When it comes to treatment, skin cancer patients and their care partners have much to consider. There are often many options available, each with advantages and disadvantages. Some people may seek clinical trials, others may have few feasible options. Understanding treatment options, goals, and what to expect are vital to achieving the best possible outcome for you.
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An Expert’s Perspective on Advanced Non-Melanoma Skin Cancer Research from Patient Empowerment Network on Vimeo.
What’s the latest in advanced non-melanoma skin cancer research? Dr. Sunandana Chandra shares an update on emerging treatments and provides reliable resources for research news.
Dr. Sunandana Chandra is a medical oncologist and Associate Professor of Medicine at Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Learn more about Dr. Chandra.
What Are Treatment Goals and Considerations for Advanced Non-Melanoma Skin Cancer? |
A Review of Current Advanced Non-Melanoma Skin Cancer Treatment Options |
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Katherine:
Are there developments in advanced non-melanoma skin cancer treatment and research that patients should know about?
Dr. Chandra:
So, you know, in the past, as a medical oncologist, we used to use a lot of chemotherapy.
So, these are drugs that are notoriously hard to tolerate. Patients, understandably, are fearful of them and many of them don’t want them. They’ve seen friends and family go through them. And frankly, they have not been the most effective or efficacious in treating non-melanoma skin cancers, traditionally. But in the past, that’s all we had.
Now, we actually have much better therapies, specifically, the category of drugs called immunotherapy drugs that really boost a person’s own immune system to fight the cancer. These drugs are fairly new in the cancer world, and certainly new in the non-melanoma skin cancer world, and so, many of our colleagues in the community may not necessarily think of them when they’re considering patients.
Perhaps, a lot of our patients haven’t even gotten a chance to hear about them. So, yes. There are new developments that I think are worth considering earlier and earlier in the course of a person’s treatment course. And so, I think an earlier referral to these multidisciplinary team members, including a medical oncologist, may not be a bad idea.
Katherine:
How can patients stay up-to-date on developing research? What’s available for them?
Dr. Chandra:
So, you know there are skin cancer patient advocacy websites that they can check out, skincancer.org. I always tell patients to be careful about what website they’re checking, because I certainly want them to go to a website that’s reputable, that’s vetted, that is something that we think has accurate information that’s evidence-based.
And so, AIM at Melanoma has a non-melanoma skin cancer educational website. It’s called SCERF, which is Skin Cancer Education and Research Foundation, and you can find that through the aimatmelanoma.org website. You can look at skincancers.org, you can try with American Cancer Society, or you can even ask your clinical care team and see if they have any suggestions. There’s a lot of resources out there. I would just urge our patients to be careful in what source they’re looking at just make sure that they’re getting accurate, evidence-based information.
Should Advanced Non-Melanoma Skin Cancer Patients See a Specialist? from Patient Empowerment Network on Vimeo.
Do advanced non-melanoma skin cancer patients need to see a specialist? Dr. Sunandana Chandra explains the benefits of working with a specialist, how she empowers patients, and when she recommends seeking a second opinion.
Dr. Sunandana Chandra is a medical oncologist and Associate Professor of Medicine at Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Learn more about Dr. Chandra.
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What Are Treatment Goals and Considerations for Advanced Non-Melanoma Skin Cancer? |
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Katherine:
Why is it important that patients speak up and have a voice in their care?
Dr. Chandra:
Well, I think for person to feel empowered, they have to understand their cancer, in my opinion.
And that’s part of my responsibility is to try to share what I know about their cancer, my medical and clinical experience dealing with that type of cancer, and really, to try to empower them by giving them knowledge about their cancer, about their diagnosis, about the prognosis, about potential treatment options. And, I really think that that knowledge is really empowering for our patients and their family members, and I think with that knowledge, they can make the most informed decision, and they can help us then figure out what the best management plan for them is. You know, I try to spend a considerable amount of time with my patients and their family members and loved ones to explain all of this at the get-go so that that way, oftentimes, they can go home, they can kind of think about it, come back with more questions.
Or, if they do some additional research on their own, hopefully some of what I’ve talked about might resonate and might even spur on more questions that usually can be very helpful for us to try to answer, helpful for the patient, I mean.
Katherine:
Absolutely. Should patients consider seeing an advanced non-melanoma skin cancer specialist?
Dr. Chandra:
You know, for a “routine” non-melanoma skin cancer of which the most common are basal cell carcinomas, squamous cell carcinomas, they may be tiny spots, maybe one, potentially multiple, that can just be excised and the person can be followed closely. For them, perhaps seeing someone locally, maybe very reasonable.
But, if the patient themselves is ever worried or unsure, or they feel like they want to see a specialist, I absolutely would encourage that. In addition, for a person who has recurrent non-melanoma skin cancers, you know, multiple occurrences, maybe even more advanced than others, I think that those particular patients going to a specialist or a number of specialists may really help with the most advanced care. Maybe it’ll allow the patient and their team to be more proactive, maybe allow for other options that are maybe not standards of care, maybe novel, but promising.
