Download Basal Cell Carcinoma

Cancer Association of South Africa (CANSA)
Fact Sheet
On
Basal Cell Carcinoma
Introduction
Basal cell carcinoma, or BCC, is a type of
skin cancer. It involves the basal cells of
the skin at the bottom of the epidermis. It
is very common and accounts for the
majority of skin cancers in South Africa.
Most Basal Cell Carcinomas are very
slow-growing and seldom spread to other
parts of the body. It often start as a small,
red, shiny spot or nodule that may bleed
occasionally.
[Picture Credit: Basal Cell Carcinoma Picture]
In many cases of basal cell carcinomas (BCC), the skin over the top can remain intact for
months. Eventually they it develop into an ulcer that does not heal. When BCCs are treated
at an early stage, most of the time it can be completely cured. However, some BCCs are
aggressive, and if left to grow may spread into the deeper layers of the skin and sometimes
to the bones, making treatment difficult. A small number of BCCs may also come back in the
same area of skin after treatment. This is known as a local recurrence.
(Macmillan).
Incidence of Skin Cancer Among Individuals of Colour
Most skin cancers are associated with ultraviolet (UV) radiation from the sun or tanning
beds, and many people of colour are less susceptible to UV damage thanks to the greater
amounts of melanin darker skin produces. Melanin is the protective pigment that gives skin
and eyes their colour, however, people of colour can still develop skin cancer from UV
damage.
Additionally, certain skin cancers are caused by factors other than UV - such as genetics or
other environmental influences - and may occur on parts of the body rarely exposed to the
sun. For example, darker-skinned people are more susceptible to acral lentiginous
melanoma (ALM), an especially virulent form of melanoma (the deadliest type of skin
cancer) that typically appears on the palms of the hands and soles of the feet.
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 1
Acral lentiginous melanoma (ALM) accounts for about 5% of melanoma cases, and is a
leading cause of skin cancer deaths. The disease initially appears as a bruise or nail streak
on the skin. Most patients do not notice ALM until it has already begun to spread
aggressively throughout the body. Bob Marley was killed from this form of malignant tumour
under his toenail. ALM (also called subungual melanoma)
affects people of Asian or African descent more than any
other race or ethnicity.
[Picture Credit: Acral Lentiginous Melanoma]
The average patient is between sixty and seventy years of
age, but ALM can affect people of any age. This
classification of the disease is generally found on the
hands, feet and other areas of the body where very little
hair grows. Presently, sunlight is not a proven cause of this condition. When the tumour is
deeper than 1.0 mm or has spread to other parts of the body through the lymph nodes, the
cancer frequently results in death.
Different ethnicities are at higher risk for particular skin malignancies: Latinos, Chinese, and
Japanese Asians tend to develop basal cell carcinoma (BCC), the most common skin
cancer. But the second most common, squamous cell carcinoma (SCC), is more frequent
among African Americans and Asian Indians.
(Skin Cancer Foundation; DermNet NZ; Know Cancer).
In South Africa, according to the National Cancer Registry (2010), the picture is very similar
as described above. Basal cell carcinoma is more common among Whites and Coloureds as
a percentage of all cancers. However, when one looks at squamous cell skin cancer, it is a
more prevalent skin cancer than basal cell skin cancer among Blacks and Asians, whereas
the opposite is true among Whites and Coloureds.
Cancer
Basal Cell Skin Cancer
Squamous Cell Skin
Cancer
Malignant Melanoma
Skin Cancer
Percentage of All Cancers
Asian
Male
Female
Black
Male
Female
Coloured
Male
Female
2,79%
1,42%
2,20%
1,46%
16,06%
13,15%
38,27%
33,69%
2,96%
1,34%
3,05%
2,05%
7,95%
5,34%
14,58%
11,42%
0,42%
0,22%
0,67%
1,11%
1,69%
1,48%
2,95%
3,14%
Male
White
Female
(National Cancer Registry).
