Sadly, at the start of 2024, that BCC was still there, slowly getting bigger and badder than it was when it was first diagnosed in 2022. That meant I had been going out in public for over a year and a half with my nose often looking something like it does in the photo above.
—Update! BCC Removed, March 1, 2024. See below for details—
To be clear, I was not overly bothered by the aesthetics of this condition. To most people I am an old man and old men are almost expected to look imperfect. However, I did get concerned that a bloody scab on the end of my nose was distracting people from the things I was trying to communicate (like make a point in a face-to-face or video meeting).
Sadly, this "remission" does not last. The area can randomly start bleeding, e.g. if I accidentally catch my nose on a towel or piece of clothing. This can trigger a repeat of the blood-scab-film process.
(Note: I take anticoagulation medication because of my atrial fibrillation, so when my blood gets out of my body it does tend to flow faster and congeal slower than average, so your BCC mileage may vary, so to speak).
Out, damned BCC! out, I say!
So, if I first spotted this is anomaly in 2022, why was it still there over 70 weeks later? Why was it not removed already? The simple answer is this:
there is a drastic shortage of dermatology care available via England's National Health Service.*
Apparently, there are only 746 dermatologists in all of England, a nation that has a population of over 55 million (source). Even if there were 1,000 dermatologists, that is only one per 55,000 people. All of which means there are long waiting times if you want to get anything dermatological done via the National Health Service. For example:
"A random check on NHS hospitals across England brought an average figure of 43 weeks [waiting time], for a dermatology appointment and commencing treatment. The NHS Constitution states that for routine conditions, treatment should commence within 18 weeks" (source).
In my case, it was 30 weeks from my doctor's referral, marked urgent, to getting the biopsy done. It eventually took 80 weeks to get from the referral to the surgery (performed March 1, 2024). Of course, your mileage may vary. NHS waiting times are very much a postcode lottery, shorter in some places than others.
Bear in mind that, of those 746 dermatologists, only a small percentage are qualified to perform the treatments used to remove a BCC. As a result, those particular dermatologists are often tempted to offer their services outside the NHS and charge a substantial fee for doing so. In other words, I could have paid someone to remove this thing back in 2022.
Why not pay privately to remove a BCC?
As I see it, there are two main reasons.
1. We've already paid for it. Most forms of healthcare offered by the NHS are provided at no charge to the patient and funded out of revenue raised by various taxes (income tax, employment tax, and VAT — a form of sales tax currently at 20%).
2. Paying privately undermines the principles and finances of the NHS. If you pay a dermatologist to remove your BCC, that delays treatment for someone who cannot afford to pay.
A complicating factor, at least in my experience, here in England, is the difficulty of finding out the current cost of removing a nasal tip basal cell carcinoma and covering up the wound with a flap of skin. One of the commonly used BCC removal procedures used is called Mohs micrographic surgery (MMS). This is often followed by a bilobed flap to protect the affected area (note: that link leads to an article that has photos, but only if you scroll down — be aware that if you google bilobed flap some of the results will be quite graphic).
Clearly, these procedures require highly specialized skills and equipment. My best guess if that the price for Mohs surgery on my BCC and repairing with a flap would have been between £4,500 and £5,500 ($5,700 and $7,000). That is based on what BCC patients have reported in online forums.
Depending on your financial circumstances you might consider that price to be anything from unaffordable to small change. But to put this in context, median disposable household income in the UK in 2022 was £32,300 (ONS). So a £5,000 medical bill is roughly one sixth of what a median household has available to spend on everything they need for a year (disposable income is basically take home pay, before rent, mortgage, heat, food, etc.).
All of which brings us back to the question: how urgently is treatment needed?
The answer will vary according to the exact nature of the BCC. There are multiple types of BCC, the main four being: superficial, nodular, pigmented, and infiltrative. You can read about them on this page which contains possibly upsetting images.
In terms of urgency, note what is said of the infiltrative type of BCC: "can be more aggressive and locally destructive than other types of BCC. They can invade more deeply and widely than their appearance suggests. For this reason, it is important to treat them early" (Source). Unfortunately, according to the dermatologists who have investigated my nasal tip carcinoma, mine is infiltrative.
Here's another quote about infiltrative BCC, from a website that has a lot of gruesome pics: "This cancer can grow both extremely wide and deep, causing it to destroy skin, deeper tissue, and can even damage bone" (US dermatology website).
