NMSC / Keratinocyte cancer

Basal Cell Carcinoma (BCC)

BCC accounts for approximately 70% of non-melanoma skin cancers. BCC usually grows slowly and the vast majority are diagnosed early and cured with surgery and radiation.

While it is very rare for it to metastasise (spread), some tumours can become advanced and penetrate deep into surrounding tissue or other parts of the body if left untreated. The spread can be disfiguring. As with all skin cancers, early detection and treatment is important.

The appearance of BCCs can vary widely, including but not limited to a small, shiny bump or pearly lump or nodule on the skin; an area of thickened skin or a red patch; a scaly, dry area that is shiny and pale or bright pink in colour; and an open sore that does not heal.

Patients who have had one BCC have an increased risk of developing a new BCC elsewhere. 40-50% of these patients will develop a new BCC within five years of their first diagnosis.

Cutaneous Squamous Cell Carcinoma (cSCC)

cSCC is the second most common type of skin cancer, accounting for approximately 30% of all non-melanoma skin cancers in Australia. It develops from squamous cells that make up much of the surface of the epidermis.

Middle-aged and elderly people are most likely to develop cSCC, especially those with light-coloured skin and a history of frequent UV exposure.

This skin cancer often appears as a bump or nodule, or as a red, scaly patch on the face, lips, mouth, or ear. It can also appear as a rapidly growing lump; an area that looks like a sore but has not healed; or an area that may be tender to touch.

cSCC often arises from small, scaly growths on the skin called actinic keratoses (see below for more on actinic keratoses). A cSCC can occur anywhere on the body because squamous cells exist on every part of our skin, even the skin inside our mouths.

cSCC is more likely than BCC to metastasise and spread to other areas of the body, so the early detection and treatment of cSCC is critical.

How is it diagnosed?

A skin cancer is often noticed by a patient, their partner, friend or even their hairdresser. Or it can be found by a GP or dermatologist. MSCAN encourages everyone to regularly undertake a full-body skin exam to look for suspicious lesions.

Skin cancers (both melanoma and non-melanoma skin cancer) are typically diagnosed after a sample of a suspicious lesion or mole has been removed and sent to a pathology lab for evaluation.

The process of removing all or part of the lesion or mole for evaluation under a microscope is called a biopsy and the type of biopsy procedure will depend on an individual’s particular situation.

Tips for Early Detection

Most skin cancers that appear on the skin can be seen with the naked eye. The best way to find them is to self-examine your skin regularly, with a complete head-to-toe skin examination at the beginning of each season. 

It can be a good idea to see a GP or skin cancer specialist for a comprehensive skin exam before you begin self-exams so that a baseline of “normal” can be established.  From that point on, you can watch for changes.

When you check your skin, note your mole patterns, freckles, and other spots.  Take photos, which will help you notice changes over time. 

You will need a full-length mirror, a hand-held mirror, a hair dryer, a chair to sit on, and a well-lit area. Since you will need to remove all clothing, a good time to do your exam is prior to a shower or bath.

Since some parts of your body, such as your back and your scalp, are difficult to see, ask your partner, family member or friend to help. 

Treatment options

Surgery is the most common treatment for NMSC, and can be done by a GP or a dermatologist; or a plastic surgeon if in a difficult part of the body. This can be a wide local excision or a surgical technique called Mohs microsurgery.

Treatment options for NMSCs

Apart from surgery, other treatments include cryotherapy, topical creams like Imiquimod, or radiotherapy. BCCs, but not cSCC can also be treated with photodynamic therapy (PDT)²

An Immunotherapy/checkpoint inhibitor, also known as a PD-1 inhibitor called LIBTAYO (cemiplimab) can be used for the treatment of adult patients with locally advanced basal cell carcinoma (BCC) that has been previously treated with a Hedgehog Pathway Inhibitor (HHI) where a HHI is not appropriate. LIBTAYO (cemiplimab) has provisional approval from the TGA in Australia for the treatment of adult patients with metastatic BCC (mBCC) that has been previously treated with a HHI where a HHI is not appropriate. Unfortunately LIBTAYO (cemiplimab) is not currently PBS reimbursed.

