Tag Archive for: dermatologist

Treatment Options for Advanced Non-Melanoma Skin Cancer

Treatment Options for Advanced Non-Melanoma Skin Cancer from Patient Empowerment Network on Vimeo.

Treatment options for advanced non-melanoma skin cancers are ever-changing. Dr. Diwakar Davar reviews current treatment options and discusses which medical professionals are involved in treating advanced non-melanoma skin cancers.

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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See More from Evolve Non-Melanoma Skin Cancer

Related Resources

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

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

What Are the Potential Benefits of an Advanced Non-Melanoma Skin Cancer Clinical Trial

What Are the Potential Benefits of an Advanced Non-Melanoma Skin Cancer Clinical Trial?

Emerging Treatments for Advanced Non-Melanoma Skin Cancer: What’s Showing Promise

Emerging Treatments for Advanced Non-Melanoma Skin Cancer: What’s Showing Promise?


Transcript:

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 incidence 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. 

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.

Download Guide

See More from Evolve Non-Melanoma Skin Cancer

Related Resources

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

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

Expert Advice for Newly Diagnosed Advanced Non-Melanoma Skin Cancer Patients

Expert Advice for Newly Diagnosed Advanced Non-Melanoma Skin Cancer Patients

Advanced Non-Melanoma Skin Cancer: Who Is on Your Healthcare Team?

Advanced Non-Melanoma Skin Cancer: Who Is On Your Healthcare Team?


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 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.  

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?  

How Is Advanced Non-Melanoma Skin Cancer Treated?

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

 

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?

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.

 

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.  

How Can Advanced Non-Melanoma Skin Cancer Patients Participate in Their Care?

How Can Advanced Non-Melanoma Skin Cancer Patients Participate in Their Care? from Patient Empowerment Network on Vimeo.

Dr. Vernon Sondak shares encouraging advice for patients to speak up and be active participants in their advanced non-melanoma skin cancer care and treatment decisions.

Dr. Vernon Sondak is the Chair of the Department of Cutaneous Oncology at H. Lee Moffitt Cancer Center and Research Institute. Learn more about Dr. Sondak, here.
 

Katherine:                  

Dr. Sondak, do you think a patient should consider a second opinion or consulting a specialist? If so, what would you say to them, to make them feel comfortable to do that?

Dr. Sondak:                

So, I would remind everyone – as we said earlier – advanced skin cancer is not something you can pass off. “Oh, it’s just skin cancer. Everybody gets skin cancer. It’s just minor. Just put a band aid on it.” I’ve seen people who’ve neglected these cancers for a long time, thinking they weren’t serious, or thinking that the treatments were gonna be too awful, too disfiguring, or too toxic. That’s just not the case anymore.

Everyone with advanced skin cancers should have cutting edge appropriate treatment. Cutting edge doesn’t always mean brand new. It might mean the same surgery we’ve been doing for many years. Just done properly and appropriately for that patient.

So, this is a kind of cancer that usually should be treated by very experienced teams. Especially when drug treatment is needed, often when radiation is needed, and certainly when major surgery is needed. Not just the use of the drugs, but the sequence. Which drug first? Which drug second? When is surgery appropriate? When do we do the radiation?

These are sophisticated decisions, and every patient is different. So, we strongly encourage people to go to a center that has a whole panel of different specialists. And they work and talk to each other. They work with each other, work together, talk to each other, and come up with a plan for each patient. If you just go to one doctor, sometimes – an old saying – when all you have is a hammer, everything looks like a nail. There are times when somebody says, “Well, I can do radiation.” Surgeon says, “I can do surgery.” Oncologist says, “I can do chemo, or targeted therapy, or immunotherapy.”

We want them all together, saying “Yeah, but what should we do for this patient?” That’s the goal that we’re striving for. That’s when you’re gonna be the most likely to get the most successful outcome.

Katherine:                  

Dr. Sondak, what would you like to leave patients with? Are you hopeful?

