I had seen a 60ish year old Caucasian patient in my hepatitis clinic numerous times as I was the clinician who treated him as he went through his 11 month treatment program successfully. Six months after finishing his treatment his blood levels still showed no evidence of a return of his hepatitis C virus, so I had dismissed him from any necessary follow-up.
So I was surprised to see him scheduled back on my clinic schedule. I walked into the exam room with a quizzical look on my face as I asked, “what brings you back into my clinic?”
“I don’t have a primary care physician, you’re the only one I’ve seen for the past couple of years. So I needed to ask you what you thought about this thing on my forehead.” Earl stated. With that he moved his second finger back and forth over his left forehead.
“Okay, let me grab a light and I’ll take a better look at it,” I replied.
I grabbed a hold of the wall mounted welch allyn otoscope light and shined it on Earl’s forehead. With the light shining over his left forehead, I used my finger to feel the skin he was questioning. He had a small raised and flat lesion in the center of his left forehead which was pearly white in color. It wasn’t very large, about ½ inch in diameter. The lesion’s border were irregular.
“Earl, I think you have skin cancer. It looks to be a basal cell cancer, which is the most common form of skin cancer. It’s easy to remove, but I’ll have to send you over to the dermatology (skin) clinic to have them remove it. So I’ll make you out a referral and you’ll have to call and make an appointment with them in 3 days, which is typically how long it takes for the referral to go through to them. Is that okay?”
“Yeah, just give me the number to call in 3 days and I’ll be happy to get this thing taken care of,” stated Earl.
“Okay, I’ll be right back, I have to get the clinic number for dermatology for you to call and a referral form,” I stated.
I came back and gave Earl the number he needed to call and his copy of the referral form.
“Nice to see you again, Earl. Don’t forget to call okay?”
“I won’t. “
With that I excused myself and went to go see another waiting patient.
Skin cancer is one of the most common forms of cancer there is. It is estimated that there are over 1 million patients per year who will have skin cancer. 80% of these skin cancers are of basal cell origin. The other forms of skin cancer are squamous cell cancer and melanoma.
Basal cell cancer is very common in Caucasian patients who have had years upon years of exposure to sun and its UV radition. A person has a 30% risk of having cancer over their lifetime.
Basal cell typically has 5 different appearances: 1) it can be red, raised, nodular in appearance, or 2) smooth, flat, glistening, pearl colored, or 3) a chronic non-healing ulcer, or 4) superficial, flat red colored lesion or 5) dark pigmented raised lesion.
About two weeks later I was walking out of clinic as Earl was just leaving the dermatology procedure room and he saw me.
“Sharon, thanks for sending me to the derm clinic. I did have basal cell cancer like you thought. Do you like my bandage?” Earl asked as he pointed to his 1 x 1” bandage on his forehead.
“You look cute. How did they remove the lesion?”
“I told them to go ahead and cut it out. So they numbed up my skin and removed it, then they put some stitches in. I have to come back in a week for them to remove the stitiches and they’ll tell me at that time whether they got it all out. Something about my needing clean margins which they won’t know until they get the pathology report back. They also told me that I have to be seen by them every year from now on to be checked for any further evidence of skin cancer.”
“Well, at least if any of your friends ask about your bandage you’ll have a good story to tell them. I’m glad you got it taken care of.”
“So am I.”
Basal cell cancer always needs to be addressed. It can become aggressive and spread locally. There are various ways of removing basal cell cancers. These methods include:
1) Surgical excision, which is where the lesion is removed by cutting it out
2) Mohs micrographic surgery, which is a surgical procedure where the dermatologist checks the skin edges of the lesion under the microscope to make sure they got it all removed (what we call histology)
3) Cryosurgery, which is a freezing technique
5) Chemotherapy, topical application of 5 FU and imiquimod
The method by which the basal cell cancer is removed is based upon where the lesion is located, the likelihood of it’s re-occurrence, and the patient’s preference. So if you have any suspicious skin lesions, please make an appointment to be seen by a dermatologist (physician who specializes in skin diseases) to have it checked, or have your primary care physician check it out for you.