Advanced Non-Melanoma Skin Cancer: What Do You Need to Know About Evolving Treatment and Research

Advanced Non-Melanoma Skin Cancer: What Do You Need to Know About Evolving Treatment and Research? from Patient Empowerment Network on Vimeo.

Treatment options for advanced non-melanoma skin cancers—such as squamous and basal cell carcinoma—are evolving quickly. Dr. Diwakar Davar shares an update on emerging research, discusses current treatment options, and provides tips for partnering with your team on care decisions.

Dr. Diwakar Davar is the Clinical Director of the Melanoma and Skin Cancer Program at UPMC Hillman Cancer Center. Learn more about Dr. Davar.

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Transcript:

Katherine:

Hello, and welcome. I’m your host, Katherine Banwell. Today’s program focuses on helping patients with advanced non-melanoma skin cancer. We’ll review treatments, and research, and share advice for getting involved in care decisions. Before we meet our guest, let’s review a few important details. The reminder email you received about this program contains a link to a program resource guide. If you haven’t already, click that link to access information to follow along during the webinar.  

At the end of this program, you’ll receive a link to a program survey. Please take a moment to provide feedback about your experience today in order to help us plan future webinars. Finally, before we get into the discussion, please remember that this program is not a substitute for seeking medical advice.  

Please refer to your healthcare team about what might be best for you. Let’s meet our guest today. Joining me is Dr. Diwakar Davar. Dr. Davar, welcome. Would you please introduce yourself? 

Dr. Davar:

Katherine, thank you for this invitation. My name is Diwakar. I’m a medical oncologist and I’m the Clinical Director of Cutaneous Malignancies and Melanoma at the University of Pittsburgh’s Hillman Cancer Center. My practice largely focuses on advanced skin cancer, including both melanoma and non-melanoma skin cancers. I also direct the translational research laboratory focusing on drug development. I’m glad to be able to contribute towards this program. And, I’m happy to answer any questions that you and your colleagues might have. 

Katherine:

Well, thank you so much for taking time out of your schedule to join us today. 

Dr. Davar:

Sure. 

Katherine:

Today, we’re focusing on the most common forms of advanced non-melanoma skin cancer. What does it mean to have advanced non-melanoma skin cancer? 

Dr. Davar:

Sure. “Non-melanoma skin cancer” is actually a very broad, heterogenous term and includes patients with cutaneous squamous cell carcinoma, which is actually the commonest cancer in the United States with approximately 1 million cases a year, the vast majority of which are actually not necessarily, particularly serious or deep but do indicate predisposition towards further cancers and exposure to carcinogenic ultraviolet light. 

It also includes the entities of Merkel cell carcinoma as well as basal cell carcinoma. These common cancers ranging from very common cutaneous squamous cell carcinoma to the least common Merkel cell carcinoma and basal cell in between are primarily seen in Caucasian patients. There is a predisposition towards these cancers we discovered in patients who are older, and certainly there is a predisposition in finding these cancers in certain anatomical regions such as the head and neck areas. Most of these cancers happen in older Caucasian patients, typically above the clavicle in the head, neck, around the ears, and on the cheeks and the face. 

Katherine:

Why is that?  

Dr. Davar:

Well, the primary etiologic agent driving carcinogenesis in these cancers is ultraviolet light.  

Again, the vast majority of ultraviolet light exposure happens to people before the age of 12, and it happens predominantly on the head and neck because that is the area that is most exposed to the sun. The cancer takes a while to form because the carcinogenic effects take a while to cause the cancer. So predominantly, patients, as they start hitting their 70s and 80s, it becomes increasingly common and occasionally, these cancers can actually end up being serious and start causing advanced cancers.  

Dr. Davar:

You know, in most cases, the definition of what is considered an advanced cancer is stage IV disease. If you have lung cancer, advanced lung cancer is stage IV cancer that has spread to the opposite lung, or to the brain, or the liver. 

If you have advanced melanoma, it is cancer that has spread to a distant organ such as the lung, the liver, or the brain. Skin cancer is very, very different. Because of its unique anatomical location, even a large tumor that potentially can be cut out but hasn’t necessarily spread can still threaten vital organs. You can have a 3 cm tumor near the eye that is threatening the globe. If it is not shrunk, the surgical resection of this tumor will potentially involve removing the eye.   

Similarly, you can have a very large tumor that is not necessarily spread, but is involving the right side of the cheek near the jaw. In which case, the potential surgical removal of this tumor would involve the extremely disfiguring surgery of jaw removal, what is known as mandibulectomy.   

Given the nature of these tumors and the location of these tumors, the definition of locally advanced for this particular cancer has started to incorporate more elements of the location and the ease of which the cancer can be removed, which is very distinct from cancers in other locations, and also the proximity of these cancers to critical structures such as the nose, the lips, the eye, as well as critical vascular and neurovascular structures in the neck, such as the carotid artery, the internal and external jugular veins, and the vagal nerve bundle. 

Katherine:

What approaches are currently available to treat these more common forms of advanced non-melanoma skin cancer? 

Dr. Davar:

Right now, the most common mode of treatment is typically treating cancer that is localized.  

