunlight and bright indoor light for at least 6 weeks after treatment.

Radiation Therapy

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. The rays come from a large machine outside the body. They affect cells only in the treated area. This treatment is given at a hospital or clinic in one dose or many doses over several weeks.

Radiation is not a common treatment for skin cancer. But it may be used for skin cancer in areas where surgery could be difficult or leave a bad scar. You may have this treatment if you have a growth on your eyelid, ear, or nose. It also may be used if the cancer comes back after surgery to remove it.

Side effects depend mainly on the dose of radiation and the part of your body that is treated. During treatment your skin in the treated area may become red, dry, and tender. Your doctor can suggest ways to relieve the side effects of radiation therapy.

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