Frontline Forum Part 3: Solutions in the Management and Treatment of Basal Cell Carcinoma

Continued from part 2.

Treatment Group Plan

The panel discussed how important it is to not only explain why you are referring a patient to a different specialist but to also explain to colleagues in other specialties why a patient needs their expertise. In Bhatia’s experience, oncologists sometimes minimize skin cancer, thinking it is only for the realm of the dermatologist.

“When we first got access to immune checkpoint inhibitor therapy for skin cancer—for nonmelanoma skin cancers, [BCC], and advanced squamous cell carcinomas—my initial conversation with some of the oncologists [was] really frustrating. They didn’t know why they should see a patient with [BCC] or squamous cell [carcinoma] because in the past, they really didn’t have anything to offer them. They just assumed these are little things we scraped off and never worried about again, so I had to advocate for patients to [oncologists] about the real need to get systemic treatment for [patients with BCC] and squamous cell carcinoma in this, as well,” Strasswimmer said. It may be easier to work with oncologists in a facility, but the dialogue between dermatologists and oncologists must be improved for comprehensive treatment, the experts explained.

Ferris said a multidisciplinary tumor board was established in Pittsburgh during the COVID-19 pandemic. She described how the board includes dermatology, Mohs, medical oncology, surgical oncology, radiation oncology, and ear, nose, and throat specialists as needed. She said community dermatologists have also been invited, and the whole group is very productive. The board looks over patients’ cases, makes quick decisions, and provides fast treatment for best outcomes. Ferris added that this board has helped other practitioners understand the potential seriousness of BCC, especially when it metastasizes. Thanks to technology, the model is not limited to a university facility setting, she explained, as video conferencing can be used to connect specialists.

Treatment Choice Factors

The panel agreed that it can be easy to become complacent with treatment methods, and that therapies such as biologics may seem daunting. The scope of practice has the opportunity to be expanded, and clinicians must seek additional knowledge and training to keep up with the best treatment methods for patients. Farberg added that dermatologists must be prepared to treat the sickest patients with the most advanced therapies. “The onus is on us to educate ourselves and our colleagues on how to be the best medical dermatologists we all can be,” he said.

Similarly, although surgery is the frontline treatment for BCC, treatment must be personalized to the patient and their condition.⁸ The experts indicated that factors such as the location of the lesion, the type, the size, and the age of the patient must be considered. For example, treatment for an 80-year-old may involve electrodesiccation and curettage, whereas Mohs may be more appropriate for a patient in their 40s. The panel emphasized that patient history of prior treatment for BCC should be carefully considered when deciding on treatment options. They said pathology is also a factor, as lesions may be found to be more complex than initially thought when Mohs is used. The frequency of needed treatment, such as in cases of immune checkpoint therapy or radiation, may also be a factor that influences treatment choice, the experts said. Because of the wide range of risks associated with treatment techniques,⁹ education and informed consent are essential. Patients’ thoughts, opinions, risk tolerance, and adverse events tolerance should also factor into treatment selection.

The experts discussed the use of hedgehog inhibitor (HHI) therapy. “They align themselves with the PD-1 inhibitors as well as either neoadjuvant, adjuvant, or primary treatment of basal carcinomas that are not surgically appropriate or [are for when] the patient just doesn’t want surgery,” Farberg said. Panelists also noted that HHIs are also excellent for palliative care of BCC.

The panel discussed struggles in patient adherence. Ultimately, 90% of patients discontinue HHI therapy.¹⁰ Bhatia stressed the importance of encouraging patients to stick with the treatment regimen, despite patient-reported effects such as altered taste. “My goal is 6 months. If you can get past that, great, but getting to it is the biggest thing,” Bhatia said. “I’ve found that the taste issue is the most limiting. Many can live with muscle aches and hair loss, but it is the taste disturbance that really throws [patients] off because they’re otherwise young and healthy, or at least healthier. They like to eat and still enjoy whatever else they taste. When they start to lose taste or have bad dysgeusia, that’s when they want to give up.”

The panel noted that the importance of a full and accurate account of all medications, supplements, and herbs the patient is taking prior to treatment to ensure optimal care when receiving HHIs. They also reiterated that HHIs take time to work; the patient will not see immediate results and may need to be persuaded to continue therapy. HHIs should not be viewed as a good monotherapy due to patients stopping the drug because of adverse effects or slow results, the experts said.

References

8. Skin cancer treatment (PDQ)–patient version. National Cancer Institute. Updated August 27, 2021. Accessed April 18, 2023. https://www.cancer.gov/types/skin/patient/skin-treatment-pdq#_92

9. Walling HW, Fosko SW, Geraminejad PA, Whitaker DC, Arpey CJ. Aggressive basal cell carcinoma: presentation, pathogenesis, and management. Cancer Metastasis Rev. 2004;23(3-4):389-402. doi:10.1023/B:CANC.0000031775.04618.30

10. Lear JT, Migden MR, Lewis KD, et al. Long-term efficacy and safety of sonidegib in patients with locally advanced and metastatic basal cell carcinoma: 30-month analysis of the randomized phase 2 BOLT study. J Eur Acad Dermatol Venereol. 2018;32(3):372-381. doi:10.1111/jdv.14542

Continued in part 4.