And so, I think for patients who are worried or for patients with more high-risk features, more increased number of skin cancers, perhaps more advanced skin cancers, I think having an expert or a team of experts on their team is certainly worth considering.
Katherine:
What is your advice for patients who may feel like they’re hurting your feelings by seeking a specialist or a second opinion? Any advice for self-advocacy?
Dr. Chandra:
Oh, gosh. I mean, I always tell our patients I strongly encourage it if they bring up especially. You know, I never want to patient of mine or their family members to look back and have any regrets. And so, from the get-go, I think that they should seek opinions. They should feel comfortable with the management that I or someone else is recommending to them.
And, if a person asks me if it’s okay if they seek an opinion, I’m actually very encouraging of it because it doesn’t hurt my feelings. In fact, I think, again, it empowers the patient, which at the end of the day I think is most important and allows, hopefully, for them to have no regrets. And, I always tell patients more heads are better than one. So, if a colleague has another idea that perhaps I didn’t think of or vice versa, having that discussion and ultimately, that may allow for better patient care, which I think is all of our goals, which is actually our ultimate goal, I should say.
Non-Melanoma Skin Cancer Treatment Options from Patient Empowerment Network on Vimeo.
What are the treatment options for advanced non-melanoma skin cancer? Dr. Sunandana Chandra shares insight on how a treatment approach is determined, the types of non-melanoma skin cancer, and discusses factors considered when choosing therapy.
Dr. Sunandana Chandra is a medical oncologist and Associate Professor of Medicine at Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Learn more about Dr. Chandra.
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A Review of Current Advanced Non-Melanoma Skin Cancer Treatment Options |
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Katherine:
How is advanced non-melanoma skin cancer treated?
Dr. Chandra:
So, usually, the first thing that might occur is a biopsy to see what it is that we think that we’re dealing with. A biopsy is then reviewed by a pathologist or a dermatopathologist, and then those results are then relayed back to the doctor who did the biopsy.
Oftentimes, it’s a dermatologist, a primary care doctor etc. Once we have the exact diagnosis and the exact pathology, we can then talk about, okay, is this removable? Is this excisable? In that situation, a dermatologist can do it; a Mohs surgeon who is a sub-specialized dermatologist can do it. In certain instances, they may say this is a larger spot, it’s a spot, etcetera, so they then may involve our surgeons or our surgical oncologists. Now, the vast majority of non-melanoma skin cancers are treated by surgery alone. They’re just excised or removed, and then the person is followed closely.
However, there are certainly situations when a person’s non-melanoma skin cancer, meaning a Merkel cell carcinoma, a cutaneous squamous cell carcinoma, or a basal cell carcinoma being the three most common non-melanoma skin cancers.
There are situations where those are too big to respect or to surgically remove. Potentially, it may cause too much disfigurement. Potentially a person or a patient may feel that they are just sick of surgery. They want no further surgery. In those instances, those patients are then often referred to medical oncologists. These are cancer doctors who treat the cancer with systemic or whole body cancer drugs and/or radiation oncologists who can use radiation beams to often treat the cancer.
Katherine:
Dr. Chandra, when you’re deciding on a treatment plan for a patient, what factors are taken into consideration?
Dr. Chandra:
So, usually, first and foremost, we have to get to know our patient and understand their own preferences, what their own goals of care are with respect to how they want to live their life, how aggressive or not they would like to be with respect to their cancer management, their functional status, which we technically call performance and status, their other illnesses or comorbidities that may kind of complicated cancer management.
For example, people with autoimmune diseases who are on steroids, or people who have uncontrolled diabetes, these are just two examples of a potential infinite list of a person’s comorbidities or illnesses that they may have that may complicate things. All of these are taken into consideration. And, I think at the end of the day, we as their doctor want to do what’s best for them and what makes the most sense to them and for them, but certainly, it takes a very detailed discussion with our patients, their loved ones, their family members, caregivers, as well as our multidisciplinary team members to kind of figure out what the next best steps are.
Dr. Chandra:
I think this is a time where if a person is diagnosed with a non-melanoma skin cancer, I want them to know that there are options out there, options that were not even available a decade ago, certainly, maybe even five years ago that have really revolutionized how we treat our patients with advanced non-melanoma skin cancers. And so, the sooner they reach out for help, I think the better the outcomes are. So, we are here to help those particular patients to the best of our ability.
Advanced Non-Melanoma Skin Cancer: Who Is on Your Healthcare Team? from Patient Empowerment Network on Vimeo.
What experts make up an advanced non-melanoma skin cancer care team? Dr. Sunandana Chandra shares an overview of typical team members who work together for optimal patient care.
Dr. Sunandana Chandra is a medical oncologist and Associate Professor of Medicine at Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Learn more about Dr. Chandra.
Why Do Advanced Non-Melanoma Skin Cancer Patients Need a Multidisciplinary Care Team? |
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Katherine:
People with advanced non-melanoma skin cancer typically need a multidisciplinary team. Who all is on that team?
Dr. Chandra:
So, typically the members of a multidisciplinary team include a dermatologist, including potentially a Mohs surgeon if one is available, a surgeon or a surgical oncologist, a pathologist, specifically, a dermatopathologist, if they’re available, because they really focus on scan pathology.