Incidence of Basal Cell Carcinoma in South Africa
According to the National Cancer Registry (2010) the following number of Basal Cell
Carcinoma cases was histologically diagnosed in South Africa during 2010:
Group - Males
2010
All males
Asian males
Black males
Coloured males
White males
No of Cases
Lifetime Risk
5 442
23
223
571
4 625
1:27
1:237
1:449
1:24
1:7
Percentage of
All Cancers
20,06%
3,16%
2,10%
17,90%
36,68%
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 2
Group - Females
2010
All females
Asian females
Black females
Coloured females
White females
No of Cases
Lifetime Risk
3 942
22
204
415
3 301
1:54
1:291
1:779
1:43
1:11
Percentage of
All Cancers
13,24%
2,30%
1,30%
13,40%
32,82%
The frequency of histologically diagnosed cases of Basal Cell Carcinoma in South Africa for
2010 was as follows (National Cancer Registry, 2010):
Group - Males
2010
All males
Asian males
Black males
Coloured males
White males
0 – 19
Years
7
0
0
0
7
20 – 29
Years
56
1
5
3
43
30 – 39
Years
279
1
11
37
218
40 – 49
Years
661
4
25
59
546
50 – 59
Years
1 245
2
62
128
1 007
60 – 69
Years
1 521
8
47
141
1 245
70 – 79
Years
1 123
3
36
130
900
80+
Years
535
2
25
46
436
Group - Females
2010
All females
Asian females
Black females
Coloured females
White females
0 – 19
Years
9
0
0
2
7
20 – 29
Years
56
1
12
8
32
30 – 39
Years
243
0
20
22
185
40 – 49
Years
515
2
33
51
405
50 – 59
Years
783
6
39
86
620
60 – 69
Years
951
7
32
89
765
70 – 79
Years
853
2
37
88
687
80+
Years
517
3
18
48
424
N.B. In the event that the totals in any of the above tables do not tally, this may be the result of uncertainties as to the age, race
or sex of the individual. The totals for ‘all males’ and ‘all females’, however, always reflect the correct totals.
Symptoms of Basal Cell Carcinoma
Most basal cell carcinomas are painless. People often first become aware of it as a scab that
bleeds occasionally and does not heal completely. Some basal cell carcinomas are very
superficial and look like a scaly red flat mark - others have a pearl-like rim surrounding a
central crater. If left for some time, the latter type can eventually erode the skin causing an
ulcer – hence the name ‘rodent ulcer’.
Other basal cell carcinomas are quite
lumpy, with one or more shiny
nodules crossed by small but easily
seen blood vessels.
(British Skin Foundation).
[Picture Credit: Basal Cell Carcinoma]
Basal
cell
carcinomas
usually
develop on sun-exposed parts of your
body, especially on the head and
neck. A much smaller number occur
on the trunk and legs. Basal cell
carcinomas can also occur on parts of the body that are rarely exposed to sunlight. Although
a general warning sign of skin cancer is a sore that won't heal or that repeatedly bleeds and
scabs over, basal cell cancer may look like:
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 3
o
A pearly white or waxy bump, often with visible blood vessels on the face, ears or
neck. The bump may bleed, develop a crust or form a depression in the centre. In
darker skinned people, this type of cancer is usually brown or black
o
A flat, scaly, brown or flesh-coloured patch on the back or chest. Over time, these
patches can grow quite large
o
More rarely, a white, waxy scar. This type of basal cell carcinoma is easy to overlook
but it may be a sign of a particularly invasive and disfiguring cancer called
morpheaform basal cell carcinoma.
(Mayo Clinic).
Risk Factors for Basal Cell Carcinoma
The following individuals are more likely to get basal cell carcinoma:
o Light-coloured skin
o Freckled skin
o Blue, green, or grey eyes
o Blond or red hair
o Overexposure to x-rays or other forms of radiation
o Many moles
o Having close relatives who have or had skin cancer
o Many severe sunburns early in life (especially before age 18)
o Long-term daily sun exposure (such as the sun exposure people who work outside
receive)
(PubMed Health).
Prevention Guidelines for Basal Cell Carcinoma
While BCCs and other skin cancers are almost always curable when detected and treated
early, it is best to prevent them in the first place. Make these sun safety habits part of daily
health care routine:
o
o
o
o
o
o
o
o
o
o
o
o
Seek shade, especially between 10:00 and 15:00
Do not sunburn
Avoid tanning booths
Cover up with clothing, including a broad-brimmed hat and UV-blocking sunglasses
(minimum UV400 protection)
Use a broad spectrum (UVA/UVB) sunscreen. Refer to the CANSA Fact Sheet on
Solar Radiation and Skin Cancer for additional information
Apply sunscreen at least 20 minutes before going out into the sun
Reapply sunscreen every two hours including after swimming or excessive sweating
Keep newborns out of the sun until at least 6 months of age
Examine the skin head-to-toe every month
See a doctor or other qualified health professional every year for a professional skin
examination
Avoid surfaces that reflect light more, such as water, sand, concrete, and whitepainted areas
Skin burns faster at higher altitudes
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 4
o Avoid sun lamps, tanning beds, and tanning salons
(Skin Cancer Foundation; PubMed Health; WebMD).
Five Warning Signs of Basal Cell Carcinoma
Frequently, two or more of features are present in one tumour. In addition, BCC sometimes
resembles non-cancerous skin conditions such as psoriasis or eczema. Only a trained
physician or health care professional, such as an oncology nurse of specialist in diseases of
the skin, can determine for sure. If any of the warning signs are observed or some other
worrisome change in the skin is noticed, one should consult a physician immediately.
