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Basal cell carcinoma

Definition
BCC is the most common form of skin cancer, originating from the basal cells in the skin's lower layer, the epidermis.
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Pathophysiology
The pathophysiology of BCC involves damage to the DNA of skin cells, primarily due to UV radiation exposure. This damage can lead to genetic mutations, causing the cells to multiply rapidly and form a tumor.
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Epidemiology
The incidence of BCC in 2021 in the US was estimated at 439 per 100,000 person-years in women and 640 per 100,000 person-years in men. The incidence of BCC in Australia is estimated at > 1,000 per 100,000 person-years.
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Disease course
Clinically, BCC often presents as raised, pearly nodules or pink patches with rolled edges. These lesions may also exhibit telangiectasia, ulceration, or bleeding. They are most commonly found on sun-exposed areas of the body, such as the face and neck.
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Prognosis and risk of recurrence
The prognosis for BCC is typically excellent due to its slow growth and low metastatic potential. Most cases can be effectively managed with early detection and treatment, although recurrence is possible.
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Key sources
The following summarized guidelines for the evaluation and management of basal cell carcinoma are prepared by our editorial team based on guidelines from the U.S. Preventive Services Task Force (USPSTF 2023; 2018), the British Association of Dermatologists (BAD 2021), the American Society of Plastic Surgeons (ASPS 2021), the British Gynaecological Cancer Society (BGCS 2020), the American Society for Radiation Oncology (ASTRO 2020), the European Association of Dermato-Oncology (EADO/EDF/EORTC 2019), and the American Academy of Dermatology (AAD 2018).
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Guidelines

1.Screening and diagnosis

Indications for screening: as per USPSTF 2023 guidelines, insufficient evidence to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adolescents and adults.
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  • Diagnosis

2.Diagnostic investigations

Noninvasive evaluation: consider obtaining dermatoscopy, reflectance confocal microscopy and/or optical coherence tomography to improve the diagnostic accuracy in patients with difficult-to-recognize BCCs.
B

3.Diagnostic procedures

Biopsy: perform a punch, shave, or excisional biopsy, depending on the characteristics of the suspected malignancy (including morphology and location) and the physician's judgment, for the diagnosis of BCC.
B
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4.Medical management

General principles: as per BAD 2021 guidelines, refer all adult patients with high-risk BCC and all adult patients with low-risk BCC to a local skin multidisciplinary team or a specialized skin cancer multidisciplinary team member in the absence of an accredited general practitioner with an enhanced role or if the primary care facility is not suitable for surgery.
A

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  • Topical agents

  • Hedgehog pathway inhibitors

  • Chemotherapy

  • Combination therapy

5.Therapeutic procedures

Curettage and electrodessication: as per BAD 2021 guidelines, do not perform curettage and cautery in adult patients with high-risk BCC unsuitable for or declining Mohs micrographic surgery or standard surgical excision.
D

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  • Cryotherapy

  • Definitive radiotherapy (indications)

  • Definitive radiotherapy (dosing)

  • Postoperative radiotherapy

  • Photodynamic therapy

  • Laser therapy

6.Surgical interventions

Surgical excision: as per BAD 2021 guidelines, perform standard surgical excision as a first-line treatment option in adult patients with low-risk BCC.
A
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7.Specific circumstances

Patients with nevoid basal cell carcinoma syndrome: as per BAD 2021 guidelines, offer vismodegib as a treatment option in adult patients with advanced BCC unsuitable for Mohs micrographic surgery, standard surgical excision or radiotherapy, including patients with nevoid BCC syndrome, following discussion at a multidisciplinary team.
A

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  • Patients with vulvar BCC

8.Patient education

General counseling
Provide verbal and written information about BCC in all adult patients with BCC, including the nature and prognosis of BCC, available treatment options and the ongoing need for sun protection and self-surveillance of their skin as part of prevention or early detection of future skin tumors.
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Inform all adult patients with BCC declining all treatments that the risk of significant progression of the tumor is at least 25% over 2-5 years.
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9.Preventative measures

Primary prevention
Counsel persons with fair skin types aged 6 months to 24 years and parents of young children about minimizing exposure to UV radiation to reduce the risk of skin cancer.
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Offer counseling selectively in adults > 24 years with fair skin types about minimizing exposure to UV radiation to reduce the risk of skin cancer, taking into consideration the presence of risk factors for skin cancer.
B

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  • Secondary prevention

10.Follow-up and surveillance

Postoperative evaluation
Do not offer routine follow-up in patients with adequately treated isolated BCC, unless for a postoperative review.
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Offer a postoperative review in adult patients with adequately treated BCC by an appropriate healthcare professional, in either secondary or primary care, if possible.
E

More topics in this section

  • Skin reconstruction after tumor resection (timing)

  • Skin reconstruction after tumor resection (perioperative antibiotics)

  • Skin reconstruction after tumor resection (perioperative antithrombotics)

  • Skin reconstruction after tumor resection (perioperative analgesics)

  • Skin reconstruction after tumor resection (follow-up)

  • Surveillance for future malignancies