The first 60 days: Locally advanced and metastatic basal cell carcinoma
Locally advanced basal cell carcinoma is a skin cancer that has grown so large or deep, usually on the face, that surgery or radiotherapy can no longer remove it without unacceptable damage. Almost all these tumours depend on the hedgehog growth pathway, and the pills vismodegib and sonidegib shrink about four in ten of them; cemiplimab is used when the pills fail or cannot be tolerated. Below, week by week, is what OnCo's record of Locally advanced and metastatic basal cell carcinoma says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- SurgeonNamed in the standard of care for: Locally advanced, first line, Neoadjuvant, Radiotherapy and local options, Gorlin syndrome.
- Medical oncologistNamed in the standard of care for: Locally advanced, first line, Neoadjuvant, After hedgehog inhibitor failure or intolerance, Metastatic disease and 2 more.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Locally advanced, first line, Radiotherapy and local options, Gorlin syndrome.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Vismodegib for several months to shrink large facial tumours before surgery and reduce the defect.
Vismodegib (ERIVANCE) or sonidegib (BOLT); intermittent dosing to limit cramps, hair loss and taste loss; surgery or radiotherapy after response where feasible.
Vismodegib or sonidegib; cemiplimab after progression; platinum chemotherapy has only case-series support.
Radiotherapy for tumours not resectable but still confined; electron beam and superficial radiotherapy for suitable sites; multidisciplinary review of all advanced cases.
Surveillance and surgery, avoidance of radiotherapy, hedgehog inhibitors for multiple advanced tumours, topical patidegib in trials.
Cemiplimab (approved 2021); clinical trials of intratumoural agents and immunotherapy combinations.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example PTCH1 loss or SMO activation, Germline PTCH1 or SUFU, SMO resistance mutations after hedgehog inhibitors, Perineural invasion and bone or orbital involvement on imaging, High ultraviolet-signature tumour mutational burden), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include Locally advanced basal cell carcinoma, Metastatic basal cell carcinoma, Hedgehog inhibitor-resistant basal cell carcinoma.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Locally advanced, first line
- For my situation (locally advanced, first line), which of the standard options do you recommend and 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.
- Am I a candidate for Vismodegib, Sonidegib, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of ERIVANCE BCC and BOLT apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Neoadjuvant
- For my situation (neoadjuvant), which of the standard options do you recommend and why?Guideline options include: Vismodegib for several months to shrink large facial tumours before surgery and reduce the defect.
- Am I a candidate for Vismodegib, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
After hedgehog inhibitor failure or intolerance
- For my situation (after hedgehog inhibitor failure or intolerance), which of the standard options do you recommend and why?Guideline options include: Cemiplimab (approved 2021); clinical trials of intratumoural agents and immunotherapy combinations.
- Am I a candidate for Cemiplimab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- 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?Trial populations differ from individual patients; ask how closely you match.
Metastatic disease
- For my situation (metastatic disease), which of the standard options do you recommend and why?Guideline options include: Vismodegib or sonidegib; cemiplimab after progression; platinum chemotherapy has only case-series support.
- Am I a candidate for Vismodegib, Sonidegib, Cemiplimab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Radiotherapy and local options
- For my situation (radiotherapy and local options), which of the standard options do you recommend and 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.
Gorlin syndrome
- For my situation (gorlin syndrome), which of the standard options do you recommend and why?Guideline options include: Surveillance and surgery, avoidance of radiotherapy, hedgehog inhibitors for multiple advanced tumours, topical patidegib in trials.
- Am I a candidate for Vismodegib, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- 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?Trial populations differ from individual patients; ask how closely you match.
Any stage
- Are there clinical trials I could join, for example of Cemiplimab, To Assess the Safety and Efficacy of SP-002 with Vismodegib for the Treatment of Locally Advanced Basal Cell Carcinoma, Clinical Trial to Evaluate BO-112 in Patients With Basal Cell Carcinoma (BCC), Efficacy and Safety of Patidegib Gel 2% for Preventing Basal Cell Carcinomas on the Face of Adults With Gorlin Syndrome?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “Hedgehog inhibitor side effects lead many patients to stop before the tumour is controlled”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Only about a third of patients respond to cemiplimab after hedgehog inhibitor failure and there is no third line”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
- Efficacy and Safety of Patidegib Gel 2% for Preventing Basal Cell Carcinomas on the Face of Adults With Gorlin SyndromePhase 3 · active · NCT06050122A Multicenter, Randomized, Double Blind, Vehicle-controlled, Phase 3 Efficacy and Safety Study of Patidegib Gel 2% for the Reduction of Disease Burden of Persistently Developing Basal Cell Carcinomas (BCCs) in Subjects With Gorlin Syndrome
- Clinical Trial to Evaluate BO-112 in Patients With Basal Cell Carcinoma (BCC)Phase 2 · active · NCT06422936SPOTLIGHT 204: A Multicenter, Phase 2b, Open-label, Non-randomized, Clinical Trial to Evaluate Safety, Tolerability and Preliminary Efficacy of Intra-lesional BO-112 in Patients With Resectable Primary Low and High Risk Basal Cell Carcinoma
- To Assess the Safety and Efficacy of SP-002 with Vismodegib for the Treatment of Locally Advanced Basal Cell CarcinomaPhase 2 · recruiting · NCT06344052A Phase 2 Study to Assess the Efficacy of SP-002 with Vismodegib for the Treatment of Locally Advanced Basal Cell Carcinoma
- Study to Investigate the Efficacy and Safety of RP1 in Adult Patients With Organ Transplants and Advanced Skin MalignanciesPhase 1/2 · active · NCT04349436An Open-Label, Multicenter, Phase 1B/2 Study of RP1 in Solid Organ and Hematopoietic Cell Transplant Recipients With Advanced Cutaneous Malignancies (ARTACUS)
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Locally advanced and metastatic basal cell carcinoma: the full pageLocally advanced basal cell carcinoma is a skin cancer that has grown so large or deep, usually on the face, that surgery or radiotherapy can no longer remove it without unacceptable damage. Almost all these tumours depend on the hedgehog growth pathway, and the pills vismodegib and sonidegib shrink about four in ten of them; cemiplimab is used when the pills fail or cannot be tolerated.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Mohs surgery: Skin cancer surgery in which the tumour is removed in thin layers, each checked under the microscope on the spot, until the edges are clear; it spares the most normal skin.
Every term links to the glossary.