A scar-like area that is white, yellow or waxy, and often
has poorly defined borders; the skin itself appears shiny
and taut. This warning sign may indicate the presence of
an invasive BCC that is larger than it appears to be on the
surface.
An open sore that bleeds, oozes, or crusts and remains
open for a few weeks, only to heal up and then bleed
again. A persistent, non–healing sore is a very common
sign of an early BCC.
A reddish patch or irritated area, frequently occurring on
the face, chest, shoulders, arms, or legs. Sometimes the
patch crusts, and it may also itch. At other times, it persists
with no noticeable discomfort.
A shiny bump or nodule that is pearly or translucent and is
often pink, red, or white. The bump can also be tan, black,
or brown, especially in dark-haired people, and can be
confused with a mole.
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 5
A scar-like area that is white, yellow or waxy, and often
has poorly defined borders; the skin itself appears shiny
and taut. This warning sign may indicate the presence of
an invasive BCC that is larger than it appears to be on the
surface.
(Skin Cancer Foundation).
Diagnosis of Basal Cell Carcinoma (BCC)
Clinically, a number of lesions can simulate the appearance of BCC, and conversely, BCC
can be mistaken for other, more benign, eyelid lesions. In a large study, 10.5% of cases
diagnosed as BCC (by an experienced clinician) represented other conditions. The most
common lesions confused with BCC include papilloma, nevus, hidrocystoma, epidermal
inclusion cyst, and squamous cell carcinoma. Small lesions (2–3 mm in size) are especially
likely to be mistaken for benign conditions.
The histopathologic differential diagnosis includes trichoepithelioma, desmosplastic
trichoepithelioma, and metastatic carcinoma. Desmosplastic trichoepithelioma and
metastatic carcinoma demonstrate a pattern similar to that of infiltrative BCC.
Basal cell carcinomas are stratified into low- and high-risk categories, depending on tumour,
site, and patient factors. Tumour factors include treatment history, that is, whether the lesion
is primary or recurrent, or has been incompletely excised; histological subtype, including the
presence of perineural invasion; tumour size; duration; ease of clinical margin definition; and
site.
Although basal cell carcinoma rarely metastasizes, a tumour can extend beneath the skin to
the bone, causing considerable local damage due to tissue destruction. This process leads
to an ulcer that is sometimes known as ulcus rodens, or a rodent ulcer.
Other medical problems/issues to consider include the following:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Dermatitis
Desmoplastic trichoepithelioma
Eczema
Intradermal nevus
Lichenoid benign keratosis
Ringworm
Fibroepithelioma of Pinkus
Adnexal carcinoma (very rare)
Actinic keratosis
Sebaceous hyperplasia
Nevi malignant melanoma
Keratoacanthoma
Seborrheic keratosis
Bowen disease
Darier disease (keratosis follicularis)[5]
Cutaneous T-cell lymphoma (mycosis fungoides)
Metastatic malignancies (Medscape Reference; Harvard Medical School; Medscape).
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 6
Staging of Basal Cell Carcinoma
Staging is the process of determining whether cancer has spread and, if so, how far. It is
important to know the stage of the disease in order to plan treatment.
The stage is based on the size of the tumour, how deeply into the skin it has grown, and
whether cancer has spread beyond the tumour to the lymph nodes. The doctor will look at
the results of the biopsy to determine the stage. If there is a positive diagnosis of squamous
cell carcinoma, the doctor may also test lymph nodes near the tumour to see if the cancer
has spread beyond the skin.
Stages are numbered in Roman numerals between 0 and IV:
o
Stage 0. Cancer is found only in the original tumour in the skin. It is only in the
epidermis and has not spread to the dermis. Stage 0 is also called carcinoma in situ
o
Stage I. The tumour is 2 centimetres wide or smaller. It may have spread into the
dermis. Cancer does not invade the muscle, cartilage, or bone and has not spread to
lymph nodes or other organs
o
Stage II. The tumour is larger than 2 centimetres and may have spread from the
epidermis into the dermis. Cancer does not invade the muscle, cartilage, or bone and
has not spread outside the skin. It may also have high risk features such as
perineural invasion
o
Stage III. The cancer has spread to areas below the skin, such as into muscle, bone,
cartilage, or lymph nodes, but only those near the original tumour. It has not spread
to distant organs. This is most worrisome around the nose, eyes, and ears
o
Stage IV. The cancer can be any size and has spread to distant lymph nodes or
organs like the lungs or bone
(Stanford Cancer Institute; PubMed Health).
