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Living with cancer·Standard of care

Locally advanced and metastatic basal cell carcinoma: the decisions you may face

Cancer page →Second-opinion finder →

6 treatment settings, 3 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.

Locally advanced

Locally advanced, first line

3 optionsCompare side by side →

Vismodegib (ERIVANCE) or sonidegib (BOLT); intermittent dosing to limit cramps, hair loss and taste loss; surgery or radiotherapy after response where feasible.

Guideline
NCCN Guidelines: Basal Cell Skin Cancer
The options, in plain words
VismodegibApprovedSmall-molecule smoothened (hedgehog) inhibitor

Vismodegib was the first hedgehog-pathway drug, for basal cell carcinomas too advanced for surgery; it shrinks most tumours but muscle cramps, taste loss and hair loss make long-term use hard.

SonidegibApprovedSmall-molecule smoothened inhibitor

Sonidegib (Odomzo) is the second hedgehog inhibitor for locally advanced basal cell carcinoma, similar in effect and side effects to vismodegib.

Hedgehog pathway inhibitorsApproved

Pills that block a developmental signalling pathway hijacked by basal cell skin cancer, shrinking tumours that cannot be operated on; also used in some leukaemia.

  • High response rates in advanced basal cell carcinoma
  • Oral
  • Neoadjuvant and intermittent regimens reduce toxicity
The evidence behind it
The main trade-offs on record
Hedgehog pathway inhibitors
  • Cramps, dysgeusia and alopecia cause discontinuation
  • Teratogenic
  • Acquired SMO resistance
Questions to ask about this decision
  1. Between Vismodegib, Sonidegib and Hedgehog pathway inhibitors, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. How closely do I match the people in ERIVANCE BCC and BOLT, and does that change what the results mean for me?
    Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
  4. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  5. Does your recommendation follow the current guideline (NCCN Guidelines: Basal Cell Skin Cancer), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  6. For my situation (locally advanced, first line), which of the standard options do you recommend and why?
    Why: Guideline options include: Vismodegib (ERIVANCE) or sonidegib (BOLT); intermittent dosing to limit cramps, hair loss and taste loss; surgery or radiotherapy after response where feasible.
  7. Am I a candidate for Vismodegib, Sonidegib, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
  8. How do the results of ERIVANCE BCC and BOLT apply to someone like me?
    Why: Trial populations differ from individual patients; ask how closely you match.

Add these to your appointment list, or take the full question set for this cancer.

One path named

Vismodegib for several months to shrink large facial tumours before surgery and reduce the defect.

Guideline
NCCN Guidelines: Basal Cell Skin Cancer
The path, in plain words
VismodegibApprovedSmall-molecule smoothened (hedgehog) inhibitor

Vismodegib was the first hedgehog-pathway drug, for basal cell carcinomas too advanced for surgery; it shrinks most tumours but muscle cramps, taste loss and hair loss make long-term use hard.

Also referenced:Mohs surgery
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record

No side-effect rates or interaction flags are recorded for these options yet. The side-effect lookup and interaction checker cover the products that have them.

Questions to ask about this decision
  1. Is Vismodegib the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?
    Why: A single standard does not mean a single choice; timing and trials are decisions too.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. Does your recommendation follow the current guideline (NCCN Guidelines: Basal Cell Skin Cancer), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  5. For my situation (neoadjuvant), which of the standard options do you recommend and why?
    Why: Guideline options include: Vismodegib for several months to shrink large facial tumours before surgery and reduce the defect.
  6. Am I a candidate for Vismodegib, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

Add these to your appointment list, or take the full question set for this cancer.

Other settings

After hedgehog inhibitor failure or intolerance

One path named

Cemiplimab (approved 2021); clinical trials of intratumoural agents and immunotherapy combinations.