Dr. Sondak:                

We have seen the most dramatic progress in the treatment of these forms of cancer of the skin – melanoma, merkel cell cancer. basal and squamous cell cancers – in my lifetime. Progress I never ever thought I would see. We are not curing everybody, but we are curing a lot more people than we used to.

Yet I still see things about these forms of cancer on the internet that say, “Oh, this is really aggressive. This needs to be treated right away. Don’t wait. Don’t make me go get a second opinion. Have somebody deal with it.”

No. Time out. First thing, it’s better to do it right than to do it right away. Second thing, you don’t get a second chance to make a first impression, and if you go down the wrong treatment path, sometimes you can’t undo that. There is always time to stop and ask, “Am I doing the right thing? Is there somebody who really specializes in this that I should be seeing?”

But the most important advice at all, of course, is you’ve got to get the diagnosis made in the first place. So, that means you have to be willing to go to the doctor, to the dermatologist, to say, “Hey, this doesn’t seem right. It’s just not healing. It just keeps getting worse. What’s going on?”, and then have to be willing to follow up and go through treatments.

If you do, we are extremely optimistic. We are seeing progress, responses, cures that we never thought possible. So, there’s a lot of reason to be optimistic. It’s not always easy. There are plenty of side effects of all the treatments that we talked about. Including surgery, radiation, and all the drugs. But it’s not like it was even 10 years ago. Huge progress for people at any age. So, really, we really are optimistic.

A Review of Current Advanced Non-Melanoma Skin Cancer Treatment Options

A Review of Advanced Non-Melanoma Skin Cancer Treatment Options from Patient Empowerment Network on Vimeo.

How is advanced non-melanoma skin cancer currently treated? Skin cancer expert Dr. Vernon Sondak reviews advanced non-melanoma skin cancer treatment approaches.

Dr. Vernon Sondak is the Chair of the Department of Cutaneous Oncology at H. Lee Moffitt Cancer Center and Research Institute. Learn more about Dr. Sondak, here.
 

Katherine:                  

Yeah. Let’s turn now to the treatment options for advanced disease. What approaches are currently available to treat advanced non-melanoma skin cancer?           

First and foremost, we always think about, can this thing be entirely removed? Can we get the cancer out and cure the patient once and for all with an operation?

Most skin cancers have not yet spread to the lymph nodes or beyond, even when they’re advanced. So, it follows that if we can remove every last cancer cell from that site, we can cure that patient. That is obviously a worthwhile goal.

But these skin cancers occur in places where a big enough surgery to remove all the cancer can be a pretty deforming surgery. It’s why plastic surgeons get involved a lot. But it’s also why we try combinations of therapy to see if we can get by with less surgery, less radical surgery. Perhaps by adding radiation or adding drug treatments to shrink the cancer.

So, surgery first. Can we do it? Can we just fix this once and for all with surgery and get it done? Whether it’s Mohs, for more advanced cases, usually a general anesthesia type surgery. Often with a skin graft or other kind of plastic surgery reconstruction. Could we just get it all out and have the pathologist tell us, “This is done. This is taken care of”? It’s not a guarantee. There’s no guarantees in this business. Only in the muffler business.

But the odds are good if the pathologist tells us the margins are completely negative. If the pathologist tells us the margins are close here, or positive there, and we don’t think removal of additional tissue is wise, then we may call in the radiation oncologist and say, “Let’s give radiation.” Kill that area where there was a positive margin and give us a margin of safety around the surgery.

In the minority of cases, we say, “This is too big to even tackle with surgery – at least at first – or two widespread. So, we’re gonna use drug treatments. If it shrinks, we may use radiation for surgery later. But first, drugs and let’s see what happens after that.”

So, today we have really three main categories of drug therapy. In the old days we had – and it wasn’t that long ago – we had really one category. I’d say that’s only been in the last – not even – ten years that we’ve had multiple options. But let’s go back 10 years.

