In part 1 of this Frontline Forum series, John M. Strasswimmer, MD, PhD; Andrew H. Weinstein, MD; Neal Bhatia, MD; Laura Ferris, MD; and Aaron S. Farberg, MD, discuss solutions for managing and treating patients with basal cell carcinoma.
The number of basal cell carcinoma (BCC) cases continues to grow, specifically in patients in their 40s, according to panelists of a recent Frontline Forum. The trend in this age group may stem from adverse effects of long-term indoor tanning1 and increased time for outdoor activities without proper sun-protective behaviors.2 In the custom Frontline Forum discussion New Directions in the Management of Basal Cell Carcinoma, the panel shared how to initiate conversations surrounding available treatment options and the potential for treatment resistance with their patients. Lastly, they highlighted the importance of a multidisciplinary team to improve outcomes in the management of patients with BCC.
Misinformation, confusion, and lack of information on the risks of sun exposure and tanning booths are the culprit behind many cases of BCC, the panel of experts explained. Younger generations are still using tanning booths or are going to the beach while using the wrong type of sunscreen—or worse, some believe sunscreen itself causes cancer. Older generations did not use sunscreen and, as a result, have BCC onset due to UV overexposure.
“When I look at a list of risk factors for nonmelanoma skin cancer, [BCC] in particular, I’d really like to see the [UV] exposure be bolded and magnified, because that plays a very important part [in] who gets these tumors,” Farberg said. “I always jokingly say to patients, ‘The biggest risk factor is you’re a golfer or you have a home in Florida,’ or ‘It is even worse if you have both, because you’re just getting a significant amount of sun exposure.’ And it really is not necessarily a generational thing, either.”
Over the years, research has identified physical and genetic risk factors that make individuals more vulnerable to developing BCC. Similarly, there are known clinical risk factors (eg, organ transplantation) that increase BCC risk by a factor of 6.3
“One of the things we did was—and I credit my colleagues—reach out to our [organ] transplant group after seeing a few horrendous squamous cells and [asked], ‘Why don’t we work a little more closely? Why don’t we see patients before they’re transplanted and give at least some counseling?’” Ferris said, as she reflected on the trend changes in patients who have undergone organ transplant. “[It is important to] see who is at high risk and who needs to be followed up with more. We’re seeing a lot more of those patients now, and they are still mostly [patients with] squamous cell carcinoma.”
Although head-to-toe screening is essential for detection, Weinstein said certain entities, such as the US Preventive Services Task Force, do not recommend full screenings because they are not cost-effective.4 He added that preventive screenings are not covered by insurance in most states.
“In Florida, we have a bill pending right now, which I think is going to pass, that will mandate insurance companies pay for screenings,” Weinstein said. “But it’s not something that is looked at as favorable [or] reasonable by insurance companies or, in fact, other policy makers.” As a result, educating primary care colleagues is an important avenue for early detection. Ferris told her colleagues about the successful primary care–based skin cancer screening initiative she helps lead in Pittsburgh, Pennsylvania. As part of a validated curriculum, they teach primary care doctors about melanoma, basal cell, and squamous cell carcinomas, and they encourage primary care doctors to integrate skin screenings as part of routine physicals. “It doesn’t have to be with dermoscopy and between every finger and toe, but just have the patient get in a gown and look,” she said. “We can’t do it alone in dermatology. We just don’t have the workforce. And we’ve got so many other things we treat, [so] for us to have dedicated screening visits for every patient is probably notfeasible. Working together with primary care—having a little more education and just the idea of everybody [getting] into a gown so at least you’re not missing the bad stuff—is important.”
The panel noted that patients may ignore or attempt to cover aggressive-growth BCC, such as using bangs to cover BCC growing on the forehead or using a beard to cover a growth on the chin. These patients often do not want to discuss the issue, which adds a psychological element to treatment. The experts stressed that although BCC is easily curable, avoiding care can result in greater treatment measures, such as extensive surgery.
Strasswimmer noted that for patients who wait too long and develop advanced BCC, there is no Current Procedural Terminology code; all incidences are reported as BCC, so it is difficult to know the number of individuals who have the advanced form of the disease. An estimated 1% to 10% of those diagnosed with BCC have an advanced form of it.5 “Curettage, excision, [and] small Mohs might not be good options for them,” he said.