A medical oncologist, a radiologist who could help us read the imaging, and a radiation oncologist who can actually use radiation to treat certain spots. Now, in addition, we can often also include our palliative and supportive oncology colleagues, especially in the settings where people may have some difficult-to-treat symptoms. They may have enough of an advanced disease where we need to start kind of talking about a person’s goals of care and what their own wishes are for their cancer management and for their life. So, these palliative and supportive oncology colleagues are very, very helpful in those situations.
Katherine:
Are there also people like social workers, nutritionists?
Dr. Chandra:
Absolutely. Absolutely.
So, you know, our social workers, our nurse navigators, our nutritionist and dietitian colleagues, our nurses, our nurse practitioners, I mean, our pharmacists, it takes such a village to help take care of our patients. And I hope a patient or a person realizes that having this village at their fingertips and at our disposal only enhances their care. It’s not meant to complicate their care. It’s not meant to add unnecessary appointments. It’s just to really deliver expert care by each of these individuals who really have a focus on a particular aspect of the delivery of care.
What Do You Need to Know About Advanced Non-Melanoma Skin Cancer? from Patient Empowerment Network on Vimeo.
What information is important for you and your loved ones to know after an advanced non-melanoma skin cancer diagnosis? This animated video reviews the types of advanced non-melanoma skin cancer, current treatment options, and important advice for engaging in your care.
What do you need to know if you or a loved one has been diagnosed with advanced non-melanoma skin cancer?
Non-melanoma skin cancer describes skin cancers that are not classified as “melanoma.” The main types of non-melanoma skin cancer include:
When a non-melanoma skin cancer is large and deeply invasive, it is considered advanced. In these cases, the cancer is managed by a multidisciplinary team that could include a dermatologist and surgical, radiation, and medical oncologists.
Treatment recommendations are based on a variety of factors, including:
If the cancer cannot be treated by surgery alone, treatment options may include:
Palliative care may be used in combination with these approaches to help reduce symptoms and to manage treatment side effects.
Now that you understand more about advanced non-melanoma skin cancer, how can you take an active role in your care?
To learn more about advanced non-melanoma skin cancer and to access tools for self-advocacy, visit powerfulpatients.org/skin.
How a Skin Cancer Expert Empowers Patients from Patient Empowerment Network on Vimeo.
Dr. Anna Pavlick is a medical oncologist with over 20 years of experience treating patients with skin cancer and is the founding Director of the Cutaneous Oncology Program at Weill Cornell Medicine and NewYork-Presbyterian. To learn more about Dr. Pavlick, visit here.
What are steps does skin cancer expert Dr. Anna Pavlick take to empower her patients? Dr. Pavlick explains how self-education and being comfortable with your healthcare team are key components of patient empowerment.
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A Review of Current Advanced Non-Melanoma Skin Cancer Treatment Options |
Katherine:
Yeah. Dr. Pavlik, how do you empower patients?
Dr. Pavlick:
You know, when I talk to patients I really do try to number one: educate them. I am big believer in bad artwork, because I’m a bad artist. And so I really try to draw out schematics to help patients understand how they therapy that I’m proposing is going to work, so they understand the mechanism. Patients will also go home with printed handouts so that they can go back and read about what we talked about, because many times patients absorb maybe one-quarter of what’s been said in a consult.
I encourage people to bring their family members or friends so that they can hear; two sets of ears is always better than one. And I fully support them; if they want to go get a second opinion, my answer is, “Absolutely.” I do not get offended. I feel that if – because a lot of times the patient’s going to say, “I don’t want a second opinion, but my family does.” You’ve got to live with your family. Go get the second opinion. 99 percent of the time, experts who do this for a living all have the same answers. And so it just is going to solidify for your family that the right thing is being done, and then you can also decide where do you feel most comfortable?
If Dr. A and Dr. B tell you the same thing, what environment do you feel most comfortable in, so in the event that you had questions, or you didn’t feel well, where do you want to go? So, I strongly encourage that. And if somebody comes back and says, “You know, I really think that this place fits me better,” my answer is, “That’s absolutely fine; thank you for letting me know. If there’s anything I can do, please reach out.” Because, again, bottom line is I just want the best outcome for the patient.
What Do Advanced Non-Melanoma Skin Cancer Patients Need to Know About Treatment and Research? from Patient Empowerment Network on Vimeo.
What therapies are emerging for advanced non-melanoma skin cancer (ANMSC)? Dr. Anna Pavlick shares the latest in ANMSC research news, including developments in targeted therapy and immunotherapy.
Dr. Anna Pavlick is a medical oncologist with over 20 years of experience treating patients with skin cancer and is the founding Director of the Cutaneous Oncology Program at Weill Cornell Medicine and NewYork-Presbyterian. To learn more about Dr. Pavlick, visit here.
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A Review of Current Advanced Non-Melanoma Skin Cancer Treatment Options |
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Is the COVID Vaccine Safe and Effective for Advanced Non-Melanoma Skin Cancer Patients? |
Katherine:
Are there developments in advanced non-melanoma skin cancer treatment and research that patients should know about?