Chemotherapy. Standard chemotherapy that people think about with cancer. Hair falls out, nausea as a prominent side effect, suppressing of your immune system, suppressing of your blood counts. That form of chemotherapy was really the only drug therapy we had for advanced melanoma. I mean, advanced non-melanoma skin cancer. Advanced melanoma too could years or more ago.

Now, through progress with melanoma, we have drugs that work in the other kinds of skin cancer. Immunotherapy took the world by storm. It worked so well for melanoma that we tried it in squamous, and merkel cell, and even basal cell cancers, and also saw great results. Now immune therapy is approved in all three of those types of non-melanoma skin cancer.

But there are problems with immune therapy if you have an altered immune system. Especially if you have a kidney transplant, or liver transplant, heart transplant, and we boost your immune system, we run a serious risk of rejection. It isn’t a guarantee, and it can sometimes be managed with additional medications. But it’s something that we have to be very, very, very cautious about, is using immune therapy in someone with a transplant.

So, targeted therapy works when we have a genetic abnormality in a cancer, that we know is only in the cancer, and that we have a drug that can block. For melanoma, if it has a BRAF mutation, we have targeted therapy drugs that target the BRAF mutation.

But non-melanoma skin cancers don’t have BRAF mutations. Squamous cell cancers don’t have mutations that today we can target. Only basal cell cancer, along with melanoma, has a mutation that we can target.

But unlike melanoma – where only some melanomas have the gene mutation in BRAF – basal cells, all the cancers have a mutation in the hedgehog pathway. You can’t pretty much have a basal cell cancer without having a mutation in the hedgehog pathway. Fortunately, we have pills that inhibit that pathway that we call hedgehog inhibitors. Vismodegib, sonidegib, and these drugs are very effective at shrinking even gigantic basal cell cancers.

But the problem with targeted therapy in general, compared to immune therapy, is that the responses don’t tend to last as long. The tumor will shrink very rapidly. But some of those cancer cells figure out a way to mutate further and avoid the drugs that we were using to treat them, and eventually grow back.          

Let me just correct one thing I said about targeted therapy, so I don’t leave the wrong impression. I said there’s not really mutations in squamous cell cancer that can be targeted. There is one called the EGF receptor, or EGFR, that we sometimes target with a drug called cetuximab.

It’s not used as much now with immunotherapy. But it turns out there is some targeted therapy, even for squamous cell cancers. But for basal cell, is where the hedgehog inhibitors are used much more effectively than targeted therapy in most other forms of skin cancer.

What Are Treatment Goals and Considerations for Advanced Non-Melanoma Skin Cancer?

What Are Treatment Goals and Considerations for Advanced Non-Melanoma Skin Cancer? from Patient Empowerment Network on Vimeo.

Skin cancer expert Dr. Vernon Sondak reviews current treatment goals for advanced non-melanoma skin cancer patients. Dr. Sondak discusses factors to consider when making treatment decisions, including age, lifestyle factors, and potential treatment side effects.

Dr. Vernon Sondak is the Chair of the Department of Cutaneous Oncology at H. Lee Moffitt Cancer Center and Research Institute. Learn more about Dr. Sondak, here.
 

Katherine:                          

There are so many factors that come into play when making a treatment decision, including a patient’s age and overall health. So, let’s walk through the considerations when choosing therapy for advanced disease. What are the treatment goals? What does that mean and what are the goals?

Dr. Sondak:                

It’s actually really important and somewhat underrated to think about, “What’s the goal of the treatment?” I think even doctors sometimes, certainly medical students and trainees, it’s something they have to learn a lot about. Because it’s easy to memorize all the names of all the drugs and all the muscles in the body. But thinking about, “What are we really trying to accomplish here?”

The first thing we would like to accomplish, when we can, is cure the cancer. Most of the advanced skin cancers we’re talking about are still curable. We can’t say all, but most. Even in the high stages they are still potentially curable with treatment.

