OnCo
cancersCancer

Basal cell carcinoma

aka BCC

Basal cell carcinoma is the most common cancer of all, caused by sun exposure and almost never fatal. Nearly all are removed surgically; the rare advanced cases are treated with drugs that block the hedgehog signalling pathway, and with immunotherapy if those fail.

Basal cell carcinoma arises from hedgehog-pathway activation in nearly every case, through loss of PTCH1 (~70%) or activating SMO mutations (~10-20%); germline PTCH1 loss causes Gorlin (basal cell nevus) syndrome. Subtypes range from indolent nodular and superficial to infiltrative, morphoeic and basosquamous tumours with higher recurrence risk.

Treatment is surgical (excision, Mohs for high-risk sites), with curettage, topical imiquimod or 5-fluorouracil, photodynamic therapy and radiotherapy as alternatives for low-risk or inoperable lesions. Vismodegib (ERIVANCE, 2012) and sonidegib (BOLT, 2015) are oral SMO inhibitors for locally advanced or metastatic BCC with ~45-60% response; their class toxicities (muscle spasms, dysgeusia, alopecia, weight loss) cause many to stop, and resistance arises through SMO mutations. Cemiplimab (2021) is approved after hedgehog-inhibitor failure or intolerance. Nicotinamide and sun protection reduce new BCCs in high-risk patients.

State of the art today

  • Hedgehog inhibitors are among the few targeted drugs whose rationale came straight from a developmental-biology pathway and a hereditary syndrome (Gorlin).
  • Cemiplimab gives a second line after hedgehog-inhibitor failure.
  • Neoadjuvant vismodegib can shrink tumours to make surgery less destructive (VISMONEO).
  • Chemoprevention (nicotinamide) reduces new keratinocyte cancers in high-risk patients.
Who it affects

The most common human cancer: several million cases per year in the US alone; metastasis is exceptionally rare (<0.1%), but locally advanced disease can be destructive.

Group
skin

Where the cases are

Cases by country · GLOBOCAN 2022
All countries →

No country-level case numbers. This cancer is not mapped to a GLOBOCAN site.

Standard of care

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Low-risk

Standard excision with 4 mm margin, curettage and electrodesiccation, or topical imiquimod / 5-FU / photodynamic therapy for superficial lesions.

NCCN · Category 2A
Fluorouracil (5-FU)
High-risk or recurrent

Mohs micrographic surgery or excision with complete margin assessment; radiotherapy if surgery not feasible.

NCCN · Category 2A
IMRT / IGRT (modern external beam)
Locally advanced or metastatic

Vismodegib or sonidegib; cemiplimab after hedgehog-inhibitor failure or intolerance; multidisciplinary review for surgery/radiotherapy after response.

NCCN · Category 2A
VismodegibSonidegibCemiplimab

Subtypes & biomarkers

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Subtypes
Biomarkers clinicians test

Target prevalence in this cancer

Target / alterationPrevalenceSource
Smoothened (hedgehog pathway)
85%
doi.org

How common each drug target or alteration is in this cancer. Population-level and approximate; see the target page for detail. Full matrix.

History

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  1. 1996PTCH1 identified as the Gorlin syndrome gene

    Hahn et al. and Johnson et al.: links human BCC to the Drosophila hedgehog pathway.

  2. 2009Vismodegib phase 1 shows responses in advanced BCC (NEJM)
    Vismodegib
  3. 2012Vismodegib approved (ERIVANCE)

    First hedgehog-pathway inhibitor.

    Vismodegib
  4. 2015Sonidegib approved (BOLT)
    Sonidegib
  5. 2015Nicotinamide reduces new keratinocyte cancers (ONTRAC, NEJM)
  6. 2021Cemiplimab approved after hedgehog-inhibitor failure
    Cemiplimab

Pipeline

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ApprovedMonoclonal antibody (anti-PD-1)
Cemiplimab · Libtayo
Not mapped hereSmall-molecule smoothened (hedgehog) inhibitor
Vismodegib · Erivedge

Open problems

  • Hedgehog-inhibitor tolerability leads most patients to stop within a year.
  • Resistance via SMO mutations has no approved next-in-class agent.
  • Huge volume: dermatology and Mohs capacity, and cost of treating millions of low-risk lesions.

Trials

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Recruiting now (live from ClinicalTrials.gov)

Recruiting trials near you · live from ClinicalTrials.gov
Basal cell carcinoma
condition: Basal cell carcinoma
Open on ClinicalTrials.gov →

Country and place are remembered in this browser only. A postcode is sent to OpenStreetMap's Nominatim service to find coordinates when you press the button; nothing else leaves your device.

Expert centres

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Where the expertise is

Centres linked to this cancer in OnCo

Seeking a second opinion: ask your oncologist for a referral to a high-volume centre; most accept records and pathology by mail or telehealth. In the US, use the NCI's Find a Cancer Center tool or the nonprofit Cancer Commons, which navigates options for advanced cancers at no cost.