Recurrent Basal Cell Carcinoma
Basal cell carcinoma (BCC) accounts for 80% of all non-melanoma skin cancers. Its
metastasis is extremely rare. The usual metastasis to lymph nodes, lungs, bones, or skin is
from the primary tumour situated in the head and neck region in nearly 85% cases (Hindawi
Publishing Corporation).
Prognosis (Outlook) of Basal Cell Carcinoma
The basal cell carcinoma prognosis is very good for most people. It is one of several types of
skin cancers and is the easiest to deal with and carries the best prognosis.
(Carcinomaprognosis.com).
Treatment of Basal Cell Carcinoma
Basal cell carcinoma very rarely spreads to other parts of the body, although it can grow into
nearby tissues if not treated. Several methods can be used to remove or destroy these
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 7
cancers. The choice may depend on factors such as the tumour size and location, and the
patient’s age, general health, and preferences.
All of the treatment methods listed here can be effective. The chance of the cancer coming
back (recurring) ranges from less than 5% for Mohs surgery to up to 15% or higher for some
of the others, but this depends on the size of the tumour. Small tumours are less likely to
recur than larger ones. Even if the tumour does recur, it can often still be treated effectively.
Curettage and Electrodesiccation - Curettage and electrodesiccation is a common treatment
for basal cell carcinomas smaller than 1 centimeter (slightly less than a half inch) across. It
might need to be repeated to help make sure all of the cancer has been removed.
Simple Excision - Simple excision (cutting the tumour out) is often used to remove basal cell
carcinomas, along with a margin of normal skin.
Mohs’ Surgery – Mohs’ surgery has the best cure rate for basal cell carcinoma. It is
especially useful in treating large tumours, tumours where the edges are not well-defined,
tumours in certain locations (such as on or near the nose, eyes, ears, forehead, scalp,
fingers, and genital area), and those that have come back after other treatments. However, it
is also more complex, time-consuming, and expensive than other methods.
New treatments for skin cancer are appearing and evolving rapidly in recent years. However,
one surgical technique has more than stood the test of time. Developed by Dr. Frederick
Mohs in the 1930s, Mohs’ micrographic surgery has, with a few refinements, come to be
embraced over the past decade by an increasing number of surgeons for an ever-widening
variety of skin cancers.
Today, Mohs’ surgery has come to be accepted as the single most effective technique for
removing Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), the two most
common skin cancers. It accomplishes the nifty trick of sparing the greatest amount of
healthy tissue while also most completely expunging cancer cells; cure rates for BCC and
SCC are an unparalleled 98 percent or higher with Mohs’ surgery, significantly better than
the rates for standard excision or any other accepted method.
[Picture Credit: Mohs’ Surgery 1]
The reason for the technique's success is its simple
elegance. Mohs’ surgery differs from other
techniques in that microscopic examination of all
excised tissues occurs during, rather than after the
surgery, thereby eliminating the need to ‘estimate’
how far out or deep the roots of the skin cancer go.
This allows the Mohs surgeon to remove all of the
cancer cells while sparing as much normal tissue as
possible. The procedure entails removing one thin
layer of tissue at a time; as each layer is removed, its margins are studied under a
microscope for the presence of cancer cells. If the margins are cancer-free, the surgery is
ended. If not, more tissue is removed from the margin where the cancer cells were found,
and the procedure is repeated until all the margins of the final tissue sample examined are
clear of cancer. In this way, Mohs’ surgery eliminates the guesswork in skin cancer removal,
producing the best therapeutic and cosmetic results.
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 8
In the past, Mohs’ surgery was rarely chosen for Malignant Melanoma surgery for fear that
some microscopic melanoma cells might be missed and end up spreading around the body
(metastasising). However, efforts to improve
the Mohs surgeon's ability to identify
melanoma cells have led to special stains
that highlight these cells, making them much
easier to see under the microscope. Thus,
more Mohs surgeons are now using this
procedure with certain melanomas. With the
rates for melanoma and other skin cancers
continuing to skyrocket, Mohs’ surgery will
play an ever more important role in the
coming decades.
(Skin Cancer Foundation).
[Picture Credit: Mohs’ Surgery 2]
Radiation Therapy - Radiation therapy is often a good option for treating patients who might
not be able to tolerate surgery and for treating tumours on the eyelids, nose, or ears – areas
that can be hard to treat surgically. It is also sometimes used after surgery if it is not clear
that all of the cancer has been removed.
Immune Response Modifiers, Photodynamic Therapy, or Topical Chemotherapy - These
treatments are sometimes considered as options for treating very superficial tumours
(tumours that have not extended too deeply under the skin surface). Close follow-up is
needed because these treatments do not destroy any cancer cells that are deep under the
surface.
