<p>Risk factors for the development of basal cell carcinoma (BCC) include extrinsic and intrinsic characteristics. Although some risk factors, such as UV radiation exposure and sunburns, can be modified through patient education and behavior change, genetic risk factors cannot. However, these can still inform long-term surveillance and prevention efforts.</p>

The most common cause of BCC is our sun, as UV radiation plays a very important role in its development. Genetics also plays a role in UV-related BCC, as people with fair skin, light eyes, and light hair are more likely to sunburn and are at greater risk for BCC. There are other genetic components of BCC besides skin, eye, and hair tone and other external and environmental causes besides UV radiation that may make people a bit more susceptible to developing BCC.

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Apart from genetics, most of the risk factors for BCC are modifiable. The risk from UV radiation may be modified by taking simple sun-protective measures, such as using sunscreen, avoiding sun exposure when the UV index is highest, and wearing UV protection factor clothing. A key thing that I like to tell patients is that, while they cannot change their past exposure, they can make changes now. I use the analogy of performing plastic surgery on people who smoke cigarettes. If those who have smoked for 30 years stop smoking and give themselves a couple of months to heal, they may have drastically better surgical outcomes. Similarly, if people stop their high-intensity sun exposure, they may develop less skin cancer. They will still probably develop skin cancer, but instead of developing 10 this year, maybe they will only develop 5. So, I encourage all of my patients to make these changes.

With BCC, we are still dealing with mistakes from our past, society wise. For example, sunscreen was not widely used until a couple of decades ago, and, with migration patterns, Northern European descendants have moved to areas that are closer to the equator, where there is high-intensity UV radiation. In addition, societal forces drive tanning, as it is often considered more attractive to have a tan. So, many factors play into a higher risk of developing BCC.

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We cannot undo the use of tanning beds in the 1980s and 1990s, nor can we undo the baby boomer generation’s previous use of baby oil for tanning. The damage has been done, so to speak, within the baby boomer population, as UV-induced DNA mutations have already occurred. As people age, they naturally lose some of their immunosurveillance of malignancy development, so we are seeing a lot of cases of BCC in these patients.

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There are things that we can do to try to further mitigate BCC risk from the damage that has already been done, and an important component of that is prevention. We can educate people about prevention moving forward. Moreover, we can identify those who had a lot of sun exposure when they were younger to surveil and potentially use preventive techniques such as nicotinamide to try to prevent the development of nonmelanoma skin cancers, including BCC.

I think it is important to recognize that a vast number of patients worldwide develop this common cancer, and it tends to occur after accumulated sun damage. The average age of my patients with BCC tends to be early 70s, but BCC can occur in younger people due to genetic predisposition from germline mutations. It is important to keep this in mind because there is a complex interplay between some genetic traits and UV radiation exposure.

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Also, I think that comprehensive education for the general population is critically important. I have been in Tampa, Florida, for approximately 10 years, and I was in Buffalo, New York, prior to that. There are big differences in temperatures and climate patterns from the north to the south, and a number of people visit Florida and other warm climates during the winter and spring break and are exposed to the sun periodically and repetitively. I think that it is important to promote education and awareness that, while the sun is important for life, it is not always our friend, particularly in terms of our skin.