Again, even with the extremely increasing incident of these cancers, the vast majority of cancers that we detect are still localized and are amenable to easy surgical eradication by a trained dermatologist or a trained mole surgeon. A trained dermatologist, a trained mole surgeon, a plastic surgeon, these are commonly the physicians that encounter these patients. Surgical removal is still the primary mode of eradications of these lesions. However, increasingly, there is a role for early systemic therapy and local regional therapy to improve patient outcomes for reasons that we can talk about. Still, the vast majority of patients are still treated surgically and then increasingly, there is the role for referral to medical oncologists and radiation oncologists to talk about alternative forms of treatment that may be needed after that. 

Katherine:

What sort of alternative therapies? Are you looking at targeted therapies? Immunotherapies?  

Dr. Davar:

The primary reason for which advances have happened in this disease is really the advent of effective systemic immunotherapy and the spillover of immunotherapy into the patient landscape in these diseases. The reason for that is as follows. Immunotherapy essentially is most effective in tumors that carry a high tumor mutation burden. For example, melanoma has a tumor mutation burden on average of about 15. And the tumor mutation burden in melanoma is driven by the fact that melanoma, cutaneous melanoma is an ultraviolet light-driven skin cancer.  

However, non-melanoma skin cancers have tumor mutation burdens that are many, many magnitudes higher than that of melanoma. For example, the median tumor mutation burden in cutaneous squamous cell carcinoma is 50. Melanoma is 15. The median tumor mutation burden in cutaneous squamous cell carcinoma is three times that of melanoma. Similarly, for Merkel cell carcinoma. A large majority of Merkel cell carcinoma is caused by an unusual virus known as a Merkel cell polyomavirus. Both the viral driven tumors and the non-viral driven tumors have high tumor mutation burdens, and the same is true of basal cell carcinoma because of ultraviolet light exposure.  

The primary reason why immunotherapy has gotten a foothold in these diseases is because the underlying etiologic agent that drives carcinogenesis, ultraviolet light for the majority of these, and the Merkel cell polyomavirus for the subcategory of non-melanoma skin cancer that is Merkel are both associated with a response to immunotherapy.  

As a result of that, immunotherapy, anti-PD-1 immunotherapy is now standard of care for patients with tumors that are either locally advanced undissectible or locally advanced and/or metastatic, that is, that they have spread. They are now available for use and FDA-approved for this indication in both Merkel, basal, as well as non-melanoma cutaneous squamous cell carcinoma. 

Katherine:

Dr. Davar, now that we understand approved approaches, can you walk us through ongoing research and developing treatments that patients should know about? 

Dr. Davar:

Yeah. Now, if you think about it, the vast majority of patients with, say, cutaneous squamous cell carcinoma is presenting with large tumors involving the areas of the head and neck region. The average tumor size is approximately 1 to 2 cm.  

There are small groups of patients with much larger tumors and/or tumors with high-risk features. These include tumors that are either anatomically large or 3 cm, 4 cm in size, tumors that involve critical locations, such as the bone, the skull table, the jaw, tumors that are very close proximity to critical structures such as the eye, or tumors involving lift nodes in the neck. 

In these patients, recent work by many groups including ours has demonstrated that perioperative immunotherapy improves outcomes. What is perioperative immunotherapy? In the context of melanoma and lung cancer, giving people immunotherapy before surgery improves patient outcomes. This the same drug that you would normally get after surgery, but giving it before surgery. The very same drug before surgery improves event-free survival.  

It improves the likelihood of cancer not coming back. The primary reason for that is by turning the immune system on even before you take the tumor out, you sensitize the immune system to tumor antigens, you kill more cancer, and you do that while the tumor is present because the immune system acts and recognizes this with the immune therapy acting as a vaccine. This approach has now migrated to non-melanoma skin cancer and is actually transformative, particularly given the location of these tumors which render surgery difficult.   

Therefore, in this disease, not only is perioperative immunotherapy especially transformative in terms in terms of producing dramatic response rates, the median response rate of pathologic perioperative immunotherapy is approximately a path CR rate of approximately 50 percent. In pivotal trials done by Neil Gross, the results of which have been published in prominent journals, neoadjuvant or perioperative Cemiplimab, anti-PD-1 inhibitor has shown path response rates of approximately 50 percent. 

Whether it’s given for two cycles over six weeks or four cycles over three months, this drug really dramatically reduces the tumor and improves the likelihood of the cancer not coming back. More interestingly, recent data has also shown that this affects surgical outcomes in other ways. Historically, in melanoma and lung cancer and other diseases where perioperative immunotherapy is a standard of care, we never considered the nature of the surgery. Patients still underwent the same surgery that they would’ve undergone anyway whether or not they got immunotherapy.  

However, given the dramatic effect of perioperative immunotherapy, increasingly, we are turning out attention, particularly in cutaneous squamous cell carcinoma, which involves critical structures, to the role of surgical de-escalation as well as radiation de-escalation.  

We’re trying to see if by using perioperative immunotherapy, you can give people potentially less radical surgery, make people heal faster, undergo less plastic surgical reconstruction, improve functional outcomes, and also reduce the need for radiation, particularly in the patients who have done extraordinarily well to reduce the risk of radiation-related early and long-term toxicity.  

