New Directions in the Treatment of Basal Cell Carcinoma - Episode 2
Drs Sherrif F. Ibrahim and Vishal Patel discuss the importance of a multidisciplinary team in the treatment of BCC as well as best practices for preventing advanced BCC.
Sherrif F. Ibrahim, MD, PhD: For a small subset of basal cell cancers, for whatever reason—maybe it’s a delay to diagnosis, maybe it’s a more aggressive basal cell cancer that has recurred after primary treatment—some of them progress to what we call a locally advanced state. By studying basal cell cancers, we know that it’s a small percentage, but those can be the most devastating tumors. As dermatologists, is there something better we can do to prevent those few from progressing to a more advanced state?
Vishal Patel, MD, FAAD, FACMS: First, as you nicely outlined, the importance of early identification and treatment is key. Obviously, the dermatologist is the gatekeeper for all things skin. But more so with cutaneous malignancies, we think about treatment, but it’s been nice to see a shift in the last 10 or 15 years with the US surgeon general identifying skin cancer as a public epidemic in our country. We need to emphasize the importance of early identification but also early prevention. That’s obviously 1 thing, that we can help educate our patients on primary prevention of the cancers in the first place, along with early preventive treatment with either field treatments or other types of therapies.
For dermatologists, in the traditional teaching for keratinocyte carcinomas, both squamous and basal cell, but basal cell as a whole, as you outlined, is slow growing and there’s a wide variety of treatment options. I like to focus and change the discussion—at least we do with our residents—around staging. The tenements of oncology are around how we risk assess a lesion to determine the best treatment option. Until last year, the AJCC [American Joint Commission on Cancer] staging system for basal cell carcinoma was combined with squamous cell carcinoma. It isn’t that relevant. We see so many cases that we sometimes don’t even think about it. But it’s helpful to start thinking about it now that we have a nice paper that came out from the group at Brigham and Women’s Hospital. It creates a dichotomy, a binary system of low- and high-risk lesions with risk factors that we should know about. Those are going to be the vast minority of tumors dermatologists see.
The high-risk features identified in that paper include tumors being greater than 4 cm, located on the head and neck, and invading past the fat. If you have 2 or 3 of those risk factors and a tumor at least 2 cm in size, then you really increase the risk of bad outcomes. We aren’t just talking about recurrence; we’re talking about nodal metastases and death. When I start thinking about how we better equip dermatologists to provide optimal care, it starts with being able to look at something and assess it. What am I worried about? Is it extremely rare? Or is it not being able to get around it the first time and clear it? That’s when we need to maybe get help from other colleagues. Or is this in a location that’s super low risk and the lesion’s low risk and maybe it makes sense for the patient to not have surgery? Maybe they’re older and there’s another better therapy for it. Without risk assessment, it makes it difficult to do that in an evidence-based and quantifiable way.
Sherrif F. Ibrahim, MD, PhD: That’s a fantastic answer. We’re also seeing the emergence of alternatives to surgery. Certainly, we’ve seen that over the last several years. Our patients are always asking about it. For us who treat these tumors surgically, we agree it’s always best to get clear margins to look at something under the microscope and say that it’s gone rather than doing something else and hoping it’s gone.
Vishal Patel, MD, FAAD, FACMS: Yes.
Sherrif F. Ibrahim, MD, PhD: Surgery is the only thing where we have this ability to examine the edges or margins under the microscope and confirm and tell the patient, “Yes, it’s out,” or “No, it isn’t out. We need to do more.”
Vishal Patel, MD, FAAD, FACMS: Exactly.
Sherrif F. Ibrahim, MD, PhD: But we’re also seeing with these patients who get more and more basal cells that they’re getting tired, what we often refer to as procedure fatigue, especially some of the patients with basal cell nevus syndrome in particular. As you said, maybe surgery isn’t right for a given person. Or you can speak to some surgeons who say, “There’s no such thing as something that isn’t surgically resectable. You can resect anything.” To some extent, that’s true. But at what cost to the patient?
Vishal Patel, MD, FAAD, FACMS: Yes.