Treatment for advanced NMSCs

A Hedgehog Pathway Inhibitor (HHI) called vismodegib can be used in people with metastatic BCC, or with locally advanced BCC where surgery and/or radiation therapy are not appropriate.³ Another HHI called sonidegib is approved for use in Australia for people with locally advanced BCC who are not amenable to curative surgery or radiation therapy; or Metastatic BCC⁴ but isn’t currently reimbursed by the PBS.

A PD-1 inhibitor (Immunotherapy/checkpoint inhibitor) called LIBTAYO (cemiplimab), has been approved for use in Australia for the treatment of adult patients with metastatic or locally advanced cSCC (mCSCC or laCSCC) who are not candidates for curative surgery or curative radiation.

Rare non-melanoma skin cancers

Rare NMSCs represent less than 1% of NMSCs and include all NMSCs other than BCCs and cSCCs. They include Merkel Cell Carcinoma (MCC), and Dermatofibrosarcoma. A report from 2016 estimated that about 900 cases of rare NMSC will be diagnosed in Australia, with people over the age of 80 accounting for the highest age-related incidence. In 2012, 307 MCC (36% of all rare NMSCs diagnosed), and 78 dermatofibrosarcoma were diagnosed (9.1% of all rare NMSCs) in Australia. There are more men than women diagnosed with these types of cancers⁵

Merkel Cell Carcinoma (MCC)

Merkel cells are found at the base of the epidermis and they help us sense touch. If these cells start to grow uncontrollably, Merkel Cell Carcinoma (MCC) can develop. It is a rare but aggressive form of skin cancer that can easily spread to other parts of the body if it is not diagnosed early.

Australia has a higher incidence of MCC than other countries around the world and is likely caused by an increased exposure to UV radiation. MCC usually appears as a red, pink, or purple, painless lump in sun damaged areas such as the neck, face, or head. People over 50 with a lower immune system are at higher risk of developing this type of skin cancer. MCC tends to grow rapidly and spread quickly to other parts of the body. Because it is quite rare, and it can present with a variety of features, it is difficult to diagnose. Treatment options for MCC depend on whether it has spread.

Surgery and or radiotherapy are the most common treatments in it’s early stages. In later stages, the recent approval of immune checkpoint inhibitors has changed the landscape of treatment options, and these options are currently being explored in clinical trials in earlier stages of the disease as well. In Australia, avelumab is currently the only immune checkpoint inhibitor approved for use in and is PBS reimbursed for use in people with advanced (metastatic) MCC. Future clinical trial areas for people with MCC include other immunotherapy agents.⁶

Other cancers and pre-cancers that appear on the skin

Actinic Keratosis (AK) 

A common pre-cancerous growth that may occasionally develop into SCC if left untreated. The growth appears as a rough, scaly patch on the skin that may be pink-red or flesh coloured. It’s most commonly found on the face, lips, ears, back of the hands, forearms, scalp, or neck, and develops from years of exposure to the sun.

AKs are usually treated with cryotherapy but can also be treated with imiquimod cream, 5-fluorouracil cream, diclofenac gel or ingenol mebutate gel. Bowen’s disease (an early, pre-cancerous form of SCC) can be treated with 5-fluorouracil cream.

Keratoacanthoma (KA) 

A low-grade, slow growing and typically benign tumour. It looks like a tiny dome or crater and originates in the skin’s hair follicles and often goes away on its own. KA is considered by some to be a highly differentiated form of squamous cell carcinoma. cSSCs can look just like keratoacanthomas which is why it is often recommended that these lesions are removed.

Kaposi Sarcoma (KS)

Not a skin cancer but a cancer that can appear on the skin or on mucosal surfaces. The lesions or tumours are often brown-red to purple or blue in colour and usually found on the legs, feet and face. It is caused by a type of herpes virus, typically in patients with weakened immune systems.

Lymphoma of the Skin, or Cutaneous Lymphoma

A rare type of non-Hodgkin lymphoma that can appear as a rash or bumps on the skin. Most cases of lymphoma form in the lymph nodes, but lymphomas may also develop in other lymphoid tissue, including the spleen, bone marrow, and skin. Mycosis fungoides is the most common type of primary cutaneous Lymphoma.