How Is Non-Melanoma Skin Cancer Treatment Evolving?

Jamie Forward:

So, Dr. Ma, how have treatment options for nonmelanoma skin cancer evolved in recent years?

Dr. Barbara Ma:

Sure. So, for basal cell carcinomas, that is one of the tumor types that where you could benefit from an oral medication.

They call it a hedgehog inhibitor, as the class of medications. And actually, it’s what we consider as the first line treatment, usually, for the basal cell carcinomas. It is an oral pill. It does have some side effects, such as taste changes or leg cramps, but it is something that is pretty effective in treating the basal cells.

It’s also something that could play a role, like if you have, for example, Gorlin syndrome or some of the syndromes that may predispose you to multiple basal cells. So, that pill is one treatment option for it. Another one is immunotherapy, and I’ve mentioned that before. That’s essentially been the biggest advance for the non-melanoma skin cancers.

The IV infusion, it can be administered intravenously every…well, three to four weeks, depending on which formulation you choose. The current FDA-approved ones are cemiplimab – the other name for it is Libtayo. There’s also pembrolizumab – the other name for it’s Keytruda. And also, nivolumab, and the other name for that is Opdivo. But for immunotherapy, I would say that that’s actually one of the biggest advances for treating nonmelanoma skin cancers. Response rates tend to be high and long-lasting. So, they’ve been the biggest advances in treating nonmelanoma skin cancers.

Jamie Forward:

Sure. And so, what is immunotherapy? Can you tell me sort of how it works and what the side effects might be from that?

Dr. Barbara Ma:

Yeah, absolutely. So, immunotherapy, again, is an IV medication. And they target something called immune checkpoints.

And how I usually think about it is, you know how when you have your home and you got your temperature? And if it gets really hot, then your air conditioning kicks in to bring it down to a more regular temperature. So, your own immune system has this mechanism where it sees a threat – whether it’s bacteria, virus, cancer cell – that it’ll ramp up to get activated. But after the threat is over or it’s addressed, then the immune checkpoint is actually what brings it back down to its normal level function pre-metastasis.

So, when you have an immune checkpoint inhibitor, you’re essentially releasing the brake on the immune system to keep it activated. And so, that is actually how it kills the skin cancer cells – and the nonmelanoma skin cancer cells, they actually do have pretty high response rates to the immune checkpoint inhibitors.

Jamie Forward:

Okay. And how are these administered and what are the side effects?

Dr. Barbara Ma:

Oh, yeah, sure. So, it is an intravenous medication. So, usually you have to get an IV just placed. And most of the time, it’s usually a 30-minute infusion. The side effects tend to be more inflammatory in nature, because we’re activating the immune system. And the most common tend to be rash, fatigue, and diarrhea. Rash, you can think of it as inflammation of the skin. Fatigue is pretty non-specific. And then, diarrhea, you can think of it as inflammation of the gut. In terms of how moderate, mild, or severe it can be – actually the range is pretty big.

But most of the times, if you do have a mild rash or something, it’s something that we can manage with topical steroids. But again, for these inflammatory side effects, or any changes, the sooner you let your treatment team know, the better. Because really it’s more about proactively addressing any potential changes.

And that’s how you prevent any of the side effects from getting any more severe or anything like that. But many of them are very manageable, as long as you inform your treatment team early.

Jamie Forward:

Right. Communication is really important, as we know. And early intervention, I would imagine. So, telling your team as soon as possible?

Dr. Barbara Ma:

Yep. Yep. Yeah. It’s also possible that you may not have side effects. But those are the stuff that we watch out for, yeah.

Jamie Forward:

Dr. Ma, how is research improving outcomes for patients with recurrent or high-risk non-melanoma skin cancer?

Dr. Barbara Ma:

Yeah, so, research is how we move the field forward. And that’s why clinical trials are important. Those clinical trials, it’s essentially access to novel therapies in a controlled setting. And some of the latest advances have included, besides ways to improve current immunotherapy.

Other things have also been using – for example, like oncolytic viruses and target injections. That’s actually one of the trials that Cornell was involved in, where we inject a modified herpes simplex virus into one of the lesions and then combine that with immunotherapy. And that was shown to actually provide also some impressive durable responses.

Especially in some of the people who had progressed and prior immunotherapy. But trials is really how we move the field forward. Because even though we have these great treatment options, there’s always room to do more and have better responses that are longer lasting. And so, I think that a couple of these have been pretty exciting, and I think it’s important that, when you’re thinking about your treatment plan, that you also consider, would I be eligible for a clinical trial?

We’ve made a lot of progress in the past years for non-melanoma skin cancers – and also melanoma. And I think a lot of advances have come with immunotherapy and oral agents, such as the hedgehog inhibitors for basal cell. I do feel encouraged that we’re getting better tools to be able to address these at earlier stages. And basal cell and squamous cell, again, they’re non-melanoma skin cancers and they’re the most common, really, tied with the sun damage. And I think more and more people are being more proactive in being sun safe and doing sun protection.

So, I think that it’s great that people are also arming themselves with the knowledge. And also, really empowering themselves to know more, to benefit not only them but also actually potentially their families. Because I think knowledge is really powerful for this.

And knowing more about treatment options, knowing that there’s a multidisciplinary component, and also that early treatment and earlier detection really does improve outcomes I think is a very powerful thing. So, I think that’s very encouraging for all of us.