Case Report Highlights Rural Care Gaps in Recurrent Merkel Cell Carcinoma

A case report published in the Journal of Clinical and Aesthetic Dermatology details the treatment course of an 80-year-old man with recurrent Merkel cell carcinoma (MCC) managed in rural North Dakota, illustrating the access barriers clinicians and patients may face across multiple lines of therapy.¹ Over approximately 2 years, the patient developed an initial MCC and 2 subsequent lesions on the left forearm, requiring repeated surgery, systemic immunotherapy, and ultimately radiation therapy.¹ The report, authored by Chantel K. Hillestad, MSN, DCNP, FNP-C, of Trinity Health in Minot, North Dakota, follows the patient from initial diagnosis through local recurrence and development of an aggressive satellite lesion.¹

Patients with MCC in rural areas have a mean overall survival of 34 months compared with 47 months for urban patients, and 5-year survival has also been reported to be lower among nonmetropolitan populations.¹ Only approximately one-tenth of US medical providers practice in rural settings, and 3% of oncologists do so, leaving approximately 70% of US counties without access to an oncologist.¹ The case report places these population-level disparities in the context of an individual patient's treatment course.

Distance to Radiation Shapes Initial Treatment

The patient first presented in April 2023 with a rapidly growing lesion on his left forearm, later confirmed by shave biopsy as MCC negative for Merkel cell polyomavirus.¹ He underwent wide local excision, and positron emission tomography (PET) showed a mildly fluorodeoxyglucose-avid left external iliac chain lymph node that was considered nonspecific and potentially reactive or metastatic.¹ Because of concern for advanced disease while sentinel lymph node biopsy (SLNB) results were pending, pembrolizumab was initiated; the SLNB subsequently returned negative.¹

Radiation therapy was discussed, but the patient expressed concerns about his ability to adhere to treatment because he lived 90 miles from the nearest radiation facility, had limited transportation, and faced potentially hazardous winter road conditions.¹ Mobility limitations related to severe bilateral knee osteoarthritis created an additional barrier to frequent appointments.¹

The patient received pembrolizumab every 3 weeks and completed 7 infusions. Before his eighth infusion, he was hospitalized with pneumonia and exacerbation of chronic heart failure that progressed to respiratory failure, ending his 6-month course.¹ He subsequently expressed hesitation about restarting pembrolizumab because he believed the therapy contributed to the hospitalization.¹ Surveillance PET scans performed every 6 months for 18 months showed no evidence of malignancy.¹

Recurrence Prompts Shift in Treatment Strategy

In April 2025, the patient developed another rapidly growing lesion near the original surgical scar. Shave biopsy confirmed recurrent MCC, prompting a second surgical excision and SLNB, which was again negative.¹ PET imaging showed no further involvement.¹

While the patient was being evaluated by radiation oncology, another pink papule was identified on the same forearm. The radiation oncologist contacted the dermatology office, which arranged evaluation and biopsy that same day.¹ Pathology again demonstrated MCC. The approximately 5-mm lesion was located 7 cm medial to the most recent surgical incision.¹

After consultation with a nationally recognized cancer center, the oncology surgeon was advised to forgo a third surgical excision and instead proceed with radiation therapy targeting the satellite recurrence.¹ Because the patient lived 90 miles from the closest cancer center and did not want to stay locally, radiation was arranged 3 times per week.¹

He ultimately completed 11 of 12 planned hypofractionated external beam radiation treatments. The final treatment was not completed as he underwent transcatheter aortic valve replacement (TAVR), after previously experiencing significant hemorrhage following dental extractions performed in preparation for the procedure.¹ The third MCC lesion completely resolved following radiation, with no additional satellite lesions reported on follow-up.^1,4

Rural Access Barriers and Outcomes in MCC

The 2025 National Comprehensive Cancer Network (NCCN) guidelines cited by the case report recommend pembrolizumab for primary or recurrent regional MCC when curative surgery and/or radiation therapy are not attainable, a pathway reflected in this patient's initial management.^1,3

In a multicenter phase 2 trial of first-line pembrolizumab for advanced MCC, the objective response rate was 58%, including complete responses in 30% and partial responses in 28% of 50 patients.² Three-year overall survival was 59.4% across the cohort and 89.5% among patients who achieved a complete or partial response.²

The case authors noted that the patient's hospitalization could not be attributed solely to pembrolizumab because of his extensive comorbidities, which included aortic stenosis, stage IV chronic kidney disease, congestive heart failure, and atrial fibrillation.¹

Distance can similarly affect the feasibility of radiation therapy. The authors cited research showing rural residents were nearly 20% more likely than nonrural patients to be nonadherent to radiation therapy, with rural patients missing approximately 10% of treatments and experiencing an 11% higher mortality rate.¹

Care Coordination May Help Bridge Rural Gaps

The patient's course also illustrates how multidisciplinary coordination can mitigate some barriers associated with rural cancer care. When radiation oncology identified the third suspicious lesion, dermatology arranged same-day evaluation and biopsy.¹ Dermatology and radiation oncology later coordinated follow-up appointments on the same days to minimize additional travel.¹

The authors identified telemedicine, travel assistance programs, patient lodging, and mobile radiation units as potential strategies to improve access for rural patients requiring complex MCC treatment.¹ More broadly, they emphasized that no single treatment approach is appropriate for every patient and that clinicians must consider individual barriers when developing treatment plans.¹

The case ultimately demonstrates the tension between guideline-directed management of an aggressive, highly recurrent malignancy and the practical realities of delivering multidisciplinary cancer care across long distances.¹

References

1. Hillestad CK. Challenges of treating recurrent Merkel cell carcinoma in the rural US: a case report. J Clin Aesthet Dermatol. 2026;19(3-4 suppl 1):S12-S18. https://jcadonline.com/wp-content/uploads/Challenges-of-Treating-Recurrent-Merkel-Cell-Carcinoma-in-the-Rural-US-A-Case-Report.pdf
2. Nghiem P, Bhatia S, Lipson EJ, et al. Three-year survival, correlates and salvage therapies in patients receiving first-line pembrolizumab for advanced Merkel cell carcinoma. J Immunother Cancer. 2021;9(4):e002478.
3. National Comprehensive Cancer Network. Merkel Cell Carcinoma. Version 2.2025. Published April 18, 2025. Accessed August 11, 2026. https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1444
4. ScienceDirect. Article S019096222502482X. Elsevier. Accessed August 11, 2026. https://www.sciencedirect.com/science/article/pii/S019096222502482X
5. Zaorsky NG, Lee CT, Zhang E, Keith SW, Galloway TJ. Hypofractionated radiation therapy for basal and squamous cell skin cancer: a meta-analysis. Radiother Oncol. 2017;125(1):13-20. doi:10.1016/j.radonc.2017.08.011.
6. Bavry A. When is the right time for TAVR? Understanding your heart valve options. UT Southwestern Medical Center. Published February 10, 2025. Accessed August 11, 2026. https://utswmed.org/medblog/tavr-when-to-get-it/
7. National Comprehensive Cancer Network. NCCN. Accessed August 11, 2026. https://www.nccn.org/