Crossing paths again weeks later, his colleague had the same scab. “I looked at him and said, ‘You really should have that looked at,’ and he said, ‘Oh, it’s just a scab, I keep hitting it when I shave,” says Dr. Lebwohl. Ultimately, his colleague did get it looked at by a dermatologist. It was skin cancer, more specifically basal cell carcinoma (BCC). Skin cancer is the most common type of cancer in the United states, and BCC is the most frequently occurring of all forms of cancer, according to the Skin Cancer Foundation. (1) Basal cell carcinoma, which can appear, as in the case of Lebwohl’s colleague, as a minor irritation, has more than 4 million cases diagnosed annually. And like Lewohl’s colleague, a wound that won’t heal is just one possible manifestation of basal cell carcinoma. RELATED: What Doctors and Specialists Treat Skin Cancer?
What Is Basal Cell Carcinoma (BCC)?
Skin cancer has two major classifications: nonmelanoma and melanoma. Melanoma is usually more serious. Basal cell carcinoma (BCC) falls under the nonmelanoma category, along with squamous cell carcinoma, which is the second most common form of skin cancer after BCC. BCC develops when there’s an uncontrolled growth of the skin’s basal cells, which line the deepest layer of the epidermis — the skin’s outermost layer. It almost never spreads to other parts of the body and it’s rarely fatal, although it can invade surrounding tissue and be disfiguring if it’s not treated. (2) Basal cell carcinoma is typically found in areas exposed to the sun, such as the head, neck, and arms. Harvard Health Publishing estimates that nearly 90 percent of basal cell carcinomas occur on the face. (2) It’s a common cancer, and highly treatable. (3) Therapies currently used to treat basal cell carcinoma offer an 85 to 95 percent recurrence-free cure rate, meaning the specific area on the skin being treated is effectively cured after the first round of treatment, according to Moffitt Cancer Center. (4) Increased risk for basal cell carcinoma includes a history of blistering sunburns in youth and intermittent or chronic exposure to the sun. A contributing factor could be growing up in a tropical place, under an ozone hole, or near the equator, says Mary Stevenson, MD, an assistant professor of dermatology at NYU Langone Health and a dermatologic surgeon specializing in Mohs surgery treatment for skin cancer. “People think that as long as they put on sunscreen they’re protected, but if you’re still getting burned or tanned your skin hasn’t been protected in the way that you think,” says Dr. Stevenson. “Maybe you have some protection, but you’re still doing damage to the DNA, which can also cause photoaging, wrinkles, and sun spots.” Stevenson urges people with fair skin and sensitive skin to be extra vigilant about sun protection. “I often tell patients there are some things that aren’t fair. Some people can eat whatever they want and stay very trim, and some people can be in the sun and not have as many issues as others,” she says. While people with fair skin may be at a higher risk, it’s another common myth that people with a darker skin tone are immune to the effects of being in the sun unprotected. Skin cancer occurs in all skin colors. “The cheat sheet is, whatever color is under your double-covered areas, so under your bra or underwear, your skin should look that same color all over your body,” says Stevenson. Lebwohl says another group at a higher risk for skin cancer are people who take medications that suppress the immune system, such as transplant patients, or patients with advanced HIV. RELATED: Your Diet May Help Prevent Sun Damage Anthony M. Rossi, MD, a dermatologic surgeon at Memorial Sloan Kettering Cancer Center in New York City who specializes in Mohs micrographic surgery and skin cancer treatment, says one of the most common scenarios is when people say they thought they had a pimple, but it wouldn’t heal or go away. “Warning signs for basal cell carcinoma include something that’s red, crusted, scaly, not healing, bleeding, or even a new shiny pearl papule” says Dr. Rossi. Basal cell carcinoma can also appear atypically — it can be flat with a whitish discoloration or appear as a bump on the skin that’s pink or brown, says Rossi. There are multiple subtypes of BCC, which, characteristically, have different degrees of pigmentation and can be broad ranging in appearance. (8) This type of skin cancer rarely causes pain as it develops. Because it can look like a scab and appear to heal repeatedly without growing, people can go for months or even years thinking the skin abnormality is just a sore or wound. If you notice a spot that won’t heal or constantly bleeds you should see a dermatologist, says Lebwohl.(9) RELATED: What Is an Actinic Keratosis? Stevenson says during the diagnosis process dermatologists are looking for papules with skin cancer characteristics. Sometimes dermatologists will use a tool called a dermatoscope, which uses a polarized light to look for other signs of skin cancer. With their training, dermatologists should be able to tell patients if the lesion is benign or something that should be removed because of a skin cancer concern. RELATED: Do You Need to Wear Sunscreen Indoors? Treatment options include one or a combination of these methods: (3)