The BCC Dilemma: Why bother?
As a medical issue, basal cell carcinoma can be confusing. I say this because, if you're just learning about BCC, it can be hard to know how serious it is or how concerned you should be if you have, or think you may have, a BCC on your body.
I was going to say "it's hard to get you head around BCC," but because many BCCs are on the head, I was worried that might come across as inappropriate humour. That said, on a personal level, I found that humour helped me live with that thing on the end of my nose without getting too stressed or angry (I went through a phase of naming it, like Basil the Basal Cell, so I could introduce people to it.)
But seriously, the dilemma I see from from the patient perspective is this: doctors tend to tell you your BCC is not a big health threat, but it should be removed. It's all a bit passive aggressive because, depending on the nature of your BCC, it could be growing and may be doing damage until removed. Then again you can get the feeling from medical staff that a BCC is not so serious that you need to rush into anything. All of that is indeed, hard to get your head around, particularly if the context is: not going to happen any time soon unless you've got a lot of money.
Then you come across this statistic: there were 918 deaths a year from non-melanoma skin cancer on average in the UK from 2018-2019 (Cancer Research UK). The same source reckons 75% of non-melanoma skin cancer is BCC. Avoiding becoming one of the 918 is probably a high priority for most people — it certainly is for me.
BCC fact: Hugh Jackman has one on his nose.
The Australian actor known for his portrayal of Wolverine in the X-Men film series, has been admirably open about his BCC experience. Jackman has leveraged his popularity to spread awareness of BCCs and what you can do to reduce your risk of developing them.
"Jackman is strongly committed to raising awareness by using social media to discuss his skin cancer history. In his [Instagram] post, he explains: "I know you’ve heard me talk about my basal cell carcinomas. I’m going to keep taking about them. And if it reminds even one person to put on sunscreen, then I’m happy."" — Skin Cancer Foundation
According to the Skin Cancer Foundation, the best way to avoid skin cancers like BCCs is: "a complete sun protection strategy – sunscreen, a hat, sunglasses, or simply seeking shade wherever you can. Ninety percent of nonmelanoma skin cancers like BCC are associated with the sun’s UV rays. This means that, with the right behaviors, they’re also generally preventable.""
One of the most interesting aspects of the operation was the application of the final dressing after the flap had been sewn into place. This dressing is built up from scratch on each patient's nose by a post-operative nurse technician. The idea is to conform the dressing to the shape of your nose to help it recover looking as much like the original as possible. This is done using many small strips of reinforced adhesive tape carefully tailored and applied.
If all goes well, the dressing comes off after three days. After that, the stitched up wound will be visible as it continues to heal. As I understand it, the healing process will take several months. I will share some photos of that process as time goes by.
Update: 250 days after Mohs surgery?
Remember when, at the top this article, I said I was not overly bothered by the aesthetics of my basal cell carcinoma?
Well, it turns out that I am bothered by the post-surgery aesthetics. My nose looks a lot different eight months after the Mohs surgery. There is a bump in the profile of my nose that wasn't there before. The skin on the tip of the nose is quite red and lumpy.
What you see on the left in the photo below is my nose in October, 2022, complete with basal cell carcinoma in remission. On the right is my nose now, in November of 2024, eight months after the Mohs surgery to remove the nasal tip carcinoma.
Useful sources
Here is a list of sources offering information about basal cell carcinomas. Note: some links include images of cancers and surgery. I cannot vouch for all of these sites being impartial or entirely accurate. Note that I am not a medically qualified person (except for a one-day Emergency First Aid training course and over 35 years living with a partner who worked as a paramedic and qualified as a ship's medical officer).
- Cancer Research UK (the main source cited by NHS England).
- The Mayo Clinic on BCC
- BCC on Wikipedia
- Dermatology support site in New Zealand
- Skin Cancer Foundation
- Skin condition website
- Mohs surgery page at Cleveland Clinic
- Article about bilobed flaps
- US dermatology website
Note:
* In my opinion, the drastic shortage of dermatology care available via England's National Health Service stems from the policies of the Conservative Party which has been "leading" the country since 2010. Many key members and supporters of the Conservative Party want to privatize all health services in order to generate profits for their wealthy friends who have the capital to fund for-profit investments in medical services and facilities. I think that is a bad idea and morally wrong.