Sherrif F. Ibrahim, MD, PhD: If patients lose an entire ear, or experience exenteration of the eye, or gross disfigurement of the nose, then are we really serving a benefit for those patients? At our institution, that’s something that we often discuss at a multidisciplinary tumor board. I’m sure you have the same at George Washington School of Medicine. We started out meeting once a month several years ago. Then it was once every 2 weeks. Now we meet once a week because there are so many cases to discuss.
From our tumor board, we’re definitely seeing more advanced cases of basal cell carcinoma. It’s anecdotal, but the cases are increasing. We’re seeing more of them despite more public mentioning of basal cell cancer. You’re seeing it in the media. You’re seeing it mentioned quite a bit more with sun protection and so forth. But we’re seeing more skin cancer. Can you tell us a little about what your multidisciplinary tumor board looks like and who’s on it? How do you decide when patients go there? What are the typical discussions you guys have?
Vishal Patel, MD, FAAD, FACMS: Absolutely. We have a multidisciplinary tumor board as well. It’s attended by myself. We have residents in general dermatology as well as in surgical subspecialty who attend, and they rotate through it. The other specialists who come include our head and neck surgeons and surgical oncologists or plastic surgeons. We’re lucky that our plastic surgeon is trained in surgical oncology and tends to do all of our non–head and neck surgical work. It’s nice to work with 1 person who’s focused on this. We have a radiation oncologist, and we also include some of the ancillary staff.
From time to time, we have social work join as well as nutrition and speech staff when it’s relevant to head and neck tumor cases. Because sometimes with some of those morbidity-related issues that impact the patient, the initial touch point is difficult from a clinical standpoint, but the journey is much harder for the patient than those non–immediately surgical issues. Those clinical partners are much more key, so they’re involved in that decision-making capacity of what it’s going to be like after time point zero post treatment.
You noted that we’re seeing an increased number of cases for a variety of reasons. There are more patients and older patients. I tell patients that these lesions tell me that, “You had a good time. You did something fun, and it was decades of fun, and now we’re seeing evidence of that.” We’re going to see this rise for decades before we can have those public health interventions. But because of that, procedural fatigue enters our thought process for the earlier patients because with some patients, you know that they’re going to have a lifetime of dealing with this. Sometimes in the back of my head, I’m thinking, maybe with that shoulder lesion at 38 years old, we can think about something else, while something on the nasal sidewall that I’m worried about could easily turn into an advanced case. But that doesn’t fit for every patient. It comes down to that discussion with our patients around their goals of care. That relates to advanced cases because that’s where it becomes complex.
It’s important to understand what we’re trying to achieve, as you said. We can operate on anything. I’m sure we can find a surgeon who will take on any case. But is that the right decision? The multidisciplinary team helps hammer that out from our standpoint, then the patient has to come into that.
Sherrif F. Ibrahim, MD, PhD: I also find myself maybe with a lower threshold in presenting a patient because we’re meeting so much more frequently, and people are getting used to seeing basal cell cancers. It used to be this unmentioned stepchild, if you will. “Who cares about basal cell cancer? It doesn’t cause any problems. Let’s talk about the more exciting melanomas and squamous cell cancers.” But with the increasing number of basal cell cancers, it’s interesting to see nondermatologists—head and neck surgeons, radiation oncologists, surgical oncologists, and medical oncologists—get involved as well.
Vishal Patel, MD, FAAD, FACMS: I should mention that we have a medical oncologist. I’m lucky enough that I partner with one, and we alternate or we both join. I can step in for that. He’ll step in as well. When we were training, I felt like squamous cell was the ugly stepchild that nobody thought about because melanoma got all the focus. Now squamous cell is popular and important, and we see it being given a lot of attention at ASCO [American Society of Clinical Oncology] and ESMO [European Society for Medical Oncology], these medical oncology conferences. Before, it wasn’t. Now, it’s almost as if basal cell has stepped up as the younger brother into the role that squamous cell had for so many years. You’re absolutely right.
Sherrif F. Ibrahim, MD, PhD: No matter what, we’re still always thinking surgery and whether there are reasons not to do surgery, at least for the time being.
Transcript Edited for Clarity