Dr. Pavlick:
Well, I think when it comes to non-melanoma skin cancers, the developments over the last five years have been groundbreaking.
I think the first major advancement we made was to identify that the hedgehog pathway is a pathway that basal cell cancers follow in order to spread to other parts of the body. And we found out that if we can block that pathway, we can control basal cell cancer very easily because more than 90 percent of basal cell cancers use that pathway to spread. So it’s like a roadblock. If you’re doing construction and you come to point where you’ve got the detour, well, you can’t keep going straight ahead – you get stopped. And that’s what targeted therapies do, and we found that there are hedgehog inhibitors that are these roadblocks for basal cell cancer.
Dr. Pavlick:
So what has been evolved since then is looking at immunotherapy as a way to control non-melanoma skin cancers because, as you know, melanoma was the first place that immunotherapy really became paramount as the key treatment that makes the hugest impact on patients. And because of what we learned in melanoma, finding out that the number of mutations that melanomas have make it very susceptible to immunotherapy. We then went and looked at, “Well, what does squamous cell cancer have, what does basal cell cancer have?”
Well, we found out that basal cell, squamous cell and Merkel cell cancer have a very high mutational burden, and translating that, we said, “Well, we now know this: these are cancers that should now response to immunotherapy as well.” And they do. And they do very, very beautifully. Unfortunately, like every story, it’s not 100 percent of the tumors that will respond. It’s basically in the 50 percent range. So although it’s still a very high number, you need to know that going into it when you treat a patient with locally advanced squamous cell cancer, only 50 percent are going to have a response. So, if you don’t see that tumor getting better pretty darn quickly, you better start thinking, “This might be somebody who’s not going to respond to immunotherapy, and what’s going to be my Plan B?”
Katherine:
Right.
Dr. Pavlick:
Because squamous cell cancers in general respond very, very quickly to immunotherapy.
Usually within a matter of four to six weeks, you’re already starting to see improvement. When it comes to basal cell cancer on the other hand, basal cell cancers – because they develop very, very slowly over years – it takes months of immunotherapy to get them to respond. So I tell patients with locally advanced basal cell, “You really have to be patient, because we expect this to take somewhere between three and 6 months for us to start seeing something get better.” It doesn’t mean that it’s not working, it’s just basal cells just respond much slower. I think when patients are prepared and knowing that this is not a quick eight weeks – we’re going to know for sure whether this helps or not – it helps patients to be able to understand that, “I’m in this for at least six months –maybe longer.”
Expert Advice for Newly Diagnosed Advanced Non-Melanoma Skin Cancer Patients from Patient Empowerment Network on Vimeo.
Dr. Anna Pavlick provides three key pieces of advice for newly diagnosed advanced non-melanoma skin cancer patients to help them feel empowered in their care and treatment decisions.
What Do Advanced Non-Melanoma Skin Cancer Patients Need to Know About Treatment and Research? |
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Katherine:
What three key pieces of advice would you have for a patient who has just been diagnosed with advanced non-melanoma skin cancer?
Dr. Pavlick:
I think the first one is number one: do your homework. Don’t just take anything for face value. You know, I tell my patients, “This is your life. If you go and do research about what appliance you’re going to put in your kitchen, I think you should also do a little bit of research about what doctor you’re going to allow care for you.” And so I always tell everybody, “Did you do your homework? Are you sure you’re in a place that is going to be able to provide you with the care that you need? Are the physicians that you’re seeing experienced in the disease that you have?” Because they may be brilliant physicians, but they may not have any expertise in that particular area. And so I think it really behooves people to – I tease my patients, I ask them if they go to “Google Medical School.”
And really, find out a little bit about our backgrounds, find out about the institution that you’re going to, and learn a little bit about the disease. I’m certainly not saying come in and tell us what you want to have done, because I would hope that it takes many years of training and expertise to know how to make a good decision. But I think the more that patients know about the physicians that they’re seeing, and their level of expertise, and their interest, the better the outcome’s going to be. So that’s number one, number two is consider clinical trial. If you are a candidate for a clinical trial, consider it.
Because we are taking promising agents and looking for ways to make patients have better outcomes. And so, many times when we talk about clinical trials, we know about the drugs, we know about their side effects, we know their efficacy, but we’re looking to find ways to make those drugs work even better. And sometimes it may be adding radiation to one of the standard drugs we have. It may be adding a different type of targeted therapy to the medicines that we have. Sometimes it’s actually taking a research medicine that looks really, really good and very promising, and adding that extra research drug to a standard drug to see if we can’t do better.
So that I think is really – my second point of advice is really consider participating in a clinical trial if it’s applicable.
Katherine:
Mm-hmm.
Dr. Pavlick:
And so what’s my third one? My third one is to really make sure that you can communicate with your team, that you trust your team, and you feel comfortable with your team. You know, there are many of us who have the expertise, but we all have very different manners in which we communicate and talk to patients and speak with family members. If you’re not comfortable with the person that you’re seeing, there is absolutely nothing wrong with going to get a second opinion to find someone who has the same level of expertise who may just fit your personality better.
