what are the treatment options?

The treatment for BCCs is usually surgical, and effective. Between 95-98% of patients are cured. Treatment may be more difficult if a BCC has been left for a very long time or if it is in an awkward place, such as near the eye, nose or ear.

Your treatment will be planned by the hospital multidisciplinary team of doctors and other health care professionals. They will tell you about the risks, benefits and side effects of the treatment you are offered, and how they may affect your life afterwards. Your wishes will be taken into account.

You will then need to agree to the treatment before it can start. This is called giving your consent. Don’t be afraid to ask questions if there is anything you don’t understand.

You will usually have treatment as an outpatient, so it should not disturb your routine too much. But it is a good idea to think about whether your treatment plan will have any practical or financial implications for you and your family. The Oncology Nurse Specialist is available to offer help and support if you have any questions or concerns. The section, Who else can help me? has the contact details of the Oncology Nurse Specialist.

Cryotherapy
Cryotherapy uses a very cold substance (liquid nitrogen) to remove the tumour by freezing it. It is only suitable if the cancer is very small. You will usually be treated in an outpatient clinic, and you will be able to go home the same day.

When the liquid nitrogen is sprayed on to the affected area you may feel a painful stinging sensation. Afterwards it may feel like a burn. A day or two later the skin may blister. It may be a blood blister. This may need draining, but the top of the blister should not be broken. It will need to be covered with a dressing until a scab has grown. After about a month, the scab will drop off, and you may have a white scar.

You will have a follow-up visit between 6 weeks and 6 months later to check that the treatment has been effective. In some cases the treatment may need to be repeated.

Surgery

Curettage & Cautery
Curettage and cautery may be used for small or surface BCC. First the treatment area is numbed with a local anaesthetic. Then, a spoon-shaped instrument with a sharp edge (a curette) is used to scrape away the cancer. The wound is then heat-sealed (cauterised). The treatment may leave a flat, white scar.

Surgical excision
A standard treatment for a BCC is surgery to cut it out along with some of the surrounding normal skin. This surgery cures 98% of the patients who receive it. It is a straightforward operation, performed under local anaesthetic. You will be given an injection to numb only the area of operation. On small wounds, stitches will be removed after a few days. For wounds on thicker skin, such as on the back, they may left in for up to two weeks.

Mohs’ micrographic surgery
In some cases a special type of surgery, called Mohs’ micrographic surgery may be used if simple surgery is not suitable. The obvious tumour is first removed by excision, or sometimes curettage. Then, after you have had a local anaesthetic, layers of skin are taken off around the tumour one layer at a time. Each piece removed is then examined in its entirety under a microscope, to see whether there are still cancer cells present at any point. This is done in order to ensure that all of the tumour is removed and to conserve as much healthy tissue as possible, and so minimise the size of the defect. Repair of the effect may require a skin graft or skin flap.

Mohs’ surgery is most often used for a BCC that has recurred, or which may have spread to a surrounding area, particularly when the cosmetic look is important - on the face, or some areas of the head and neck.

You will usually be treated in an outpatient clinic, and you will be able to go home the same day.

Skin grafts and skin flaps
If surgery leaves a significant wound, or it is in a highly visible place, such as the face, a small skin graft or skin flap (plastic surgery) may be needed to improve the look.

For a graft, a thin layer of healthy skin is taken from another part of the body. To get the best colour match, skin is usually taken from behind the ear for a face graft. For a graft for other areas of the body, skin is taken from somewhere that is usually hidden, such as the inner thigh area. The two areas involved in the graft will look unattractive to begin with. Within a week or two they will have healed and the scars begun to fade.

In some cases, a general anaesthetic is needed.

With most operations you will be able to go home the same day. Very occasionally patients will need to stay in hospital for 1-2 days while the grafted skin sticks and heals.

For a flap, a slightly thicker layer of skin, including blood vessels, is cut from skin next to the BCC wound, and moved to cover the wound. It is usually all done under local anaesthetic, as part of the same surgical procedure.

• Preparing for a general anaesthetic
  In the few cases that need a general anaesthetic, your fitness for the anaesthetic will be tested, usually by a nurse specialist at a pre-assessment clinic. An appointment will be arranged with you before the planned date for your surgery. You will be asked about your general health, about any breathing or chest problems you have, about any medicines or supplements you are taking, and allergies. A blood sample may be taken. Your pulse and heart-rate may be monitored. You will not be asked to do exercises.

Additional treatment
Careful examination of the tumour and surrounding tissue removed during surgery will help your doctors to decide whether to recommend any additional treatment.

We have a list of questions you might like to ask your surgeon, and more general information about surgery.

Radiotherapy
Radiotherapy uses radiation to kill cancer cells. It may be given from inside or outside the body. When given from outside the body it is called external beam radiotherapy, and a machine directs high energy x-rays at the cancer. External beam radiotherapy is normally used in treating BCC.

Photodynamic therapy (PDT)
Photodynamic therapy is a new form of treatment for BCC. Its use is promising for thin or superficial BCC, but it is not yet an established treatment.

A light-sensitive drug in a cream is spread on to the area to be treated 4-6 hours beforehand. Then, light from a special light source is beamed at the treatment area. This triggers the chemical that destroys the cancer cells, while causing very little damage to the skin. Exposure to the light will be for between 20-45 minutes, but it may be less with some machines. Two treatments are usually given.

If needed, you will be given a local anaesthetic before treatment. Afterwards, you may be given a steroid cream for pain-relief at home. The wound is similar to a graze, and its care is the same. The skin will heal within 7-10 days, but it depends on the size of the wound. Most patients will not scar.

Topical therapy (creams)
A special cream that interferes with the growth of the BCC cells can be applied to the skin (called topical application). You will normally be asked to use the cream for 3-4 weeks. The most commonly used is 5-Fluorouracil (5-FU). Topical imiquimod looks promising, but its use and effectiveness are still being evaluated. Generally, these are only suitable for thin BCCs and they are not often used on the face (especially near the eyes).

After treatment
Whatever treatment you have had, you should be given clear, written instructions about the care of your wound. If you have had surgery needing stitches, you will be given instructions about when and where to get them removed. You should also be given follow-up information, with a contact telephone number of the Oncology Clinical Nurse Specialist, for your further information or assistance.