So, of course, if we can cure someone, we might be more aggressive with our treatment plan. More intensive with our treatment than if we’re not intending to cure them. Why wouldn’t we want to cure them? Why would we have a different intention? We’d always want to, but there are times when we say, “Gee, the standard treatments haven’t worked. Now we have to think about what other goals? We can’t cure you anymore.”

It’s pretty rare with skin cancer. But it happens. It happens with melanoma, and it happens with basal, and squamous cell cancers, but rarely.

We can’t cure you. We can help you feel better because the symptoms that this large skin cancer – this advanced skin cancer – is causing. Whether they might be bleeding, or pain, or pressure on a nerve, or whatever it might be. If we can relieve that, that’s palliation. That’s relieving symptoms. There are times we say, “We want to prevent that symptom from happening in the first place. If we don’t remove this, this is gonna start bleeding, or it’s gonna press on the nerves.”

So, even if we can’t cure you, we might want to treat one or more spots to prevent symptoms from occurring. Only in the most extreme, end of the line, kind of situations would we say now our goal is just comfort. We can no longer do anything to really alter the disease. When and how we make those decisions, obviously, they are challenging. But if you don’t start with that point, then you can’t get to the right treatment decision.

If you’ve got a patient who’s not curable, you want to do the least treatment to make them feel better or prevent them from feeling bad. Whereas if you’ve got a patient who is curable, you may be willing to justify much more aggressive treatment, if that’s what’s needed to cure them. 

Katherine:                  

How do patient specific factors, like lifestyle and pre-existing conditions, impact treatment choices?

Dr. Sondak:                

It really depends, but in skin cancer it can affect them a lot.

Number one: Lifestyle. Well, how did we get skin cancers in the first place? Whether they’re melanoma, basal, squamous? Usually, the one common denominator is ultraviolet light. Got it from being out in the sun or occasionally from being in a tanning bed. Something like that. Melanomas, and to a small extent basal cell cancers, tend to be associated with brief intermittent heavy exposure, meaning sunburns. Squamous cell cancer tends to be associated with chronic cumulative years of sun exposure. I was out in the sun all my life, I fished all the time, I was a lifeguard, what have you. That’s generalization.

A lot of overlap. But the common denominator, the common theme, is ultraviolet exposure. One thing about the sun, it doesn’t just shine on one spot all the time. It shines on lots of places. So, you may have a skin cancer here, but that doesn’t mean you didn’t get sun exposure there, or here, or anywhere else.

So, lifestyle factors. One: We can’t undo the ultraviolet exposure you already had. But we can prevent it from accumulating further. So, once a person is diagnosed with skin cancer, they really need to think about protecting themselves from the sun, avoiding sun exposure, and covering their skin, and protecting their skin when they’re in the sun. Ideally, they think about it before they got skin cancer. So, they don’t get skin cancer. Or if they get it, they get a mild, minimal, non-advanced, and easily treatable case.

But we want to make sure that once a person has skin cancer, that they recognize that their lifestyle needs to change. Cigarette smoking, unbeknownst to a lot of people, is also associated to some degree with skin cancers and a lot of other big and bad medical problems. So, we would love to alter people’s lifestyle as far as smoking is concerned. Those are the couple of key lifestyle factors that we always think about.

I think the other area that is so important in deciding about treatment is the overall health of the patient, other medical conditions that they might have, and then lastly, what the patient’s own specific concerns and considerations are.

How Is Advanced Non-Melanoma Skin Cancer Staged?

How Is Advanced Non-Melanoma Skin Cancer Staged? from Patient Empowerment Network on Vimeo.

Skin cancer expert Dr. Vernon Sondak describes how advanced non-melanoma skin cancer is staged and explains which factors are taken into consideration to understand an individual’s diagnosis.

Dr. Vernon Sondak is the Chair of the Department of Cutaneous Oncology at H. Lee Moffitt Cancer Center and Research Institute. Learn more about Dr. Sondak, here.
 