You know, everybody’s different. You have to find the health care team that fits for you. And I think that’s so important, because you’re trusting us with your life. And if you don’t feel comfortable, then we shouldn’t be the ones taking care of you.
Katherine:
Yeah. This is all about self-advocacy.
Dr. Pavlick:
That’s right.
Katherine:
The more you know, the better care you’re going to get, and the more comfortable I think you’ll feel with your treatment.
Dr. Pavlick:
Correct.
Katherine:
Yeah.
Dr. Pavlick:
And again, I think treatment – yes, people come to us for our recommendations, but it really is a team effort. My feeling is the more that patients understand why we’re doing what we’re doing, and are part of that decision-making process, the smoother treatment goes.
Katherine:
Sure.
Dr. Pavlick:
I really think education is important – of the patient and the family.
I think being able to ask your physician questions without feeling that you’re threatening – it’s something you should be able to do. And I think it just provides with better care.
Katherine:
Dr. Pavlik, how do you empower patients?
Dr. Pavlick:
You know, when I talk to patients I really do try to number one: educate them. I am big believer in bad artwork, because I’m a bad artist. And so I really try to draw out schematics to help patients understand how they therapy that I’m proposing is going to work, so they understand the mechanism. Patients will also go home with printed handouts so that they can go back and read about what we talked about, because many times patients absorb maybe one-quarter of what’s been said in a consult.
I encourage people to bring their family members or friends so that they can hear; two sets of ears is always better than one. And I fully support them; if they want to go get a second opinion, my answer is, “Absolutely.” I do not get offended. I feel that if – because a lot of times the patient’s going to say, “I don’t want a second opinion, but my family does.” You’ve got to live with your family. Go get the second opinion. 99 percent of the time, experts who do this for a living all have the same answers. And so it just is going to solidify for your family that the right thing is being done, and then you can also decide where do you feel most comfortable?
If Dr. A and Dr. B tell you the same thing, what environment do you feel most comfortable in, so in the event that you had questions, or you didn’t feel well, where do you want to go? So, I strongly encourage that. And if somebody comes back and says, “You know, I really think that this place fits me better,” my answer is, “That’s absolutely fine; thank you for letting me know. If there’s anything I can do, please reach out.” Because, again, bottom line is I just want the best outcome for the patient.
Where Do Clinical Trials Fit Into a Non-Melanoma Skin Cancer Treatment Plan? from Patient Empowerment Network on Vimeo.
At what point should advanced non-melanoma skin cancer patients consider participating in a clinical trial? Dr. Anna Pavlick discusses the benefits of trial participation and how the eligibility process works.
Dr. Anna Pavlick is a medical oncologist with over 20 years of experience treating patients with skin cancer and is the founding Director of the Cutaneous Oncology Program at Weill Cornell Medicine and NewYork-Presbyterian. To learn more about Dr. Pavlick, visit here.
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A Review of Current Advanced Non-Melanoma Skin Cancer Treatment Options |
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What Do Advanced Non-Melanoma Skin Cancer Patients Need to Know About Treatment and Research? |
Katherine:
Where do clinical trials fit into the treatment plan?
Dr. Pavlick:
You know, for me clinical trials are something that patients need to see as an opportunity.
It should always be the first question that a patient should say, “Hey doc, what about a clinical trial?” Clinical trials provide patients with such great resources to either get a standard therapy with something extra, or to look at a novel way of using a known therapy. I think it’s something that every patient should ask their physicians about – and not everybody is eligible, or should go on a clinical trial – but it’s certainly worth asking, “Is there a clinical trial that I could participate in?”
Katherine:
So, who might be eligible? What’s the criteria?
Dr. Pavlick:
Well, each trial has different criteria. So, depending on the trials that are available at the institution where you’re being seen – for example, if you have, let’s say, basal cell cancer – the clinical trial may be looking at two immunotherapies as opposed to one immunotherapy. So when we do a clinical trial, there are what we call inclusion and exclusion criteria, and those are pre-determined criteria that you have to check those boxes to make sure those patients fit that particular study.
So it’s not a random, “You can’t participate because you’re wearing a purple shirt today.” It is, “You have basal cell, but you have never had this drug that the study says you have to have been treated with this drug in order to go on to this study.” So you can’t jump from A to Z. You have to go from A to B to get to C. So, it really is just checking the boxes, making sure that patients fit whatever the deemed criteria are, and make sure they also don’t fall into the exclusion criteria.
You know, trials will also say, “If you have an unstable medical condition –,” you know if I have a patient who’s telling me that they’re in and out of the E.R. with chest pain because the doc thinks that they have unstable angina and may need a stint – well, that’s not a patient that you want to put on a clinical trial at that point in time. Not to say that it can’t be re-explored at a different point, but people with active other medical issues just add to the complexity of being able to determine what are the side effects, and what are the not – what’s related to study drug, and what’s related to underlying problem?
How Is Advanced Non-Melanoma Skin Cancer Treated? from Patient Empowerment Network on Vimeo.