These results, some of which are recently being presented at prominent national meetings by Dr. Zuur from the Dutch NKI. As well as Dr. Ascierto from the Italian National Cancer Institute in Naples have shown that firstly, the pathological response rates are high but very provocatively, surgical de-escalation has been achieved and is associated with good quality of life. What we are seeing here is that perioperative immunotherapy really has an increasing role. Particularly in this disease, for reasons that have to do with the unique anatomical location of perioperative cutaneous squamous carcinoma.  

Perioperative immunotherapy is also migrating to other non-melanoma skin cancers including Merkel and basal cell carcinoma. Early trials have been done. The drugs appear to be effective. However, trials are still needed to further understand the role of perioperative immunotherapy in these other two entities. However, in cutaneous squamous cell carcinoma, perioperative trials are very advanced, pivotal trials are being designed, and increasingly, this is considered a standard of care for potentially resectable patients.  

You and I have talked about the role of immunocompetent non-melanoma skin cancer but one thing that patients do not necessarily realize that if you have a solid organ transplant such as a liver transplant, a heart transplant, or a kidney transplant, the primary reason for mortality in the first one year is allograft failure. However, if you make it past three years, the primary reason for mortality is cancer, and not cancer of the lung, but primarily, skin cancer. In this instance, the reason that skin cancer is common now, on average, skin cancers in transplant patients are much more common than skin cancer in non-transplant patients.  

In fact, patients with solid organ transplants had 100-fold higher risk of developing skin cancer compared to the general population. It has to do with the immunosuppression that is used. The immune suppression that maintains allograft tolerance also reduces T cell function. 

That reduction in T cell function allows for immune escape and the development of high-risk skin cancers. The most important thing that transplant patients need to do is make sure that they see a dermatologist. Increasingly, as we discover high risk skin cancer, there have been two main approaches that have been identified that are potentially helpful. The first is investigators at two primary sites. One, Dr. Evan Lipson at the Johns Hopkins University and Dr. Glenn Hanna at Mass General Hospital have independently demonstrated, and very provocatively, that in organ transplant patients, very close titration of immunosuppression can be done to allow for the concomitant use of immune modulating therapy.  

Historically, this is a patient population for whom systemic anti PD-1 immunotherapy was technically contraindicated because the primary risk was allograft failure. What Dr. Hanna and Dr. Lipson have demonstrated is that by carefully modulating the doses of immune suppression, you can co-administer systemic anti PD-1 without allograft rejection, and these transformative results have been publicly represented by Dr. Hanna and Dr. Lipson as a paper under review in a prominent journal.  

Concurrently, work by a biopharmaceutical company has demonstrated that the intralesional administration of an oncolytic virus, a cancer killing virus known as RP1, has provocatively demonstrated anti-cancer effect in high-risk, advanced transplant-associated skin cancers.  

These data have been presented by many colleagues, including myself and others at several recent meetings. And the most recent publication of which was by Dr. Mike Migden of MD Anderson Cancer Center in a recent transplant meeting. This drug, which was injected within the tumor by direct visual injection has dramatic effect in up to about 25 percent of the treated patients without any risk of allograft rejection and/or herpes serial conversion because this is an attenuated herpes virus. These two advances have dramatically altered the potential for patients with solid organ cancers who are developing skin cancers to potentially get novel agents that would otherwise, the absence of which, potentially result in mortality. 

Katherine:

Wow. That’s really exciting news. Research often moves quickly and I think you’re just pointing this out. How can patients stay up to date with what’s going on? 

Dr. Davar:

Well, it’s very difficult. The information is moving at the speed of light in this disease. In fact, the first study of perioperative immunotherapy was done two years ago. Right now, perioperative immunotherapy is on NCCN guidelines. 

It’s not FDA-approved, but it’s a strong Class One recommendation on NCCN given the dramatic data that Dr. Gross and many of our colleagues have generated. Just in the span of three years, much has been achieved. The way to stay up to date is to read and also to seek out information from well-trusted sources. Information such as what has been generated by the Health Content Collective, information that is from WebMD and these other areas are very useful, but do check in with your providers. Please make sure your providers are up to date and do not be afraid of asking questions. No provider would ever feel insulted that you are questioning his or her judgment by asking a question.  

I often welcome patients to ask me questions about whether or not I feel like this is the best therapeutic modality. And, do ask if there is a role for novel treatments. This is particularly because when you advance, as I mentioned, at the speed of light, particularly in the context of patients who are immunosuppressed.

Katherine:

Dr. Davar, thank you for that detailed information. It is really valuable. You mentioned, a few moments ago, clinical trials. What are the benefits of participating in a clinical trial? 

Dr. Davar:

Well, the first and the most important benefit of participating in a clinical trial is that oftentimes, your team is larger. Normally, a patient has a doctor. We have a PA and we have a nurse taking care of them. When you have a clinical trial, at that clinical trial, you have three, four, five times that number of people taking care of you. There are research nurses, research coordinators, nurse navigators, and all of these people are looking over your chart helping the doctor cross check and check to make sure that nothing falls through the cracks.  

The first and the most important thing is when you enter a clinical trial, your team grows. You have a primary physician taking care of you, but he has more help and more support. That helps ensure that the best possible care is delivered for our patients. The second benefit of taking part in clinical trials is that you oftentimes have access to the latest and the greatest.  