Guideline
NCCN Guidelines: Basal Cell Skin Cancer
The path, in plain words
CemiplimabApprovedMonoclonal antibody (anti-PD-1)

A PD-1 blocker that is the standard for advanced skin squamous cell carcinoma, and in 2025 became the first adjuvant immunotherapy for it.

The evidence behind it
The main trade-offs on record

No side-effect rates or interaction flags are recorded for these options yet. The side-effect lookup and interaction checker cover the products that have them.

Questions to ask about this decision
  1. Is Cemiplimab the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?
    Why: A single standard does not mean a single choice; timing and trials are decisions too.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. How closely do I match the people in Clinical Trial to Evaluate BO-112 in Patients With Basal Cell Carcinoma (BCC) and Study to Investigate the Efficacy and Safety of RP1 in Adult Patients With Organ Transplants and Advanced Skin Malignancies, and does that change what the results mean for me?
    Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
  4. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  5. Does your recommendation follow the current guideline (NCCN Guidelines: Basal Cell Skin Cancer), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  6. For my situation (after hedgehog inhibitor failure or intolerance), which of the standard options do you recommend and why?
    Why: Guideline options include: Cemiplimab (approved 2021); clinical trials of intratumoural agents and immunotherapy combinations.
  7. Am I a candidate for Cemiplimab, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
  8. How do the results of Clinical Trial to Evaluate BO-112 in Patients With Basal Cell Carcinoma (BCC) and Study to Investigate the Efficacy and Safety of RP1 in Adult Patients With Organ Transplants and Advanced Skin Malignancies apply to someone like me?
    Why: Trial populations differ from individual patients; ask how closely you match.

Add these to your appointment list, or take the full question set for this cancer.

Advanced, first line

Metastatic disease

3 optionsCompare side by side →

Vismodegib or sonidegib; cemiplimab after progression; platinum chemotherapy has only case-series support.

Guideline
NCCN Guidelines: Basal Cell Skin Cancer
The options, in plain words
VismodegibApprovedSmall-molecule smoothened (hedgehog) inhibitor

Vismodegib was the first hedgehog-pathway drug, for basal cell carcinomas too advanced for surgery; it shrinks most tumours but muscle cramps, taste loss and hair loss make long-term use hard.

SonidegibApprovedSmall-molecule smoothened inhibitor

Sonidegib (Odomzo) is the second hedgehog inhibitor for locally advanced basal cell carcinoma, similar in effect and side effects to vismodegib.

CemiplimabApprovedMonoclonal antibody (anti-PD-1)

A PD-1 blocker that is the standard for advanced skin squamous cell carcinoma, and in 2025 became the first adjuvant immunotherapy for it.

The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record

No side-effect rates or interaction flags are recorded for these options yet. The side-effect lookup and interaction checker cover the products that have them.

Questions to ask about this decision
  1. Between Vismodegib, Sonidegib and Cemiplimab, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. Does your recommendation follow the current guideline (NCCN Guidelines: Basal Cell Skin Cancer), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  5. For my situation (metastatic disease), which of the standard options do you recommend and why?
    Why: Guideline options include: Vismodegib or sonidegib; cemiplimab after progression; platinum chemotherapy has only case-series support.
  6. 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.

Add these to your appointment list, or take the full question set for this cancer.

Other settings

Radiotherapy and local options

3 options

Radiotherapy for tumours not resectable but still confined; electron beam and superficial radiotherapy for suitable sites; multidisciplinary review of all advanced cases.

Guideline
NCCN Guidelines: Basal Cell Skin Cancer
The options, in plain words
IMRT / IGRT (modern external beam)Standard of care

IMRT and IGRT shape the radiation beam to the tumour's outline from multiple angles and check the patient's position with a scan before every session, so surrounding organs receive less dose. Fewer, larger doses are now standard in breast and prostate cancer, but a low-dose bath still spreads across normal tissue.