Developments in advanced non-melanoma skin cancer treatment and research continue to evolve. Dr. Anna Pavlick reviews important treatment considerations and discusses targeted therapy options.
Dr. Anna Pavlick is a medical oncologist with over 20 years of experience treating patients with skin cancer and is the founding Director of the Cutaneous Oncology Program at Weill Cornell Medicine and NewYork-Presbyterian. To learn more about Dr. Pavlick, visit here.
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What Do Advanced Non-Melanoma Skin Cancer Patients Need to Know About Treatment and Research? |
Katherine:
How is advanced non-melanoma skin cancer treated?
Dr. Pavlick:
Everybody’s locally advanced non-melanoma skin cancer really has to be looked at as a personal type of management.
There is no cookie-cutter answer to say, “Well you just cut it out, or you just radiate it.” Again, it’s going to be contingent upon where is this located, how extensive is it, what is the patient’s preference, what is the patient’s performance status? You know, when you talk about offering radiation, although it’s a very good therapeutic option for many of these tumors, there are some patients who can’t travel hours to get to a radiation facility, and radiation is given every day for several weeks. So that’s an option – though it’s a treatment option, it may not be a feasible option. And so I think there are multiple factors. If you cut it out, is the patient going to be left with a disfiguring outcome?
I know many times I get sent older patients because this is a disease many times of older patients, where they have these very large lesions and the thought of doing a surgery – not that you can’t – but can the patient withstand such an extensive procedure? What are they going to look like and what kind of functional deficits are you going to leave them with? You know, all of this really has to come into play, and then again, is the patient well enough tolerate a medical therapy that I have to offer? So this is why when you deal with these cancers, it really is a group effort. We all know the patient. We all get to see the patient.
And then we all get together and say, “Okay, what are the pros and cons, and really what is the optimal way for us to best serve this patient to get rid of their cancer but also preserve their quality of life?”
Katherine:
So other than surgery what other options are available to patients?
Dr. Pavlick:
So surgery’s obviously the first and foremost because if you can take it out, it’s a one-and-done, patient can heal, patient can move on.
But again, depending on location, depending on extent of the disease, sometimes we consider radiation therapy, sometimes we consider medical therapy, which would mean using different types of systemic therapies, whether it be pills – depending upon the type of cancer it is – or even intravenous immunotherapy to help either control this disease and shrink it up, then allowing the surgeon to go in and remove it. Or, best case scenario is that the immunotherapy will completely eradicate the tumor and spare the patient from having to undergo any type of procedure.
Why Do Advanced Non-Melanoma Skin Cancer Patients Need a Multidisciplinary Care Team? from Patient Empowerment Network on Vimeo.
Skin cancer expert Dr. Anna Pavlick explains what it means to have advanced non-melanoma skin cancer and discusses why patients should seek a multidisciplinary care team.
Dr. Anna Pavlick is a medical oncologist with over 20 years of experience treating patients with skin cancer and is the founding Director of the Cutaneous Oncology Program at Weill Cornell Medicine and NewYork-Presbyterian. To learn more about Dr. Pavlick, visit here.
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What Do Advanced Non-Melanoma Skin Cancer Patients Need to Know About Treatment and Research? |
Katherine:
Let’s start with some basic information for patients. What is advanced non-melanoma skin cancer?
Dr. Pavlick:
That’s actually a really good question, because many people think skin cancer is just skin cancer is just skin cancer. But when it comes to non-melanoma skin cancers, those are the types of cancers that are really much more common than melanoma. So we’re talking about your basal cell cancer, your squamous cell cancer, and even a more rare type of cancer called Merkel cell. Locally advanced non-melanoma skin cancers mean that these are lesions that are not easily removed by the dermatologist. So, it’s not a tiny little thing where you go in, you usually have a Mohs procedure for most of these types of cutaneous malignancies.
And a Mohs procedure is where a dermatologic surgeon will go and take thin layers – layer by layer – and look at it with a pathologist in order to determine if they’ve successfully cleared out the cancer. It allows for us to be very meticulous in how we take things out, but it also allows us to have a nice, clean, smaller resection area, so healing is also much nicer than if you had to cut out a big chunk of tissue.
But when you have locally advanced disease, sometimes that includes having such extensive disease that maybe cutting the lesion out is going to cause disfigurement, or they may be involved lymph nodes, and so we’re afraid that maybe this cancer can now go to other parts of the body. You know, it is just not a simple cut it out and you’re done kind of cancer.
It’s a kind of cancer that really requires a multidisciplinary team to really think about what are the best ways to manage this for the patient that’s going to provide the patient with the best cosmetic outcome, and long-term outcome control as well.
Katherine:
Who’s on that team?
Dr. Pavlick:
So in our academic center that team, or even in a community setting, that team should include a dermatologist, a medical oncologist, a surgeon – depending on where that cancer is located – many times it’s on the head and neck, so it would be a head and neck surgeon. If it’s an extremity or a trunk lesion, then it may be an oncologic general surgeon. Radiation oncology is also important to include because sometimes these are very radiation-sensitive tumors, and radiation may be a part of the whole treatment plan.