For example, in the context of non-melanoma skin cancer that is transplant associated, these provocative approaches that are being tested, immune augmentation of immune suppression with concurrent systemic immunotherapy without causing allograft rejection, this is only available in the context of an NCI, ECTCN funded trial that Dr. Lipson is leading. If you’re not a member of one of the ECTCN sites, you do not have access to this trial. If you’re not a patient that is being seen at one of these sites, you, unfortunately, do not have access to this trial.  

The key thing here is, entering a clinical trial represents the ability, potentially, to get a treatment that potentially could improve cancer and save one’s life without causing allograft rejection. In the context of the RP1 study, you could potentially be getting a drug that doesn’t cause allograft rejection and causes cancer aggression in a significant number of patients. But again, it is not a standard of care agent. 

Entering clinical trials helps you because it allows you access to the latest and the greatest in terms of treatment modalities. But also, it allows you to receive the best possible care.  

Katherine:

You know, Dr. Davar, we often hear this term “personalized medicine.” What does it mean? 

Dr. Davar:

Personalized medicine really means individualizing the patient’s treatment for that particular patient’s tumor. No two tumors are the same. Every tumor is different just as every person is different. Therefore, identifying and crafting the optimal treatment plan really involves identifying the most available and up-to-date information about the person’s tumor and contextualizing the treatment options in that setting.  

For example, in the context of Merkel cell polyoma, the virus associated with Merkel cell carcinoma, the treatment options would certainly include checkpoint inhibitor therapy with the understanding that the Merkel cell polyomavirus status could change both the response to the treatment but also the monitoring of the treatment because there is and acid that uses antibody titers to track the disease.  

In the context of patients with advanced cutaneous squamous cell carcinoma, the presence or absence of intratumoral CD8 T cells very provocatively can affect the response of checkpoint inhibitor therapy. The key thing to understand about personalized medicine is the more information we have about your tumor, the more informed we are about not only your current treatment, but also what future treatments might be available to you if the current treatment stops working. 

Katherine:

Aside from testing, what other factors are involved when choosing therapy? 

Dr. Davar:

These factors include, particularly for non-melanoma skin cancers, the patient’s age and performance status. We do know that as patients get older, their comorbid piece changes. They have a higher risk of having concomitant second illness such as cardiac issues, diabetes, high blood pressure, cholesterol issues, strokes, and coronary artery disease.  

These diseases in and of themselves do not necessarily affect one treatment choice over another, but it may change how you treat the patient. For example, a 60-year-old patient with melanoma may be a great surgical candidate. A 60-year-old patient with squamous cell carcinoma maybe a great surgical candidate. However, an 85-year-old patient with cutaneous squamous cell carcinoma with a tumor near the eye may not necessarily be a great surgical candidate because even though the tumor could be removed, it would result in the removal of that person’s eye.  

If this person has already has got, for example, age-related issues with balance, age-related issues with difficulty and vision and depth perception, removing this person’s eye, which is a very morbid procedure, but can be done at relatively low surgical risk, could really affect this patient’s quality of life and may force you to rethink what you would do and may result in you offering this patient a different treatment modality such as upfront use of systemic therapy rather than a standard surgical approach.  

The idea is that the more information you have about the patient, the easier it is to contextualize the treatment for a particular patient and particularly in the context of non-melanoma skin cancer. Which often time happens to patients who are, on average, one decade older than patients with melanoma. Taking their age and taking their comorbid conditions is very important in determining the treatment modality and also in making individualized patient recommendations. 

Katherine:

It’s not always easy to access the latest treatments or to find a specialist. I’m wondering what the common obstacles patients face in accessing the best care.  

Dr. Davar:

Some of the major issues are access to highly specialized treatment centers. Across the entire United States, there are clearly comprehensive cancer centers where the NCIS designated these places as being areas where patient care can deliver clinical trials available.  

Oftentimes, there is the breadth of research all the way from population research all the way to clinical trials. Not everybody has access to a comprehensive cancer center. Some patients may be living in a geographical location that is remote. Some patients could be living in a location that is not necessarily remote from a comprehensive cancer center, but may have social determinants of health that make it hard for them to access these comprehensive cancer centers. The only way around this is information.  

Patients need to be able to access information in a fashion that is both trusted, and up-to-date, and secure so that they are enabled and equipped with the right information for them to be able to have informed discussions about their care with their providers. 

Katherine:

This is all such great information, Dr. Davar. As we wrap up, I would like to get your thoughts.  

How do you feel about the future of advanced non-melanoma skin cancer research? 

Dr. Davar:

I am actually extraordinary optimistic about this landscape. When I started out as an oncologist, my big focus was in melanoma. I very quickly realized that most of the excitement was certainly, while in melanoma, was being generated, it was actually spilling over into non-melanoma skin cancer and the primary reason for that is the unique patient level challenges that make this disease a difficult disease to treat. The patient age, the comorbidities, the fact that a vast majority of our patients had gotten transplants, and that resulted in a relative contraindication of the administration of the effective agents that were developed that eradicated the majority of this disease.   

What oftentimes is a challenge, what is one man’s challenge is another man’s potential cure and it’s a potential benefit in an area in which it could be studied.  

What we realize about these challenges is they actually give us opportunities and avenues for research. As we think about non-melanoma skin cancer, we realize that this is an area in which there is tremendous potential where you can potentially give people immune therapy and improved outcomes, but not just improve patient outcomes in making people live longer, but also by reducing the burden of care by reducing the amount of surgery and radiation that people need that enables people to not just live longer, but live longer and maintain their quality of life as they age, and allows them to age with dignity. 

