Sun exposure often a factor in this slow-growing skin cancer

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Basal cell carcinoma is the most common form of skin cancer, and we'll learn all about it from my guest dermatologist Ramsay Farah. Dr. Farah is an associate professor and division chief of dermatology at Upstate. Welcome back to "The Informed Patient," Dr. Farah.

[00:00:30] Ramsay Farah, MD: Thank you. It's good to be here.

[00:00:33] Host Amber Smith: Basal cell carcinoma was in the news not too long ago when First Lady Jill Biden had surgery to remove a spot, and her doctor wound up discovering and removing a second spot at the same time. Is it typical for there to be more than one of these skin cancers that need to be removed?

[00:00:52] Ramsay Farah, MD: Yes. I would say it is quite common. It's common in the sense that if you've had one skin cancer, you've had enough kind of DNA damage to your skin to produce sufficient DNA changes, that it's going to be much more likely, statistically, to get a second skin cancer. So usually people with one skin cancer, I would say, very often have another skin cancer down the line when more time has passed.

But I have seen many times in our practice, the concurrence of two simultaneous basal cells. So it does happen fairly frequently.

[00:01:31] Host Amber Smith: How serious is basal cell carcinoma?

[00:01:35] Ramsay Farah, MD: Well, of all of the skin cancers to get, it's probably the one that is the most favorable to get. And the reason I say that is because it's very slow growing. It rarely, if ever, metastasizes, which means it spreads to other parts of the body.

Now, that's not to say that it can't do that. It can. So certain basal cells that are neglected for many years, like, five years or 10 years, and of course, how easily they metastasize also depends on where they occur. So if it's occurring on the back, it's much less likely to spread.

But if it's occurring anywhere on the head and neck area, near the eyes, or the ears, for example, then it can actually spread and track down some of the fascial planes of the face and so forth. So the bottom line is, if you want to say, it's a good cancer to have, I suppose you could say that in the sense that it's very slow growing, and if it's not neglected, by and large, it's easily treated without a problem.

But again, the qualifier is if you neglect them, they can be trouble. And metastasis is one way that they can be trouble. But the more common way they can be trouble is they can be locally destructive. So for example, If you have a basal cell on the nose, while it may not spread to other body parts, it can certainly degrade the nose and involve a large part of the nose so that the surgery could be very, very extensive.

[00:03:14] Host Amber Smith: So the removal might cause some disfigurement in that case?

[00:03:19] Ramsay Farah, MD: Well, we've gotten a lot better at avoiding disfigurement, but if it's large enough, then yes, it could be disfiguring, even with the best surgical techniques of repair. I would say it rarely gets to the point of disfigurement, but of course, also, you have to keep in mind that a scar is in the eye of the beholder. A minor scar for one patient may be something that they're distraught about and they might not like it a lot. There could be a more extensive scar on another patient, and they're not at all bothered by it. So when we use the terms disfigurement and things like that, we have to keep in mind that it is in the eye of the beholder. I just want to qualify that.

[00:04:10] Host Amber Smith: What is a basal cell, anyway? What is its job in our body? Why do we have basal cells?

[00:04:18] Ramsay Farah, MD: Basal cell is the bottom most cell in your skin. There are several layers to the skin. There's the epidermis, the top part; the dermis, the middle part where all of your collagen is; and then there's the fat layer. Oftentimes people don't think of the fat as part of the skin, but it is. So if we go back to that very top layer, the epidermis, the epidermis itself has multiple layers, the bottom of which is comprised of these basal cells. And they are defined as pluripotent cells. So in other words, they are the cells from which your skin is made.

They are the cells that differentiate into the different parts that make up your skin. So that is their job. They are kind of like the stem cell of the skin. And, they can get DNA damage as well. And when they do, they proliferate in an uncontrolled manner. Proliferate means they kind of grow, and grow, and grow and they never stop. And that's when you get a basal cell.

[00:05:26] Host Amber Smith: So how would somebody know that they have basal cell carcinoma?

[00:05:32] Ramsay Farah, MD: Clinicians are -- specifically dermatologists, of course -- are trained to recognize the clinical features of basal cells. And I can go through those characteristics that clinicians use.

But for the layperson, basically you want to watch out for a new spot on your skin, a spot that bleeds very easily. And by that I mean if you're toweling your face off after a shower and you've got a spot that consistently bleeds, that's not a good sign. A spot that is eroded and just keeps coming and going, healing, and then gets eroded again, that's another sign. And then, a spot that's actually growing. So a new spot, a growing spot, a spot that never heals. Those can be signs of basal cells.