Cryosurgery - Cryosurgery can be used for some small basal cell carcinomas but is not
recommended for larger tumours or those on certain parts of the nose, ears, eyelids, scalp,
or legs.
Targeted Therapy for Advanced Basal Cell Cancers - In rare cases where basal cell cancer
spreads to other parts of the body or can’t be cured with surgery or radiation therapy, the
targeted drug vismodegib (ErivedgeTM) can often shrink or slow the growth of the cancer.
This drug is taken daily as a pill.
Topical Medications – The following topical medicines are used:
Imiquimod is FDA-approved only for superficial BCCs, with cure rates generally between 80
and 90 percent. The 5% cream is rubbed gently into the tumour five times a week for up to
six weeks or longer. It is the first in a new class of drugs that work by stimulating the immune
system
5-Fluorouracil (5-FU) also has been FDA-approved for superficial BCCs, with similar cure
rates to imiquimod. The 5% liquid or ointment is gently rubbed into the tumour twice a day
for three to six weeks
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 9
Trials with more invasive BCCs are under way for both imiquimod and 5-FU. Side effects are
variable, and some patients do not experience any discomfort, but redness, irritation, and
inflammation are predictable
(American Cancer Society; Skin Cancer Foundation; WebMD; Harvard Medical School).
Complications of Basal Cell Carcinoma
Complications of basal cell carcinoma can include:
o
A risk of recurrence - Basal cell carcinomas commonly recur. Even after successful
treatment, they may recur, often in the same place.
o
An increased risk of other types of skin cancer - A history of basal cell carcinoma
may also increase the chance of developing other types of skin cancer, such as
squamous cell carcinoma and melanoma.
o
Cancer that spreads beyond the skin - Rare, aggressive forms of basal cell
carcinoma can invade and destroy nearby muscles, nerves and bone. Very rarely,
basal cell carcinoma can spread to other areas of the body.
(Mayo Clinic).
About Clinical Trials
Clinical trials are research studies that involve people. These studies test new ways to
prevent, detect, diagnose, or treat diseases. People who take part in cancer clinical trials
have an opportunity to contribute to scientists’ knowledge about cancer and to help in the
development of improved cancer treatments. They also receive state-of-the-art care from
cancer experts.
Types of Clinical Trials
Cancer clinical trials differ according to their primary purpose. They include the following
types:
Treatment - these trials test the effectiveness of new treatments or new ways of using
current treatments in people who have cancer. The treatments tested may include new
drugs or new combinations of currently used drugs, new surgery or radiation therapy
techniques, and vaccines or other treatments that stimulate a person’s immune system to
fight cancer. Combinations of different treatment types may also be tested in these trials.
Prevention - these trials test new interventions that may lower the risk of developing certain
types of cancer. Most cancer prevention trials involve healthy people who have not had
cancer; however, they often only include people who have a higher than average risk of
developing a specific type of cancer. Some cancer prevention trials involve people who have
had cancer in the past; these trials test interventions that may help prevent the return
(recurrence) of the original cancer or reduce the chance of developing a new type of cancer
Screening - these trials test new ways of finding cancer early. When cancer is found early, it
may be easier to treat and there may be a better chance of long-term survival. Cancer
screening trials usually involve people who do not have any signs or symptoms of cancer.
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 10
However, participation in these trials is often limited to people who have a higher than
average risk of developing a certain type of cancer because they have a family history of that
type of cancer or they have a history of exposure to cancer-causing substances (e.g.,
cigarette smoke).
Diagnostic - these trials study new tests or procedures that may help identify, or diagnose,
cancer more accurately. Diagnostic trials usually involve people who have some signs or
symptoms of cancer.
Quality of life or supportive care - these trials focus on the comfort and quality of life of
cancer patients and cancer survivors. New ways to decrease the number or severity of side
effects of cancer or its treatment are often studied in these trials. How a specific type of
cancer or its treatment affects a person’s everyday life may also be studied.
Where Clinical Trials are Conducted
Cancer clinical trials take place in cities and towns in doctors’ offices, cancer centres and
other medical centres, community hospitals and clinics. A single trial may take place at one
or two specialised medical centres only or at hundreds of offices, hospitals, and centres.
Each clinical trial is managed by a research team that can include doctors, nurses, research
assistants, data analysts, and other specialists. The research team works closely with other
health professionals, including other doctors and nurses, laboratory technicians,
pharmacists, dieticians, and social workers, to provide medical and supportive care to
people who take part in a clinical trial.
Research Team
The research team closely monitors the health of people taking part in the clinical trial and
gives them specific instructions when necessary. To ensure the reliability of the trial’s
results, it is important for the participants to follow the research team’s instructions. The
instructions may include keeping logs or answering questionnaires. The research team may
also seek to contact the participants regularly after the trial ends to get updates on their
health.