Katherine:

Dr. Davar, it all sounds so exciting. I want to thank you for taking the time to join us today. 

Dr. Davar:

Well, thank you for having me on this lovely program. 

Katherine:

And, thank you to all of our collaborators. If you would like to watch this webinar again, there will be a replay available soon. You’ll receive an email when it’s ready. Don’t forget to take the survey immediately following this webinar. It will help us as we plan future programs.  

To learn more about advanced non-melanoma skin cancer, and to access tools to help you become a proactive patient, visit powerfulpatients.org. I’m Katherine Banwell. Thanks for joining us today.  

Non-Melanoma Skin Cancers and Clinical Trials | Advancing Science for Everyone

Non-Melanoma Skin Cancers and Clinical Trials: Advancing Science for Everyone from Patient Empowerment Network on Vimeo.

What is the value of non-melanoma skin cancer clinical trials? Expert Dr. Silvina Pugliese from explains why clinical trial participation is important and shares advice for patients.

Silvina Pugliese, M.D., is a Clinical Assistant Professor of Dermatology and Attending Physician at the Stanford Medicine Outpatient Center and Stanford Cancer Institute. Learn more about Dr. Pugliese.

[ACT]IVATION TIP

“…if you are interested in participating in a clinical trial, in advancing medical knowledge, and you feel comfortable doing so, please ask your dermatologist or your oncologist, whether they’re aware of any clinical trials that are available for your particular type of skin cancer.”

Download Guide  |  Download Guide en español

See More from [ACT]IVATED Non-Melanoma Skin Cancer

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What Should Non-Melanoma Skin Cancer Patients Consider About Treatment?

Hopeful Outcomes In Immunotherapy for Non-Melanoma Skin Cancers

What Is the Role of Immunotherapy for Non-Melanoma Skin Cancers?


Transcript:

Mary Leer:

Why is clinical trial participation so important in non-melanoma skin cancers, and what advice do you have for patients considering a clinical trial?

Dr. Silvina Pugliese:

This is a great question. So it is much more common to have early stage localized disease for basal cell cancer and squamous cell cancer. So the overall case number that we see for advanced or unresectable or metastatic disease for squamous cell cancer and especially for basal cell cancer is much lower than the usual numbers we hear of 4 million cases annually of basal cell cancer in the U.S., and 2 million of squamous cell cancer. And the reason this is important is because when we have a lower pool to evaluate or study, when we think about these more advanced skin cancers, we have less patients to recruit for some of these studies. This is especially important when we think about advanced or metastatic basal cell cancer, which is very rare.

Also very important we think about less common skin cancers like Merkel cell carcinoma or DFSP. And when we think about how uncommon these skin cancers can be in skin of color, we realize we’re really drawing from a very small pool of patients. So my point here is that you can make a true impact by enrolling in a clinical trial, especially as we’re looking at what are some of the best treatment options for these more advanced skin cancers or metastatic skin cancers? Because we do need the right patients to be enrolled in order to study these research questions.

So my activation tip is, if you are interested in participating in a clinical trial, in advancing medical knowledge, and you feel comfortable doing so, please ask your dermatologist or your oncologist, whether they’re aware of any clinical trials that are available for your particular type of skin cancer. Of course, never feel any pressure to do this, it’s completely optional, but often it can provide more, a novel treatment option for your cancer or allow you to have certain treatment that’s not available through insurance, for example, at the moment. And also in doing so, advance the knowledge that we have in our field and help patients in the future who have your same skin cancer and are in your same position. 


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What Should Non-Melanoma Skin Cancer Patients Consider About Treatment?

What Should Non-Melanoma Skin Cancer Patients Consider About Treatment? from Patient Empowerment Network on Vimeo.

What is vital for non-melanoma skin cancer patients to know about treatment decisions? Expert Dr. Silvina Pugliese from Stanford Cancer Center explains how she works with patients and shares advice for communicating with your doctor.

Silvina Pugliese, M.D., is a Clinical Assistant Professor of Dermatology and Attending Physician at the Stanford Medicine Outpatient Center and Stanford Cancer Institute. Learn more about Dr. Pugliese.

[ACT]IVATION TIP

“…making sure that you have received all the information that you want, that you’ve received the opinions that you think are important for making that decision, and that you feel comfortable like you were able to make an informed decision.”

Download Guide  |  Download Guide en español

See More from [ACT]IVATED Non-Melanoma Skin Cancer

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Non-Melanoma Skin Cancers and Clinical Trials | Advancing Science for Everyone

Non-Melanoma Skin Cancers and Clinical Trials | Advancing Science for Everyone

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Melanoma vs. Non-Melanoma Skin Cancer | What’s the Difference?

Melanoma vs. Non-Melanoma Skin Cancer | What’s the Difference?


Transcript:

Mary Leer:

Dr. Pugliese, I’m curious, how do you work with your patients to make treatment decisions? And my curiosity in part is coming from, I have several family members that have had non-melanoma skin cancer, so I’m curious how you work with your patients and with the increase in treatment options, what should non-melanoma skin cancer patients consider when they’re deciding on a treatment?