[00:06:28] Host Amber Smith: Can your trained eye tell the difference between a basal cell carcinoma that's caused by sun exposure, regular sun exposure, versus indoor tanning machines?

[00:06:41] Ramsay Farah, MD: No, they would look the same. So the basal cell carcinoma is kind of the end point of DNA damage, and those cells have become malignant, and they turn into the basal cell. How you get that DNA damage doesn't necessarily change the appearance of the basal cell. Once you've got enough DNA damage to get the basal cell, they'll all look like basal cells. So I can't look at a basal cell and say, "oh, you got that because you were on the beach," versus, "oh, because you were in a tanning salon." So no, it doesn't work that way.

[00:07:21] Host Amber Smith: But will they show up in areas of your body that would've had sun exposure?

[00:07:27] Ramsay Farah, MD: Yeah, so almost certainly they will show up in sun exposed skin, the most DNA damaged skin from the sun. So the rates of basal cell are going to be more common on the head and neck area than they are on the foot, for example. Now that doesn't mean you can't get a basal cell anywhere on your body. You can - even in the groin area, that's of course, covered much more than the face. So, sun is the major driving force for basal cell cancers, and that's why sun exposed areas are going to have them more commonly than non sun exposed areas. But I do want to make clear that anywhere where you have skin, you have the potential of getting a skin cancer.

[00:08:13] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Ramsay Farah. He's the chief of dermatology at Upstate, and we're talking about the most common of skin cancers, basal cell carcinoma.

I'd like you to compare basal cell carcinoma with squamous cell carcinoma. We hear about that, as well. What is the main difference between those two types of skin cancers?

[00:08:39] Ramsay Farah, MD: So basal cell is the most common skin cancer, um, in the skin. It's also, incidentally, the most common human cancer. Squamous cell is number two in terms of its frequency in the skin. And one of the main differences is the cell of origin. So basal cells come from basal cells, and squamous cells come from keratinocytes, which is another skin cell in the epidermis of the skin, that top layer of the skin. So, basal cells kind of tend to look a little more pearly. And what I mean by that is, when you shine a light on it, they sort of reflect the light the way a pearl would. Also, you can sometimes get the illusion that you're looking through the skin when you're looking at the basal cell. And basal cells have very tiny telangiectasias on them, or kind of very tiny broken capillaries that you can see.

Squamous cells, on the other hand, look keratotic, more keratotic, which means they produce a lot of scale. They can produce what looks like a horn on the skin. They can tend to be a little bit more painful clinically, and they tend to grow faster on the skin than basal cells do. And squamous cells have more of a propensity or more of a chance of spreading than basal cells do. So they grow faster, and they can metastasize or spread more easily than basal cells, and they look like they've got a lot of hard sort of crumbly like scale on top of them, versus the basal cells.

[00:10:30] Host Amber Smith: Do you have to differentiate which one you're dealing with before you start treatment?

[00:10:35] Ramsay Farah, MD: Yes. So it's always a good idea to know what kind of a skin cancer you're dealing with so that you can focus your treatment most accurately.

There are so many factors that dictate what kind of treatment you're going to get, whether you're going to have a surgery, what kind of surgery, what kind of clinical margins you want to excise, whether you are going to elicit the help of colleagues in a multidisciplinary approach, like an ENT colleague, a plastic surgery colleague, an oncology colleague, which is a cancer doctor. All of those things are means by which we can approach and treat a skin cancer. And, we use them to varying degrees, depending on the cancer. So I'm much more likely, for example, to have the help of an oncologist when I have a melanoma on my hands than when I have a basal cell.

So yes, it's actually not just nice to know what skin cancer you're dealing with. I think it's an absolute necessity for the doctor.

[00:11:47] Host Amber Smith: So what are the treatment options for basal cell carcinoma?

[00:11:52] Ramsay Farah, MD: They are many, and they range from old treatments to new treatments. They range from creams to surgeries. But, in short, one of the older -- I'll start off with the older treatments that's really fallen out of favor, just for completeness -- but in the past they used to freeze basal cells. So if you froze a basal cell with liquid nitrogen, which is a very, very cold spray, you basically froze the skin that was involved with the basal cell and you killed that skin, and it basically scabs off and it takes the basal cell with it. So that is an old way of treating it, but it's fallen out of favor because it results in unacceptable scars in terms of today's standards, and also the cure rates are not really acceptable given some of the better treatments we have.

Freezing is one thing. You can also, depending on the subtype of the basal cell, meaning if the basal cell is a very thin basal cell and it's not occurring on areas of skin that have hair, you can do an electrodesiccation and currettage, which means that you can basically burn and scrape it off.