Katherine:                  

And we are going to focus today on advanced disease. So, what makes this type of cancer considered advanced?

Dr. Sondak:                

So, this also is somewhat – I won’t say controversial. I’ll just say it’s not uniformly agreed on by everybody. Not everyone means the exact same thing or has the exact same definition in their mind when they say advanced.

It’s a little different than the stage. The staging of skin cancer is mostly based on the size. So, a small skin cancer is almost never an advanced skin cancer. By small I mean less than 2 centimeters, sometimes. Depending where. Two centimeters is just under an inch.

But 2 centimeters in the middle of your face or on the tip of your nose. That’s already a pretty big problem. So, somebody might say, “Well, that’s kind of advanced.” Yes it is. But that’s not what we’re really talking about here. We’re talking about larger tumors. Tumors that have spread deeply into the tissues, or tumors that have spread and gotten to the next stages. Stage III, meaning in the lymph nodes. Or stage IV, meaning it’s spread beyond the lymph nodes, to the lungs and beyond.  

In terms of stages, in terms of stage III and stage IV, basal and squamous cell cancers, we are talking about much fewer than 2 percent of all those skin cancers. For basal cell, way fewer. For squamous cell, slightly fewer than 2 percent of all cases ever getting to a higher stage, like stage III and stage IV.

Sometimes they can be very advanced without ever spreading to the lymph nodes or beyond because they invade down into the bone. Could be on the top your scalp and invade down into your skull bone. Can be on the cheek, and invade, and follow the track along the nerves of the face. A lot of ways that the skin cancer can become advanced without spreading. But cancers that have spread are automatically considered advanced.

Katherine:                  

Right. That helps us understand the disease and how it progresses.

Is the COVID Vaccine Safe and Effective for Advanced Non-Melanoma Skin Cancer Patients?

Is the COVID Vaccine Safe and Effective for Advanced Non-Melanoma Skin Cancer Patients? from Patient Empowerment Network on Vimeo.

Dr. Vernon Sondak discusses the safety and efficacy of the COVID vaccine for advanced non-melanoma skin cancer patients.

Dr. Vernon Sondak is the Chair of the Department of Cutaneous Oncology at H. Lee Moffitt Cancer Center and Research Institute. Learn more about Dr. Sondak, here.
 

Katherine:                  

Is the COVID vaccine safe and effective for advanced non-melanoma skin cancer patients?

Dr. Sondak:                

I’ve spent my entire career studying the human immune system and vaccines for cancer. The COVID vaccine is the safest, most effective vaccine we have ever seen. It is like the difference between the Wright brothers airplane and the Apollo spaceships in terms of sophistication.

It is a vaccine that has gotten politicized and has gotten tangled up in all kinds of stuff. But again, it is the safest, most effective vaccine we’ve ever seen. I highly recommend it for all of our patients. I believe that all of our patients with cancer, and their family members, and their children of appropriate age should be vaccinated and boosted.

Even if you do that, as I have done, I go vaccinated, I got boosted, and I got COVID. It was milder than the usual cold I get every year before COVID. If I hadn’t been tested, I wouldn’t have even known I had it. I only get tested to avoid spreading it to family members and especially to vulnerable patients. If your immune system is weakened and it’s even more important to be vaccinated.

So, the only advice I give to my patients about the vaccine, and the vaccination specifically, is think about which arm to have it in. If you’ve got an active cancer, say in the left arm, have it in the right arm. Not because it will hurt the cancer, but because in the early days after the vaccine, you may get a little bit of swelling of the lymph nodes. We don’t want your doctor or anybody doing a CAT scan, or ultrasound, or mammogram, or any other test to accidentally think that those enlarged lymph nodes are from the cancer.

If you had the vaccine recently and are getting any type of diagnostic procedure, like a CAT scan mammogram or ultrasound of those lymph nodes, tell the team that you had a recent COVID vaccine.

Katherine:                  

That’s excellent advice. Thank you. Good to know.