Clinical Trial Protocol
Every clinical trial has a protocol, or action plan, that describes what will be done in the trial,
how the trial will be conducted, and why each part of the trial is necessary. The protocol also
includes guidelines for who can and cannot participate in the trial. These guidelines, called
eligibility criteria, describe the characteristics that all interested people must have before
they can take part in the trial. Eligibility criteria can include age, sex, medical history, and
current health status. Eligibility criteria for cancer treatment trials often include the type and
stage of cancer, as well as the type(s) of cancer treatment already received.
Enrolling people who have similar characteristics helps ensure that the outcome of a trial is
due to the intervention being tested and not to other factors. In this way, eligibility criteria
help researchers obtain the most accurate and meaningful results possible.
National and International Regulations
National and international regulations and policies have been developed to help ensure that
research involving people is conducted according to strict scientific and ethical principles. In
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 11
these regulations and policies, people who participate in research are usually referred to as
“human subjects.”
Informed Consent
Informed consent is a process through which people learn the important facts about a clinical
trial to help them decide whether or not to take part in it, and continue to learn new
information about the trial that helps them decide whether or not to continue participating in
it.
During the first part of the informed consent process, people are given detailed information
about a trial, including information about the purpose of the trial, the tests and other
procedures that will be required, and the possible benefits and harms of taking part in the
trial. Besides talking with a doctor or nurse, potential trial participants are given a form,
called an informed consent form, that provides information about the trial in writing. People
who agree to take part in the trial are asked to sign the form. However, signing this form
does not mean that a person must remain in the trial. Anyone can choose to leave a trial at
any time—either before it starts or at any time during the trial or during the follow-up period.
It is important for people who decide to leave a trial to get information from the research
team about how to leave the trial safely.
The informed consent process continues throughout a trial. If new benefits, risks, or side
effects are discovered during the course of a trial, the researchers must inform the
participants so they can decide whether or not they want to continue to take part in the trial.
In some cases, participants who want to continue to take part in a trial may be asked to sign
a new informed consent form.
New interventions are often studied in a stepwise fashion, with each step representing a
different “phase” in the clinical research process. The following phases are used for cancer
treatment trials:
Phases of a Clinical Trial
Phase 0. These trials represent the earliest step in testing new treatments in humans. In a
phase 0 trial, a very small dose of a chemical or biologic agent is given to a small number of
people (approximately 10-15) to gather preliminary information about how the agent is
processed by the body (pharmacokinetics) and how the agent affects the body
(pharmacodynamics). Because the agents are given in such small amounts, no information
is obtained about their safety or effectiveness in treating cancer. Phase 0 trials are also
called micro-dosing studies, exploratory Investigational New Drug (IND) trials, or early phase
I trials. The people who take part in these trials usually have advanced disease, and no
known, effective treatment options are available to them.
Phase I (also called phase 1). These trials are conducted mainly to evaluate the safety of
chemical or biologic agents or other types of interventions (e.g., a new radiation therapy
technique). They help determine the maximum dose that can be given safely (also known as
the maximum tolerated dose) and whether an intervention causes harmful side effects.
Phase I trials enrol small numbers of people (20 or more) who have advanced cancer that
cannot be treated effectively with standard (usual) treatments or for which no standard
treatment exists. Although evaluating the effectiveness of interventions is not a primary goal
of these trials, doctors do look for evidence that the interventions might be useful as
treatments.
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 12
Phase II (also called phase 2). These trials test the effectiveness of interventions in people
who have a specific type of cancer or related cancers. They also continue to look at the
safety of interventions. Phase II trials usually enrol fewer than 100 people but may include as
many as 300. The people who participate in phase II trials may or may not have been
treated previously with standard therapy for their type of cancer. If a person has been treated
previously, their eligibility to participate in a specific trial may depend on the type and amount
of prior treatment they received. Although phase II trials can give some indication of whether
or not an intervention works, they are almost never designed to show whether an
intervention is better than standard therapy.
Phase III (also called phase 3). These trials compare the effectiveness of a new intervention,
or new use of an existing intervention, with the current standard of care (usual treatment) for
a particular type of cancer. Phase III trials also examine how the side effects of the new
intervention compare with those of the usual treatment. If the new intervention is more
effective than the usual treatment and/or is easier to tolerate, it may become the new
standard of care.
Phase III trials usually involve large groups of people (100 to several thousand), who are
randomly assigned to one of two treatment groups, or “trial arms”: (1) a control group, in
which everyone in the group receives usual treatment for their type of cancer, or 2) an
investigational or experimental group, in which everyone in the group receives the new
intervention or new use of an existing intervention. The trial participants are assigned to their
individual groups by random assignment, or randomisation. Randomisation helps ensure
that the groups have similar characteristics. This balance is necessary so the researchers
can have confidence that any differences they observe in how the two groups respond to the
treatments they receive are due to the treatments and not to other differences between the
groups.