SurgeryRadiation therapyImmune response modifiersPhotodynamic therapyTopical chemotherapyCryotherapyMedication to shrink or slow tumor growth
Surgery is the most common treatment, and micrographic surgery is considered to be the gold standard. (11,12) In that category, Mohs surgery, which allows surgeons to closely examine the margins — the area surrounding the tumor — to make sure no cancer cells have encroached in those areas has the highest cure rate of all therapies and is especially effective for high-risk basal cell carcinomas. (9) “With Mohs micrographic surgery, the dermatologist is both the surgeon and the pathologist,” says Rossi, explaining Mohs surgery. “You’re actually examining all the margins and looking at it in real time, whereas in a traditional excision, the surgeon removes the tissue and sends it to a pathologist and they examine only a portion of the margin.” Mohs surgery is often used for large tumors, tumors where the edges are not well-defined, tumors in sensitive locations such as on the head or face, hands, or genital area, and for tumors that have come back after other treatments. (3) After surgery — which in addition to Mohs surgery includes curettage and electrodesiccation and excision — radiation therapy is commonly used, especially for patients who aren’t able to have surgery or patients with BCC in areas that are hard to treat surgically. (3)
Scarring After Surgery
One consideration many patients don’t always initially think about is the cosmetic aspect of treatment, especially if the tumor is in a highly visible area. For surgery, Rossi encourages doctors and patients to discuss and understand what scars might look like and how big the scars will be after surgery. “Usually scars get better around the three- to six-month mark, and scars will continue to improve over the year,” says Rossi. “You can help those along with lasers and other cosmetic treatments.”
The Stages of BCC
Stage 0 Cancer is found only in the original tumor in the skin and only in the epidermis. It hasn’t spread to the dermis. (13)
Stage 1 The tumor is two centimeters wide or smaller. It may have spread into the dermis, but it hasn’t invaded the muscle, cartilage, or bone and it hasn’t spread to lymph nodes or other organs. (13)
Stage 2 The tumor has grown larger than two centimeters and may have spread into the dermis. It hasn’t invaded muscle, cartilage, or bone and it hasn’t spread outside the skin. At this stage, tumors can be any size if there are two or more high-risk features. (13)
Stage 3 The basal cell carcinoma has spread to areas besides the skin such as muscle, bone, cartilage, or lymph nodes. The cancer has not spread to distant organs at this stage. (13)
Stage 4 At this stage, the cancer can be any size; it may have spread to nearby lymph nodes, and it has spread to areas outside the skin such as distant organs like the brain or lungs or has invaded the skeleton. (13)
RELATED: More Evidence That Sunscreen Chemicals Seep Into the Bloodstream “The number one thing people can do is to practice good sun protection and sun avoidance, meaning wear sunscreen and protect the skin from getting sun damage,” says Stevenson. “It’s also important to get skin checks regularly for early detection.” Stevenson says if someone is prone to skin cancers — for example, has very fair skin, sunburns as a child, or a history of skin cancer in the family — it’s better to go out in the late afternoon or early morning when the sun isn’t as strong, or stay primarily in the shade. Anyone spending time in the sun, regardless of complexion, should practice sun protective behaviors, including wearing sunscreen. The Centers for Disease Control and Prevention (CDC) recommends a sunscreen with a minimum sun protection factor (SPF) of 15, and UVA and UVB broad spectrum protection. It also advises people to stay in the shade as much as possible and wear protective clothing including brimmed hats and sunglasses. (14) Stevenson suggests looking for a SPF over 30. Lebwohl says the SPF number directly correlates with the amount of protection it gives you. He says to divide the amount of time in the sun by the SPF number. For example, if someone is in the sun for 60 minutes, and wearing SPF 30, it’s as if they were exposed to two minutes of damaging rays rather than the full 60 minutes. There’s also a fair amount of misinformation around sunscreen, according to Lebwohl, including that some sunscreens are unhealthy for you, particularly chemical sunscreens. “There’s not one iota of evidence other than a rare allergy that a single person has ever been harmed by sunscreen,” he says. “There is a ton of evidence that patients have been helped by sunscreen.” Perception is a key factor in society’s attitude toward sun protection. Quality education about skin cancer prevention and sun damage is changing perception for the better, says Lebwohl. So, while a post-vacation tan may have garnered compliments in years past, people are starting to understand and accept that there’s no such thing as a “healthy tan.”