Questions to ask

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Bring to your appointment

Questions to ask your oncologist about Basal cell carcinoma

Generated from this cancer's standard of care, biomarkers, and pipeline · 14 questions

Newly diagnosed

  1. What is my exact diagnosis, stage, and grade, and which tests established them?
    Why: Everything else follows from an accurate stage and subtype.
  2. Which biomarkers have been tested on my tumour (for example Histologic subtype and high-risk location, PTCH1 / SMO / SUFU alterations, Perineural invasion, Germline PTCH1), and what were the results?
    Why: These results decide eligibility for targeted therapy, immunotherapy, and trials.
  3. Which subtype is my cancer, and does that change the recommended treatment?
    Why: Recognised subtypes for this cancer include Nodular, Superficial, Infiltrative / morphoeic.
  4. Is germline (inherited) genetic testing recommended for me or my family?
    Why: Inherited variants can change treatment and matter for relatives.

Low-risk

  1. For my situation (low-risk), which of the standard options do you recommend and why?
    Why: Guideline options include: Standard excision with 4 mm margin, curettage and electrodesiccation, or topical imiquimod / 5-FU / photodynamic therapy for superficial lesions.
  2. Am I a candidate for Fluorouracil (5-FU), and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

High-risk or recurrent

  1. For my situation (high-risk or recurrent), which of the standard options do you recommend and why?
    Why: Guideline options include: Mohs micrographic surgery or excision with complete margin assessment; radiotherapy if surgery not feasible.

Locally advanced or metastatic

  1. For my situation (locally advanced or metastatic), which of the standard options do you recommend and why?
    Why: Guideline options include: Vismodegib or sonidegib; cemiplimab after hedgehog-inhibitor failure or intolerance; multidisciplinary review for surgery/radiotherapy after response.
  2. Am I a candidate for Vismodegib, Sonidegib, Cemiplimab, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

Any stage

  1. Are there clinical trials I could join, for example of Cemiplimab, Vismodegib?
    Why: Trials are how the next standard of care is set; asking early keeps options open.
  2. Would a second opinion at a high-volume centre change anything, and can you help arrange it?
    Why: Rare or high-stakes decisions benefit from a centre that treats many similar patients.
  3. What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?
    Why: Supportive care improves quality of life and helps patients complete treatment.
  4. I read that “Hedgehog-inhibitor tolerability leads most patients to stop within a year”. How does that affect my plan?
    Why: Open problems are where trials and second opinions matter most.
  5. I read that “Resistance via SMO mutations has no approved next-in-class agent”. How does that affect my plan?
    Why: Open problems are where trials and second opinions matter most.

Print this page for your appointment (your browser's print command). These prompts are for discussion; your clinical team knows your case.

Everything relevant

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Direct links plus the targets, companies, and technologies of this cancer's products.

technologies

6
Chemoprevention & risk-reducing surgeryCytotoxic chemotherapyDermoscopy, total-body photography & AI skin analysisImmune checkpoint inhibitorsIMRT / IGRT (modern external beam)Small-molecule kinase inhibitors

targets

2
PD-1Smoothened (hedgehog pathway)

drugs

4
ApprovedMonoclonal antibody (anti-PD-1)
Cemiplimab · Libtayo
Not mapped hereFluoropyrimidine antimetabolite
Fluorouracil (5-FU) · Adrucil / Efudex
Not mapped hereSmall-molecule smoothened inhibitor
Sonidegib · Odomzo
Not mapped hereSmall-molecule smoothened (hedgehog) inhibitor
Vismodegib · Erivedge

companies

3
RegeneronRoche / GenentechSanofi

institutions

1
University of Arizona Cancer Center

terms

1
Immune-related adverse events (irAEs)

Latest papers

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Latest papers · live from Europe PMC
Open in Europe PMC

Query for this cancer: (TITLE:"Basal cell carcinoma" OR ABSTRACT:"Basal cell carcinoma" OR TITLE:"BCC" OR ABSTRACT:"BCC") AND (treatment OR therapy OR trial OR survival OR diagnosis). Results are unfiltered search hits about Basal cell carcinoma, not a curated reading list.

Connected

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Pages like this

not linked directly; found by shared links

technologies

5
Chemoprevention & risk-reducing surgeryDermoscopy, total-body photography & AI skin analysisImmune checkpoint inhibitorsIMRT / IGRT (modern external beam)Small-molecule kinase inhibitors

targets

2
PD-1Smoothened (hedgehog pathway)

drugs

4
ApprovedMonoclonal antibody (anti-PD-1)
Cemiplimab · Libtayo
Not mapped hereFluoropyrimidine antimetabolite
Fluorouracil (5-FU) · Adrucil / Efudex
Not mapped hereSmall-molecule smoothened inhibitor
Sonidegib · Odomzo
Not mapped hereSmall-molecule smoothened (hedgehog) inhibitor
Vismodegib · Erivedge

companies

3
RegeneronRoche / GenentechSanofi

institutions

1
University of Arizona Cancer Center

terms

1
Immune-related adverse events (irAEs)