  • Conformal dose, fewer side effects
  • Hypofractionation saves visits
Superficial and orthovoltage radiotherapy for skin cancerEstablished

Low-energy X-rays that stop within a few millimetres, used to cure basal and squamous cell skin cancers where surgery would scar or is not wanted.

  • Non-invasive cure for skin cancers
  • Good cosmesis in the face
  • Cheap, simple machines
Electron beam therapy systems (linac electrons, total skin electron units, mobile electron IORT)Standard of care

Electron beams stop within a few centimetres of the skin, so they treat surface tumours, scars and the whole skin without reaching the organs underneath. Most linacs make them; special set-ups spread them over the entire body or deliver them during surgery.

  • Sharp dose fall-off spares organs under the skin
  • Available on most C-arm linacs
  • Total skin and intraoperative variants for special needs
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
IMRT / IGRT (modern external beam)
  • Low-dose bath to normal tissue
  • Motion management
Superficial and orthovoltage radiotherapy for skin cancer
  • Multiple visits
  • Late skin changes over years
  • Less suitable in young patients
Electron beam therapy systems (linac electrons, total skin electron units, mobile electron IORT)
  • Cannot reach deep tumours
  • Bone and air cavities distort the dose
  • Not offered on ring-gantry linacs
Questions to ask about this decision
  1. Between IMRT / IGRT (modern external beam), Superficial and orthovoltage radiotherapy for skin cancer and Electron beam therapy systems (linac electrons, total skin electron units, mobile electron IORT), which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. Does your recommendation follow the current guideline (NCCN Guidelines: Basal Cell Skin Cancer), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  5. For my situation (radiotherapy and local options), which of the standard options do you recommend and why?
    Why: Guideline options include: Radiotherapy for tumours not resectable but still confined; electron beam and superficial radiotherapy for suitable sites; multidisciplinary review of all advanced cases.

Add these to your appointment list, or take the full question set for this cancer.

Other settings

Gorlin syndrome

One path named

Surveillance and surgery, avoidance of radiotherapy, hedgehog inhibitors for multiple advanced tumours, topical patidegib in trials.

Guideline
NCCN Guidelines: Basal Cell Skin Cancer
The path, in plain words
VismodegibApprovedSmall-molecule smoothened (hedgehog) inhibitor

Vismodegib was the first hedgehog-pathway drug, for basal cell carcinomas too advanced for surgery; it shrinks most tumours but muscle cramps, taste loss and hair loss make long-term use hard.

The evidence behind it
The main trade-offs on record

No side-effect rates or interaction flags are recorded for these options yet. The side-effect lookup and interaction checker cover the products that have them.

Questions to ask about this decision
  1. Is Vismodegib the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?
    Why: A single standard does not mean a single choice; timing and trials are decisions too.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. How closely do I match the people in Efficacy and Safety of Patidegib Gel 2% for Preventing Basal Cell Carcinomas on the Face of Adults With Gorlin Syndrome, and does that change what the results mean for me?
    Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
  4. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  5. Does your recommendation follow the current guideline (NCCN Guidelines: Basal Cell Skin Cancer), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  6. For my situation (gorlin syndrome), which of the standard options do you recommend and why?
    Why: Guideline options include: Surveillance and surgery, avoidance of radiotherapy, hedgehog inhibitors for multiple advanced tumours, topical patidegib in trials.
  7. Am I a candidate for Vismodegib, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
  8. How do the results of Efficacy and Safety of Patidegib Gel 2% for Preventing Basal Cell Carcinomas on the Face of Adults With Gorlin Syndrome apply to someone like me?
    Why: Trial populations differ from individual patients; ask how closely you match.

Add these to your appointment list, or take the full question set for this cancer.

How to read this page. Options and results come from OnCo records with their sources; the settings are the standard-of-care rows on the cancer page, and the lines of therapy are on the sequencing grid. Where a setting names one path, the choice is usually about timing, trials and where to be treated: see expert centres. OnCo is orientation, not medical advice.