“It’s only a little spot on my nose that bleeds when I wash — I can’t be going to the hospital, I look after my husband”

Basal cell carcinoma (BCC) is the commonest skin cancer, typically on sun-exposed skin of the head and neck in older people. It presents as a slowly enlarging, pearly or translucent nodule with a rolled edge and telangiectasia, often with central ulceration or crusting that bleeds and fails to heal. It grows locally and can destroy surrounding tissue, but metastasis is very rare. NICE NG12 recommends considering routine referral for a skin lesion that raises suspicion of BCC, and considering a suspected cancer pathway referral only if there is particular concern that a delay may have a significant impact because of factors such as lesion site or size; facial lesions near the eyes, nose and lips are high-risk sites for recurrence and are often handled through local pathways. GPs should not treat suspected facial BCCs with creams or minor surgery outside accredited arrangements. Specialist treatment options include surgical excision, Mohs micrographic surgery (tissue-sparing, used for high-risk facial sites and recurrent tumours), radiotherapy for some older patients, and topical treatments or curettage for selected low-risk superficial lesions. The contrast with the related case of a suspected squamous cell carcinoma is important: SCC is faster-growing, often tender and can metastasise, so NG12 recommends a suspected cancer pathway referral. The consultation challenge here is an older carer who minimises the lesion because of fear of disfigurement from a family experience and because she cannot leave her husband. Honest, proportionate information, addressing the specific fear, practical help with caring responsibilities (respite, transport, a Carer’s Assessment under the Care Act 2014), and respect for her autonomy lead to a plan she can accept.