A Patient’s Perspective | Participating in a Clinical Trial from Patient Empowerment Network on Vimeo.
Colorectal cancer survivor Cindi Terwoord recounts her clinical trial experience and explains why she believes patients should consider trial participation.
Dr. Pauline Funchain is a medical oncologist at the Cleveland Clinic. Dr. Funchain serves as Director of the Melanoma Oncology Program, co-Director of the Comprehensive Melanoma Program, and is also Director of the Genomics Program at the Taussig Cancer Institute of the Cleveland Clinic. Learn more about Dr. Funchain, here.
Cindi Terwoord is a colorectal cancer survivor and patient advocate. Learn more about Cindi, here.
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Katherine Banwell:
Cindi, you were diagnosed with stage IV colorectal cancer, and decided to participate in a clinic trial. Can you tell us about what it was like when you were diagnosed?
Cindi Terwoord:
Yeah. That was in September of 2019, and I had had some problems; bloody diarrhea one evening, and then the next morning the same thing. So, I called my husband at work, I said, “Things aren’t looking right. I think I’d better go to the emergency room.”
And so, we went there, they took blood work – so I think they knew something was going on – and said, “We’re going to keep you for observation.” So, then I knew it must’ve been something bad. And so, two days later, then I had a colonoscopy, and that’s when they found the tumor, and so that was the beginning of my journey.
Katherine Banwell:
Mm-hmm. Had you had a colonoscopy before, or was that your first one?
Cindi Terwoord:
No, I had screenings, I would get screenings. I had heard a lot of bad things about colonoscopies, and complications and that, so I was always very leery of doing that. Shame on me. I go for my other screenings, but I didn’t like to do that one. I have those down pat now, I’m very good at those.
Katherine Banwell:
Yeah, I’m sure you do. So, Cindi, what helped guide your decision to join a clinical trial?
Cindi Terwoord:
Well, I have a friend – it was very interesting.
He was probably one of the first people we told, because he had all sorts of cancer, and he was, I believe, one of the first patients in the nation to take part in this trial. It’s nivolumab (Opdivo), and he’s been on it for about seven years. And he had had various cancers would crop up, but it was keeping him alive.
And so, frankly, I didn’t know I was going to have the option of a trial, but he told me run straight to Cleveland Clinic, it’s one of the best hospitals. So, I took his advice. And the first day the doctor walked in, and then all these people walked in, and I’m like, “Why do I have so many people in here?” Not just a doctor and a nurse. There was like a whole – this is interesting.
And so, then they said, “Well, we have something to offer you. And we have this immunotherapy trial, and you would be one of the first patients to try this.”
Now, when they said first patient, I’m not quite sure if they meant the first colon cancer patient, I’m not sure. But they told me the name of it, and I said, “I’m in. I’m in.” Because I knew my friend had survived all these years, and I thought, “Well, I’ve gotten the worst diagnosis I can have, what do I have to lose?” So, I said, “I’m on board, I’m on board.”
Katherine Banwell:
Mm-hmm. Did you have any hesitations?
Cindi Terwoord:
Nope. No, I’m an optimistic person, and what they assured me was that I could drop out at any time, which I liked that option.
Because I go, “Well, if I’m not feeling well, and it’s not working, I’ll get out.” So, I liked that part of it. I also liked, as Dr. Funchain had said, you go in for more visits. And I like being closely monitored, I felt that was very good.
I’ve always kept very good track of my health. I get my records, I get my office notes from my doctor. I’m one of those people. I probably know the results of blood tests before the doctor does because I’m looking them up. So, I felt very confident in their care. They watched me like a hawk. I kept a diary because they were asking me so many questions.
Katherine Banwell:
Oh, good for you.
Cindi Terwoord:
I’m a transcriptionist, so I just typed out all my notes, and I’d hand it to them.
Katherine Banwell:
That’s a great idea.
Cindi Terwoord:
Here’s how I’m feeling, here’s…And I was very lucky I didn’t have many side effects.
Katherine Banwell:
In your conversations with your doctor, did you weigh the pros and cons about joining a trial? Or had you already made up your mind that yes, indeed, you were going for it?
Cindi Terwoord:
Yeah, I already said, “I’m in, I’m in.” Like I said, it had kept my friend alive for these many years, he’s still on it, and I had no hesitation whatsoever.
I wish more people – I wanted to get out there and talk to every patient in the waiting room and say, “Do it, do it.”
I mean, you can’t start chemotherapy then get in the trial. And if I ever hear of someone that has cancer, I ask them, “Well, were you given the option to get into a trial?” Well, and then some of them had started the chemo before they even thought of that.
Katherine Banwell:
Mm-hmm. So, how are you doing now, Cindi? How are you feeling?
Cindi Terwoord:
Good, good, I’m doing fantastic, thank goodness, and staying healthy. I’m big into herbal supplements, always was, so I keep those up, and I’m exercising. I’m pretty much back to normal –
Katherine Banwell:
Cindi, what advice do you have for patients who may be considering participating in a trial?