Dr. Silvina Pugliese:

Those are great questions. So one of the first things that I do when working with patients to make any kind of treatment decision is, of course, first establish just a very open and trusting relationship where patients feel comfortable talking to me about what their concerns are with their skin cancer diagnosis and what their treatment preferences are because we could have all the information in the world, but it’s really not ideal to make a decision if we don’t know what a patient wants to do and what their fears are and what their questions are. So just having a really open and trusting relationship I think is an important foundation that we need before we can really counsel anyone on treatment decisions. And then the next component is really that knowledge piece. So presenting all the options that are available to me that I know of.

And, of course, always connecting patients when needed to other resources. I work very closely with other oncologists, with oncologists, I’m sorry, with other dermatologists, with oncologists, with radiation oncologists, with medical oncologists, with surgical oncologists because often the treatment for patients that have more advanced squamous cell cancer is going to be a multidisciplinary treatment, involving many different specialties.

So for that reason, it’s very important to make sure that I’m not only discussing the things that I can do in dermatology, but that I’m connecting patients to all of the available resources. I do provide my opinion when patients ask, but again it’s really about what patients want to do. And I do think that it’s a very personal decision. We think about treatment options for treating non-melanoma skin cancers.

So listening, establishing a good relationship, providing all of the available treatment options, and then just having a conversation and being available when questions arise. I find that some patients want the lowest risk of recurrence always, and other patients are more focused on side effects. So that is going to impact how we frame, we discuss the treatment options available.

The good news, I will say for most squamous cell cancer and basal cell cancer is that, again, the treatment options are going to be lower risk, so for most basal cell and squamous cell, we will discuss depending on the subtype, either using topical creams or doing surgical excision or doing Mohs surgery depending on the location, and then based on that, I would ask patients what their greatest concerns are, what their goals are, and what their clinical follow-up can be so that we make the best decision for patients.

So my activation tip for patients in terms of this question is to make sure that before making any kind of treatment decision, you feel comfortable asking questions, that you feel like all your answers have been addressed. You should never make a decision where you think you’re making it based on incomplete information, and, of course, we can never know the outcome, and we can’t know everything about everything.

But I think it is really important that you feel the most comfortable possible when you make a treatment decision, it is very impactful. So again, just making sure that you have received all the information that you want, that you’ve received the opinions that you think are important for making that decision, and that you feel comfortable like you were able to make an informed decision.


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What Is the Role of Immunotherapy for Non-Melanoma Skin Cancers?

What is the Role of Immunotherapy for Non-Melanoma Skin Cancers? from Patient Empowerment Network on Vimeo.

What should non-melanoma skin cancer patients know about immunotherapy? Expert Dr. Silvina Pugliese explains common situations when immunotherapy is used and updates about immunotherapy treatment and research.

Silvina Pugliese, M.D., is a Clinical Assistant Professor of Dermatology and Attending Physician at the Stanford Medicine Outpatient Center and Stanford Cancer Institute. Learn more about Dr. Pugliese.

[ACT]IVATION TIP

“…recognizing that immunotherapy can be utilized in certain cases when we consider a systemic treatment of cutaneous squamous cancer and basal cell cancer. As a whole, immunotherapy is not currently first line treatment, but utilized when there is a high risk tumor or whether it’s metastatic disease or where there is locally advanced disease.”

Download Guide  |  Download Guide en español

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An Oncodermatologist Shares Treatment Updates for Basal and Squamous Cell Skin Cancers

Which Non-Melanoma Skin Cancer Treatments Are Available for Patients?

How Do Non-Melanoma Skin Cancers Impact Non-White Populations?

How Do Non-Melanoma Skin Cancers Impact Non-White Populations?

Occupational Exposures and Non-Melanoma Skin Cancer | Understanding Risk Factors

Occupational Exposures and Non-Melanoma Skin Cancer | Understanding Risk Factors


Transcript:

Mary Leer: 

Dr. Pugliese, what is the role of immunotherapy in patients with non-melanoma skin cancers, specifically those whose cancer is in an advanced stage or in their first line of treatment?

Dr. Silvina Pugliese:  

Immunotherapy is used in non-melanoma skin cancers in certain specific scenarios. First, PD-1 is a receptor that inhibits the activity of a sub-type of T-cells, this inhibition inhibits the, controls I could say the immune response, which is helpful because in exuberant and immune response can sometimes contribute to auto-immunity. However, cancer cells can unfortunately hijack this mechanism to suppress an anti-tumor response. So the immunotherapy we will be discussing today are monoclonal antibodies against PD1, and they work by encouraging and an anti-tumor response. And before diving into immunotherapy and when it is used, I first want to say that for most cutaneous squamous cell cancers and most cutaneous basal cell cancers, which are very different entities, but most of them can be treated by surgical excision or mohs micrographic surgery. In certain subtypes of both types of tumors, they can even be treated by topical medications, including topical chemotherapy and topical immunotherapy, so the cases where we think about more aggressive treatments are usually higher risk and more advanced and also unable to be treated with surgery or the other modalities mentioned. So in the case of cutaneous squamous cell cancer, the two FDA-approved PD-1 inhibitors that are used for treatment of continuous squamous cell cancer are pembrolizumab (Keytruda) and cemiplimab (Libtayo), some scenarios in which these PD1 inhibitors can be used are in the treatment of locally advanced cutaneous squamous cell cancer, not curable by surgery or radiation, as well as metastatic cutaneous squamous cell cancer.