Randomisation is usually done by a computer program to ensure that human choices do not
influence the assignment to groups. The trial participants cannot request to be in a particular
group, and the researchers cannot influence how people are assigned to the groups.
Usually, neither the participants nor their doctors know what treatment the participants are
receiving.
People who participate in phase III trials may or may not have been treated previously. If
they have been treated previously, their eligibility to participate in a specific trial may depend
on the type and the amount of prior treatment they received.
In most cases, an intervention will move into phase III testing only after it has shown promise
in phase I and phase II trials.
Phase IV (also called phase 4). These trials further evaluate the effectiveness and long-term
safety of drugs or other interventions. They usually take place after a drug or intervention
has been approved by the medicine regulatory office for standard use. Several hundred to
several thousand people may take part in a phase IV trial. These trials are also known as
post-marketing surveillance trials. They are generally sponsored by drug companies.
Sometimes clinical trial phases may be combined (e.g., phase I/II or phase II/III trials) to
minimize the risks to participants and/or to allow faster development of a new intervention.
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 13
Although treatment trials are always assigned a phase, other clinical trials (e.g., screening,
prevention, diagnostic, and quality-of-life trials) may not be labelled this way.
Use of Placebos
The use of placebos as comparison or “control” interventions in cancer treatment trials is
rare. If a placebo is used by itself, it is because no standard treatment exists. In this case, a
trial would compare the effects of a new treatment with the effects of a placebo. More often,
however, placebos are given along with a standard treatment. For example, a trial might
compare the effects of a standard treatment plus a new treatment with the effects of the
same standard treatment plus a placebo.
Possible benefits of taking part in a clinical trial
The benefits of participating in a clinical trial include the following:





Trial participants have access to promising new interventions that are generally not
available outside of a clinical trial.
The intervention being studied may be more effective than standard therapy. If it is
more effective, trial participants may be the first to benefit from it.
Trial participants receive regular and careful medical attention from a research team
that includes doctors, nurses, and other health professionals.
The results of the trial may help other people who need cancer treatment in the
future.
Trial participants are helping scientists learn more about cancer (e.g., how it grows,
how it acts, and what influences its growth and spread).
Potential harms associated with taking part in a clinical trial
The potential harms of participating in a clinical trial include the following:


The new intervention being studied may not be better than standard therapy, or it
may have harmful side effects that doctors do not expect or that are worse than
those associated with standard therapy.
Trial participants may be required to make more visits to the doctor than they would if
they were not in a clinical trial and/or may need to travel farther for those visits.
Correlative research studies, and how they are related to clinical trials
In addition to answering questions about the effectiveness of new interventions, clinical trials
provide the opportunity for additional research. These additional research studies, called
correlative or ancillary studies, may use blood, tumour, or other tissue specimens (also
known as ‘biospecimens’) obtained from trial participants before, during, or after treatment.
For example, the molecular characteristics of tumour specimens collected during a trial
might be analysed to see if there is a relationship between the presence of a certain gene
mutation or the amount of a specific protein and how trial participants responded to the
treatment they received. Information obtained from these types of studies could lead to more
accurate predictions about how individual patients will respond to certain cancer treatments,
improved ways of finding cancer earlier, new methods of identifying people who have an
increased risk of cancer, and new approaches to try to prevent cancer.
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 14
Clinical trial participants must give their permission before biospecimens obtained from them
can be used for research purposes.
When a clinical trial is over
After a clinical trial is completed, the researchers look carefully at the data collected during
the trial to understand the meaning of the findings and to plan further research. After a phase
I or phase II trial, the researchers decide whether or not to move on to the next phase or
stop testing the intervention because it was not safe or effective. When a phase III trial is
completed, the researchers analyse the data to determine whether the results have medical
importance and, if so, whether the tested intervention could become the new standard of
care.
The results of clinical trials are often published in peer-reviewed scientific journals. Peer
review is a process by which cancer research experts not associated with a trial review the
study report before it is published to make sure that the data are sound, the data analysis
was performed correctly, and the conclusions are appropriate. If the results are particularly
important, they may be reported by the media and discussed at a scientific meeting and by
patient advocacy groups before they are published in a journal. Once a new intervention has
proven safe and effective in a clinical trial, it may become a new standard of care.
(National Cancer Institute).
Medical Disclaimer
This Fact Sheet is intended to provide general information only and, as such, should not be
considered as a substitute for advice, medically or otherwise, covering any specific situation.