Cindi Terwoord:
Do it. Like I said, I don’t see any downside to it. You want to get better as quickly as possible, and this could help accelerate your recovery. And everything Dr. Funchain mentioned, as far as – I really never brought up any questions about whether it would be covered.
And then somewhere along the line, one of the research people said, “Well, anything the trial research group needs done – like the blood draws – that’s not charged to your insurance.” So, that was nice, that was very encouraging, because I think everybody’s afraid your insurance is going to drop you or something.
And then the first day I was in there for treatment, a social worker came in, and they talked to you. “Do you need financial help? We also have art therapy, music therapy,” so that was very helpful. I mean, she came in and said, “I’m a social worker,” and I’m like, “Oh, okay. I didn’t know somebody was coming in here to talk to me.”
But that was all very helpful, and I did get free parking for a few weeks. I mean, sometimes I’d have to remind them. I’d say, “It’s costing me more to park than to get treated.” But, yeah, like I said, I’m a big advocate for it, because you hear so many positive outcomes from immunotherapy trials, and boy, I’d say if you’re a candidate, do it.
Katherine Banwell:
Dr. Funchain, do you have any final thoughts that you’d like to leave the audience with?
Dr. Pauline Funchain:
First, Cindi, I have to say thank you. I say thank you to every clinical trial participant, everybody who participates in the science. Because honestly, whether you give blood, or you try a new drug, I think people don’t understand how many other lives they touch when they do that.
It’s really incredible. Coming into clinic day in and day out, we get to see – I mean, really, even within a year or two years, there are people that we’ve seen on clinical trial that we’re now treating normally, standardly, insurance is paying for it, it’s all standard of care. And those are even the people we can see, and there are so many people we can’t see in other centers all over the world, and people who will go on after us, right?
So, it’s an amazing – I wouldn’t even consider most of the time that it’s a personal sacrifice. There are a couple more visits and things like that, but it is an incredible gift that people do, in terms of getting trials. And then for some of those trials, people have some amazing results.
And so, just the opportunity to have patients get an outcome that wouldn’t have existed without that trial, like Cindi, is incredible, incredible.
What Are the Risks and Benefits of Joining a Clinical Trial? from Patient Empowerment Network on Vimeo.
Why should a cancer patient consider a clinical trial? Dr. Pauline Funchain of the Cleveland Clinic explains the advantages of clinical trial participation.
Dr. Pauline Funchain is a medical oncologist at the Cleveland Clinic. Dr. Funchain serves as Director of the Melanoma Oncology Program, co-Director of the Comprehensive Melanoma Program, and is also Director of the Genomics Program at the Taussig Cancer Institute of the Cleveland Clinic. Learn more about Dr. Funchain, here.
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Katherine Banwell:
Why would a cancer patient consider participating in a clinical trial? What are the benefits?
Dr. Pauline Funchain:
So, I mean, the number one benefit, I think, for everyone, including the cancer patient, is really clinical trials help us help the patient, and help us help future patients, really.
We learn more about what good practices are in the future, what better drugs there are for us, what better regimens there are for us, by doing these trials. And ideally, everyone would participate in a trial, but it’s a very personal decision, so we weigh all the risks and benefits. I think that is the main reason.
I think a couple of other good reasons to consider a trial would be the chance to see a drug that a person might not otherwise have access to. So, a lot of the drugs in clinical trials are brand new, or the way they’re sequenced are brand new. And so, this is a chance to be able to have a body, or a cancer, see something else that wouldn’t otherwise be available.
And I think the last thing – and this is sort of the thing we don’t talk about as much – but really, because clinical trials are designed to be as safe as possible, and because they are new procedures, there’s a lot of safety protocols that are involved with them, which means a lot of eyes are on somebody going through a clinical trial.
Which actually to me means a little bit sort of more love and care from a lot more people. It’s not that the standard of care – there’s plenty of love and care and plenty of people, but this doubles or triples the amount of eyes on a person going through a trial.
Katherine Banwell:
Yeah. When it comes to having a conversation with their doctor, how can a patient best weigh the risks and benefits to determine whether a trial is right for them?
Dr. Pauline Funchain:
Right. So, I think that’s a very personal decision, and that’s something that a person with cancer would be talking to their physician about very carefully to really understand what the risks are for them, what the benefits are for them. Because for everybody, risks and benefits are totally different. So, I think it’s really important to sort of understand the general concept. It’s a new drug, we don’t always know whether it will or will not work. And there tend to be more visits, just because people are under more surveillance in a trial.
So, sort of getting all the subtleties of what those risks and benefits are, I think, are really important.
Katherine Banwell:
Mm-hmm. What are some key questions that patients should ask?
Dr. Pauline Funchain:
Well, I think the first question that any patient should ask is, “Is there a trial for me?” I think that every patient needs to know is that an option. It isn’t an option for everyone. And if it is, I think it’s – everybody wants that Plan A, B, and C, right? You want to know what your Plan A, B, and C are. If one of them includes a trial, and what the order might be for the particular person, in terms of whether a trial is Plan A, B, or C.