For basal cell cancer, the FDA-approved treatment is cemiplimab. This is utilized for patients who have locally advanced or metastatic basal cell cancer that was previously treated with a hedgehog inhibitor or whom a hedgehog inhibitor is not appropriate. I should mention that immunotherapy is currently not first-line treated for either cutaneous squamous cell cancer or cutaneous basal cell cancer. Now because I mentioned hedgehog inhibitors, I wanted to say that this is another systemic treatment option that is utilized for more aggressive, locally advanced or metastatic high-risk basal cell cancer. Hedgehog inhibitors work by inhibiting a receptor called smoothened, and this inhibition also inhibits tumor growth. And again, these hedgehog inhibitors are utilized for local high-risk basal cell cancer, there’s a positive margin after mohs micrographic surgery, residual cancer after multiple excisions and can be primary treatment if radiation or surgery is not possible due to the size of the tumor, these can also be utilized for locally advanced or metastatic basal cell cancer, which can’t be treated topically, surgically or with radiation, because those treatments would not be curative in those cases. The two FDA-approved hedgehog inhibitors are vismodegib and sonidegib, my activation tip for this section is recognizing that immunotherapy can be utilized in certain cases when we consider a systemic treatment of cutaneous squamous cancer and basal cell cancer. As a whole, immunotherapy is not currently first line treatment, but utilized when there is a high risk tumor or whether it’s metastatic disease or where there is locally advanced disease. 


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Which Non-Melanoma Skin Cancer Treatments Are Available for Patients?

Which Non-Melanoma Skin Cancer Treatments Are Available for Patients? from Patient Empowerment Network on Vimeo.

Which non-melanoma skin cancer treatments are available for patients? Expert Dr. Silvina Pugliese from Stanford Cancer Center shares updates on treatments for basal cell carcinoma and squamous cell cancer.

Silvina Pugliese, M.D., is a Clinical Assistant Professor of Dermatology and Attending Physician at the Stanford Medicine Outpatient Center and Stanford Cancer Institute. Learn more about Dr. Pugliese.

[ACT]IVATION TIP

“…if you have a diagnosis, a new diagnosis of basal cell cancer and squamous cell cancer, to know that the treatment options that are available to you are often going to be things that are fairly minimally invasive. So you might be recommended to try a topical cream for the earlier variants of basal cell cancer and squamous cell cancer, or you will have an outpatient procedure to have the skin cancers cut out, either with a surgical excision or with the procedure called Mohs micrographic surgery.”

Download Guide  |  Download Guide en español

See More from [ACT]IVATED Non-Melanoma Skin Cancer

Related Resources:

How Do Non-Melanoma Skin Cancers Impact Non-White Populations?

How Do Non-Melanoma Skin Cancers Impact Non-White Populations?

Occupational Exposures and Non-Melanoma Skin Cancer | Understanding Risk Factors

Occupational Exposures and Non-Melanoma Skin Cancer | Understanding Risk Factors

Hopeful Outcomes In Immunotherapy for Non-Melanoma Skin Cancers

What Is the Role of Immunotherapy for Non-Melanoma Skin Cancers?


Transcript:

Mary Leer:

Dr. Pugliese, what promising treatments are available for newly diagnosed patients with non-melanoma skin cancers?

Dr. Silvina Pugliese:

For the purposes of answering this question, I’m going to focus on the two most common types of non-melanoma skin cancer, which are basal cell cancer and squamous cell cancer. And one of the things I tell my patients who are newly diagnosed is letting them know that most basal cancer and most squamous cell cancer can be treated with fairly, and I’ll call them simple procedures or treatment in the sense that most of these skin cancers will not need any radiation or any type of chemotherapy or immunotherapy. So that’s the majority, it’s not all.

But, for example, for basal cell cancer, it’s really just a very low number of patients that have advanced basal cell cancer or metastatic basal cell cancer. For a very early stages of the disease or certain subtypes such as superficial basal cell cancer, which just lives on the top surface of the skin, we can even treat that with a topical medication, such as a topical chemotherapy medication called Fluorouracil or another topical cream called imiquimod (Aldara, Zyclara). For other subtypes of basal cell cancer, which invade a little deeper into the skin, surgical excision is preferred. If it’s in a functionally sensitive area such as the face, for example, this will generally be treated with the type of procedure called Mohs micrographic surgery. 

A very similar treatment algorithm exists for squamous cell cancer. Early squamous cell cancers that are insight to in the very top layer of the skin can also be treated, it’s off-label treatment, but can be treated with topical fluorouracil cream or topical imiquimod cream. And for squamous cell cancers that are more invasive or for squamous cell cancers that have some more aggressive features, those would be treated with surgical excision and in certain areas, Mohs micrographic surgery would be utilized. 

Activation tip for this question is that if you have a diagnosis, a new diagnosis of basal cell cancer and squamous cell cancer, to know that the treatment options that are available to you are often going to be things that are fairly minimally invasive. So you might be recommended to try a topical cream for the earlier variants of basal cell cancer and squamous cell cancer, or you will have an outpatient procedure to have the skin cancers cut out, either with a surgical excision or with the procedure called Mohs micrographic surgery.