Users should seek appropriate advice before taking or refraining from taking any action in
reliance on any information contained in this Fact Sheet. So far as permissible by law, the
Cancer Association of South Africa (CANSA) does not accept any liability to any person (or
his/her dependants/estate/heirs) relating to the use of any information contained in this Fact
Sheet.
Whilst the Cancer Association of South Africa (CANSA) has taken every precaution in
compiling this Fact Sheet, neither it, nor any contributor(s) to this Fact Sheet can be held
responsible for any action (or the lack thereof) taken by any person or organisation wherever
they shall be based, as a result, direct or otherwise, of information contained in, or accessed
through, this Fact Sheet.
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 15
References and Sources
Acral Lentiginous Melanoma
http://www.dermnetnz.org/lesions/alm.html
American Cancer Society
http://www.cancer.org/cancer/skincancer-basalandsquamouscell/detailedguide/skin-cancerbasal-and-squamous-cell-treating-basal-cell-carcinoma
Basal Cell Carcinoma Picture
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alte&utm_campaign=DC%2BWeiterf%C3%BChrende%20Inhalte%20pictures.doccheck.com
British Skin Foundation
http://www.britishskinfoundation.org.uk/SkinInformation/AtoZofSkindisease/BasalCellCarcino
ma.aspx
Brown University
http://news.brown.edu/pressreleases/2012/07/carcinoma
Carcinomaprognosis.com
http://www.carcinomaprognosis.com/basal-cell.php
DermNet NZ
http://www.dermnetnz.org/lesions/alm.html
Harvard Medical School
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d_treating_basal_cell_carcinoma
Hindawi Publishing Corporation
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Know Cancer
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Macmillan
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skincancer.aspx
Mayo Clinic
http://www.mayoclinic.com/health/basal-cell-carcinoma/DS00925/DSECTION=prevention
http://www.mayoclinic.com/health/basal-cell-carcinoma/DS00925/DSECTION=treatments-anddrugs
http://www.mayoclinic.com/health/basal-cell-carcinoma/DS00925/DSECTION=tests-and-diagnosis
http://www.mayoclinic.com/health/basal-cell-carcinoma/DS00925/DSECTION=preparing-for-yourappointment
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Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 16
http://www.mayoclinic.com/health/basal-cell-carcinoma/DS00925
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Medline Plus
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Medscape
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Medscape Reference
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Moh’s Surgery 1
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isch&sa=X&ei=WnHHUn5NsaM7AaRoIDYBQ&sqi=2&ved=0CAYQ_AUoAQ#facrc=_&imgdii=_&imgrc=f0zTOy4tzXt
OIM%253A%3B3miN9jUgLw69M%3Bhttp%253A%252F%252Fwww.skincancer.org%252FMedia%252FDefault%2
52FPage%252Fskin-cancer-information%252Fmohs-surgery%252Fevolution-ofmohs%252FMohsSurgery.jpg%3Bhttp%253A%252F%252Fwww.skincancer.org%252Fskin-cancerinformation%252Fmohs-surgery%252Fevolution-of-mohs%3B455%3B245
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mw34xM%253A%3BY_VhF88Cc9y_PM%3Bhttp%253A%252F%252Fwww.hopkinsmedicin
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y%252Freconstructive_procedures%252Fskin_cancer_mohs_surgery.html%3B1028%3B68
8
National Cancer Institute
http://www.cancer.gov/about-cancer/treatment/clinical-trials
Skin Cancer Foundation
http://www.skincancer.org/skin-cancer-information/basal-cell-carcinoma/the-five-warning-signsimages#panel1-5
http://www.skincancer.org/skin-cancer-information/basal-cell-carcinoma/bcc-preventionguidelines
http://www.skincancer.org/skin-cancer-information/basal-cell-carcinoma/bcc-treatmentoptions
http://www.skincancer.org/skin-cancer-information/mohs-surgery/mohs-overview
http://www.skincancer.org/skin-cancer-information/ask-the-experts/can-darker-skinnedpeople-get-skin-cancer
PubMed Health
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001827/
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
Page 17
Skin Cancer Foundation
http://www.skincancer.org/skin-cancer-information/basal-cell-carcinoma/bcc-preventionguidelines
http://www.skincancer.org/skin-cancer-information/ask-the-experts/can-darker-skinnedpeople-get-skin-cancer
Stanford Cancer Institute
http://cancer.stanford.edu/skincancer/basal_cell_carcinoma/staging.html
University of Maryland Medical Center
http://www.umm.edu/imagepages/9099.htm#ixzz2MZsVBIKB
WebMD
http://www.webmd.com/melanoma-skin-cancer/basal-cell-carcinoma?page=2
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Wok]
December 2015
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