Coordination, Continuity, and Team-Based Approaches in Advanced cSCC Care

Cutaneous squamous cell carcinoma (cSCC) is usually treated with surgery or radiation, but when the disease advances beyond curative-intent treatment, management stops being a single specialty’s decision. At 3 recent Dermatology Times Evolving Paradigms events, Darrell S. Rigel, MD, MS; Neal Bhatia, MD; and Gaurav Singh, MD, MPH, FACMS, moderated discussions with dermatologists, Mohs surgeons, and medical oncologists on advancing multidisciplinary care in cSCC. All 3 groups reviewed a case of a 72-year-old man with locally advanced, node-positive disease and examined how systemic immunotherapy options are reshaping referral and treatment decisions. Rather than focusing on individual presentations, discussions centered on shared clinical challenges: comparing trial data across 3 approved checkpoint inhibitors, reading cross-trial comparisons with appropriate caution, managing immune-related adverse events, and bridging referral gaps between dermatology and oncology. Rigel is a dermatologist at Cooper Clinic in Dallas, Texas, clinical professor of dermatology at NYU Grossman School of Medicine in New York, and adjunct professor of dermatology at UT Southwestern Medical School; Bhatia is a dermatologist and director of clinical dermatology at Therapeutics Clinical Research in San Diego, California; and Singh is a dermatologist and Mohs micrographic surgeon at City of Hope Cancer Center Chicago in Illinois.

Catch up on part 1 here and part 2 here.

Referral Pathways and Multidisciplinary Coordination

Discussion at Bhatia’s and Singh’s events turned to how patients move between specialties once systemic therapy becomes a consideration. Several dermatologists described inconsistent referral timelines shaped by insurance networks, multidisciplinary access, and how quickly pathology results trigger a phone call.

“I think the problem is the sequencing. You’re trying to get this hot potato out of your hands,” an attendee at Bhatia’s event said. Another, describing a multidisciplinary tumor board that meets weekly, said referrals move within 3 to 4 weeks. Bhatia pushed the group to consider whether dermatologists are sending enough clinical detail, not just a diagnosis, when referring out.

Bhatia also raised the use of gene expression profile testing for risk stratification in borderline cases, which drew a mixed reception, with several oncologists noting it is not validated or guideline supported for cSCC. At Singh’s event, clinicians described fragmented referral pathways, inconsistent pathology reporting of high-risk features, and a timing problem in which a complete excision can foreclose a neoadjuvant approach. “I wish there was a clear pathway for this,” said one dermatologist, recounting the coin flip of which specialist a patient happens to see first.

Social determinants, insurance step-therapy hurdles, and access to skin-focused tumor boards shaped decisions as much as response rates did. When oncologists at Rigel’s event described how they select among the available agents, cemiplimab emerged as the most commonly used drug in current practice. “It comes down to effectiveness, the [adverse] effect profile, and then from the patient perspective, the logistics, how often they have to come in,” one attendee said.

The Dermatologist’s Role After Referral

Rigel stressed the dermatologist’s ongoing role even after referral, following patients for subsequent lesions and ensuring they return for skin checks, a step attendees acknowledged can be difficult to maintain once patients enter the oncology system. “Sometimes when they are referred to medical oncology, it’s hard for them to come back,” an attendee noted. “They don’t come back for their skin checks. They feel like they got treated and they’re done.”

Bhatia echoed the point at his own event. “The key for the dermatologist is not to think this is not our disease and to stay involved,” he said, adding that oncologists should keep referring clinicians looped in through notes and continued tumor board participation. He framed referrals as a 2-way relationship rather than a handoff.

“That’ll lead to more exchange of ideas and exchange of business also,” he said.

Looking Ahead

If anything united the 3 groups more than any single drug, it was the operational reality of advanced cSCC. The consensus across events was less about choosing an agent and more about building the team: medical oncology to manage systemic therapy and toxicity, and dermatology to flag who needs it and to catch the next malignancy.

Rigel suggested the group had identified a practical need on the dermatology side: a concise reference tool summarizing which patient features, staging, genomic risk markers, and pathologic characteristics should prompt referral for consideration of systemic therapy. “That’s a really good idea,” Rigel said. “That should come out of this [discussion].”

This supplement has been produced independently by Dermatology Times and supported through an educational grant by Sun Pharmaceuticals.

Click here to download the full supplement: “Coordinating Systemic Therapy for Advanced Cutaneous Squamous Cell Carcinoma”