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Do Non-Melanoma Skin Cancers Differ in Diverse Patient Populations?

Do Non-Melanoma Skin Cancers Differ in Diverse Patient Populations? from Patient Empowerment Network on Vimeo.

Can non-melanoma skin cancers vary in diverse patient populations? Expert Dr. Silvina Pugliese explains how the occurrence and treatment of squamous cell cancer and basal cell cancer can differ in diverse population groups and advice for patients to help ensure their best care.

Silvina Pugliese, M.D., is a Clinical Assistant Professor of Dermatology and Attending Physician at the Stanford Medicine Outpatient Center and Stanford Cancer Institute. Learn more about Dr. Pugliese.

[ACT]IVATION TIP

“…be aware that some common skin cancers can present looking very different in skin of color patients. To know that skin of color patients can develop these skin cancers so that you feel empowered to ask your doctor to take a look at something and to really feel like you can advocate for yourself if you are worried about something, to ask for biopsy or just monitoring or whatever you feel most comfortable with so that we don’t allow some of these skin cancers to go undiagnosed for a longer period of time, unnecessarily.”

Download Guide  |  Download Guide en español

See More from [ACT]IVATED Non-Melanoma Skin Cancer

Related Resources:

Melanoma vs. Non-Melanoma Skin Cancer | What’s the Difference?

Melanoma vs. Non-Melanoma Skin Cancer | What’s the Difference?

Explaining Skin Cancer to Newly Diagnosed Patients | An Oncodermatologist Weighs In

Explaining Skin Cancer to Newly Diagnosed Patients | An Oncodermatologist Weighs In

Non-Melanoma Skin Cancer Subtypes | Are Some Populations More At-Risk?

Non-Melanoma Skin Cancer Subtypes | Are Some Populations More At-Risk?


Transcript:

Mary Leer:

Do non-melanoma skin cancers differ in a diverse patient population, and how does that difference if there is one, impact treatment?

Dr. Silvina Pugliese:

So there is a lot to talk about with this question. I think that one aspect of this question is the clinical appearance difference. And the answer is sometimes yes. So in certain patient populations, I’m talking primarily about skin of color currently, certain skin cancers like basal cell cancer can look different. They can have a more purple or blue appearance as opposed to the classic shiny pink red bump that you might hear about or be educated about. Another skin cancer presents a little bit differently in certain patients and specifically in a skin of color patients is squamous cell cancer. So there’s a higher likelihood of having a squamous cell cancer and in a chronic wound or on a scar in patients who are Black as opposed to lighter skin patients. And also, squamous cell cancer can present in different locations, like the genitals, perianal skin, or the lower legs. This is really important in terms of impacting treatment because you can imagine that if a lesion is not picked up early, the way something may be when it has a classic presentation, by the time that it’s diagnosed, it can be much larger or much more advanced. And this impacts treatment because that could mean a larger surgery, it could mean in certain cases needing to do treatments beyond surgery to completely get rid of the skin cancer.

But even just with surgery alone, having a larger surgery can cause a larger scar. It can cause some functional impairment after surgery, or it can even cause some other problems like impaired nerve sensation, for example. So it’s really important that we think about the different presentations of skin cancer across all skin types, and be mindful of both looking for those different kinds of skin cancers when we’re doing our skin checks as doctors, but also be really mindful of how can we educate all of our patients for what to look out for, because often our education is be mindful of sun-exposed areas, wear sunscreen, make sure that you’re looking at your ears and your nose and your face, but we’re not really educating about examining the genital area for skin cancer or being mindful of burns or being mindful of scars.

So my activation tip for this question is to be aware that some common skin cancers can present looking very different in skin of color patients. To know that skin of color patients can develop these skin cancers so that you feel empowered to ask your doctor to take a look at something and to really feel like you can advocate for yourself if you are worried about something, to ask for biopsy or just monitoring or whatever you feel most comfortable with so that we don’t allow some of these skin cancers to go undiagnosed for a longer period of time, unnecessarily.


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An Expert’s Perspective on Advanced Non-Melanoma Skin Cancer Research

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.

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?

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.

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

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.

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?

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.

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?

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: 

  • Basal cell carcinoma 
  • Squamous cell carcinoma 
  • And Merkel cell carcinoma 

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: 

  • The location and size of the cancer. 
  • Test results, including genetic test results. 
  • Potential treatment side effects. 
  • And the patient’s overall health and personal preferences. 

If the cancer cannot be treated by surgery alone, treatment options may include: 

  • Chemotherapy 
  • Radiation therapy 
  • Targeted therapy
  • Immunotherapy
  • Or a clinical trial 

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?  

  • First, continue to educate yourself about your condition. Ask your healthcare team to recommend credible resources for information.
  • Next, understand the goals of treatment and share your personal preferences with your doctor.
  • Consider a second opinion with a specialist following a diagnosis to confirm your treatment approach.
  • And write down your questions before and during your appointments. Visit powerfulpatients.org/skin to access office visit planners to help you organize your thoughts. Bring loved ones to your appointments to help you recall information and to keep track of important details.
  • Ask your doctor whether a clinical trial might be right for you.
  • Finally, remember that you have a voice in your care. Don’t hesitate to ask questions and to share your concerns. You are your own best advocate.

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

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.

 

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?

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

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

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.

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
 

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?

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

 

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?