Is Basal Cell Carcinoma on Your Radar?

The Cancer Council of Australia names non-melanoma skin cancer (NMSC) as Australia’s most common cancer, and basal cell carcinoma (BCC) leads the way. Two out of three people in your care may be diagnosed with skin cancer. As a nurse, do you feel confident that you could identify abnormal skin lesions and organise a referral for your patient?

This slow growing tumour arises from damaged epidermal basal layer and hair follicle cells.

Occurrence:

• Usually sun exposed sites
• Predominantly head and neck, also trunk and less commonly across other skin sites
• More commonly in males and older people
• As single or multiple lesions
• In children and young adults, associated with genetic syndromes, for example xeroderma pigmentosum

Presentation

A BCC can present as one of several subtypes, each with specific characteristics of appearance, recurrence risk and aggressiveness. Unlike other skin cancers that can develop from a pre-existing lesion, BCCs arise on skin probably sun damaged, but otherwise appearing “normal”. Tumour appearance corresponds to the size, shape, location and growth habits of the tumour nests.

Main tumour features can include:

• Nodular:
  1. A pearly papule or nodule
  2. Eroded with bleeding (often from minimal trauma)
  3. Crusting
  4. Rolled (raised) edge
  5. Small branching visible blood vessels
• Superficial:
  1. Plaque
  2. Pink, scaling, well defined
• Morphoeic: pale, firm, flat or depressed – scar like

BCCs can also contain pigment, commonly appearing as black-blue or brown areas (pigmented BCC). It is important to differentiate a pigmented lesion from a melanoma.

Patient Cues

Be alert to a lesion that:

• Heals incompletely then breaks down repeatedly
• Bleeds on minimal trauma

Causes

The main cause of BCC is intense intermittent ultra violet radiation (UVR), resulting in:

• DNA damage, reducing genetic function, impairing normal cell behaviour
• Reduced skin immune function; our innate protection against skin cancer development

Risk Factors: UVR from natural or artificial sources; exposure pattern (recreational or occupational), severity (sunburn and blistering) and age (childhood or adult), induce skin changes – increasing susceptibility to skin cancer.

Additional risk factors include:

• Ionizing radiation
• Arsenic
• Immune suppression; time span and level of suppression (consider organ transplant patients)
• Exposures to petroleum byproducts (tar)
• Chronic tissue inflammation (scars or wounds)
• Personal or family history of BCC

Diagnosis

A clinical examination can often be sufficient. However, it’s important to appreciate that mixed morphology lesions are common, recurrent lesions may be active and infiltrate before being clinically apparent, and some anatomical sites, especially the face, can challenge the cosmetic and treatment outcomes. It’s important to confirm the presence of a BCC through a biopsy (a punch biopsy provides full-thickness tissue) or dermoscopy (visualisation of the upper dermal architecture and colours, correlating to histologic features).

You can examine the lesion under a bright overhead light, optimally natural light. By applying gentle stretch to the surrounding skin the lesion borders may become visible.

Treatment

BCCs respond to a range of treatments especially when identified and treated early. Well established tumours may extend deeply, invading nerves or cartilage (for example ear or nose) leading to local tissue destruction and, rarely, metastasis.

Treatments can be:

• Destructive; topical treatments such as photodynamic therapy leave no suitable tissue for confirmation of completeness of removal. Useful for lower risk tumours (the exception being radiotherapy).
• Excisional; provides histologic information on diagnosis, adequacy of removal and tumour risk.

Skin cancer is a very real threat, especially with Australia’s intense sun and beach/outdoors culture. As such, the Cancer Council of Australia advocates for opportunistic screening. Health professionals are encouraged to understand the risks of developing skin cancer to more easily recognise the “at risk” individual. Whilst the individual themselves are ultimately responsible and are encouraged to request regular skin checks. Encouraging patients to follow up after skin cancer treatment is also important. It is recommended that patients become familiar with their skin as recurrence and new lesions are always a possibility. Finally, a full skin check may identify lesions not visible to the patient.

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Resources

• Skin cancer screening
• Checking your own skin
• Clarke, P 2012, ‘ Non-melanoma skin cancers treatment options’ Australian Family Physician vol. 41, no. 7, viewed 8 November 2015, http://www.racgp.org.au/af[…]ns/

References

• Bader, RS 2015, ‘http://emedicine.medscape.com/ar[…]ll,’ Medscape, viewed 8 November 2015
• Duncan R, Van Onselen J, Ersser S 2010, ‘Skin cancer and its prevention’, in R Penzer & SJ Ersser (ed.), Principles of skin care: A guide for nurses and other health care professionals, Wiley-Blackwell, Chichester United Kingdom, pp. 195-219.
• National Cancer Institute (n.d.) Genetics of Skin Cancer for health professionals, viewed 5 November 2015
• Oakley, A 2015, ‘http://www.dermnetnz.org/le[…]ml’ DermNet NZ viewed 8 November 2015
• Papa, CM 1990, ‘Skin’, in HK Walker, WD Hall, JW Hurst, (eds.) Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Butterworths, Boston. Viewed 8 November 2015
• Ranaweera, A (n.d.), ‘http://www.dermnetnz.org/pa[…]ml’, viewed 5 November 2015
• Rosendahl, C, Cameron, A, McColl, I & Wilkinson, D 2012, ‘Dermatoscopy in routine practice; Chaos and Clues‘ Australian Family Physician vol. 41, no.7, pp. 482-487 viewed 8 November 2015
• Sinclair, R 2014, Skin carcinomas linked to increased risk of other cancers, viewed 5 November 2015
• Weedon, D. ed., 2010. Weedon’s Skin Pathology. 3rd ed. Churchill Livingstone Elsevier online text pp. 682-690; no city name found on the copyright page
• Zuber, TJ 2002, ‘Punch Biopsy of the Skin’, Am Fam Physician; vol. 65, no. 6 pp.1155-8 viewed 5 November 2015

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