Similarly, those very thin basal cells not found on hair-bearing areas -- so, for example, on the forehead would be an example of a non hair bearing area. You can also use one of two chemotherapy creams, and you can use a cream against it. So you can use a cream, you can burn and scrape it off. In the past we used to freeze them off.

But, more and more the standard of care is becoming surgery, right? So you would just cut it out, and again, how you cut it out depends on where it is. So generally speaking, if you have a basal cell on the head and neck area, meaning anywhere from the neck up, you can do a special kind of surgery called Mohs surgery, M O H S. And what's special about Mohs is that it has the highest cure rate, anywhere between 98 to 99% for a first time basal cell. And, it's tissue sparing. So it means we can achieve that cure rate without cutting off a lot of extra skin, which is, of course. More important on the head and neck area than it would be on your back where there is lots of extra skin. So you can do Mohs surgery. You can also excise them, meaning you can cut them out in a more traditional way that is non Mohs.

And finally, two other options for very large basal cells or inoperable basal cells for whatever reason, whether they're large or the location or the age of the patient and their underlying medical conditions which would make them a poor surgical candidate. You can use radiation against basal cells.

And then the very last modality is to give an oral chemotherapy agent, and there are a couple of new medicines out that increasingly have been used in basal cell, and they're used either as a primary treatment. Or even to shrink the basal cell down, if it's one of those very large neglected tumors that we were talking about earlier, you can shrink them down with these medicines and then do a surgery, which would be far less heroic when it's smaller. There's really a large selection of possible treatments.

[00:15:32] Host Amber Smith: And when you say "cure rate," that means it doesn't grow back after it's removed?

[00:15:38] Ramsay Farah, MD: Yeah, exactly. So it doesn't grow back. Now that doesn't mean you can't get another one at a different location, right? Because that depends on how much DNA damage is in your skin. But for a lesion itself that is a first time basal cell treated with Mohs, yes, that cure rate can be 98 to 99 percent.

[00:16:02] Host Amber Smith: And then we talked a little about this at the beginning, but if someone has basal cell carcinoma, never has it diagnosed, therefore never has it treated, what might happen to that basal cell carcinoma? Will it keep spreading?

[00:16:17] Ramsay Farah, MD: Yeah, I mean, it'll keep spreading essentially forever. So it'll keep going, and going, and going. And that's the kind of scenario where you can get into trouble depending on where it is, right?

So if it's a basal cell that's close to your eye, then in fact it can metastasize. It can go into the eye and then potentially into the brain.

If it's on your scalp, it can start to erode away at the bone. So those scenarios are the scenarios that result in the most trouble and morbidity, and even mortality, meaning death for a patient. Again, for a basal cell, it's rare, but the point you're trying to make is very important. If you don't treat a basal cell, it's not going away. It's going to keep growing forever.

[00:17:05] Host Amber Smith: When people go to their primary care provider for their annual exam, is this something they should bring up to their primary care provider, or do they need to see a dermatologist regularly to have marks or moles or things that seem to pop up on their skin looked at regularly?

[00:17:24] Ramsay Farah, MD: Patients have two options. They can go to their primary care, or they can go directly to a dermatologist. I mean, I think the fact of the matter is, primary care doctors need to be very well versed in these skin cancer issues, at least the top three skin cancers -- basal cells, squamous cells and melanoma -- because a lot of people go to primary cares. More people go to primary cares than go to dermatologists simply because there are more primary cares and they've established wonderful relationships with them and trusting relationships.

Primary cares are in many ways on the front line. I think they need to be doing skin cancer screens, and then if they see something that they're suspicious of, then they should send it to a dermatologist for sure.

But of course people have the choice of going directly to a dermatologist, and dermatologists, really all they do is they do skin, so I think they've become quite expert at seeing lesions, all kinds of lesions with all kinds of nuances and are able to make a very accurate diagnosis. So obviously I'm a little bit prejudiced. I'm a dermatologist, so I think people should go to a dermatologist because that's what we do. But I guess what I was trying to say with the primary care is, primary cares also have a role in screening and then getting those patients to us if they find something suspicious.

[00:18:54] Host Amber Smith: Well, Dr. Farah, I really appreciate you making time to tell us about basal cell carcinoma. Thank you.

[00:18:59] Ramsay Farah, MD: My pleasure.

[00:19:00] Host Amber Smith: My guest has been dermatologist Ramsay Farah. He's an associate professor and division chief of dermatology at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.