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Expert Insights Into Locally Advanced Basal Cell Carcinoma


Drs Sarah Arron and Nathalie Zeitouni share their insights into how they define locally advanced basal cell carcinoma and when they introduce multidisciplinary care.

Sarah Arron, MD, PhD: Locally advanced basal cell cancer has really been an evolving definition over the past few years. How do you define those locally advanced tumors?

Nathalie Zeitouni, MD, FAAD: That’s a great question. I think it’s still an evolving definition. I would say large infiltrative tumors, tumors that are recurrent following either surgery or radiation or multiple surgeries, are probably what I would consider locally advanced. Sometimes folks will mention resectable versus unresectable. Again, it depends on whose hands they may be unresectable. In my hands, as a Mohs surgeon, but maybe not so much in head and neck surgeon’s hands. If we’re talking about surgery being resectable and nonresectable, does it lead to any morbidity or deformity doing the surgery? If the answer is yes, then probably I would consider that a locally advanced case.

Sarah Arron, MD, PhD: So a tumor maybe near the eye where we could take it out, but would be sacrificing the patient’s vision is a nonsurgical approach may be better for the overall health of the patient?

Nathalie Zeitouni, MD, FAAD: Correct. And of course, we always take into patient’s consideration. What would they like to do? How do they see it? Also, around that definition, I would consider a patient if he or she has multiple basal cell carcinomas where the tumor burden becomes very important—that overall high tumor burden. It may not be 1 locally advanced, but the sheer number of it makes it a little bit more challenging in terms of managing the patient.

Sarah Arron, MD, PhD: You mentioned resectable, unresectable, the idea that small basal cell cancer might be treated by a general dermatologist, one that’s more complex or on the face might require Mohs surgery, and then the ones that may invade deeper could involve other types of surgeons and maybe other options for treatment. When do you refer to other specialties?

Nathalie Zeitouni, MD, FAAD: So, again, great question. I’ll consider a multidisciplinary approach or discussing these cases or calling one of my colleagues when one I feel it is not a Mohs case anymore. Or when the patient will say, “You know, I’ve had multiple surgeries. I’ve had radiation. What other options are there?” That’s when I start picking up the phone and I’ll start with my medical oncologist colleague, and I’ll say, “I’d like to refer this case. I’d like to discuss this. Can we add it to tumor board? Do you think we should get the radiation oncologists on board? Do you think the head and neck surgeon should be involved as well in this conversation?” That’s usually that point that I’ll kind of start making those phone calls. I tend to call or text my colleagues directly versus sending a referral or fax. I want to make sure that whoever I’m discussing the case with has a really good understanding of the patient, what the patient also is expecting.

Sarah Arron, MD, PhD: That’s terrific and great. It’s great when your physician has cell phone contact with their collaborating physicians and surgeons because I really think that type of doctor-to-doctor communication can really help with coordinating some of these complicated care patterns. In my practice, we’ve traditionally referred from surgery to radiation to systemic therapies. Now that we have more data on hedgehog pathway inhibitors and immunotherapies for advanced basal cell carcinoma, one thing I’ve been thinking about a lot is when I moved to systemic therapy earlier in the treatment course in situations where the surgery may be too morbid for the patient or the patient may be terrified to undergo radiation, which is a long and extensive course of treatment. Have you thought about using systemics earlier in some of these patients?

Nathalie Zeitouni, MD, FAAD: Yes. Now that we have more options that are available in terms of systemic therapies, I do. I do. And I have that conversation with the patients where I’ll mention a couple of different systemic options in terms of, again, if it’s a locally advanced tumor, if the patient has had multiple surgeries or radiation and is maxed out on that, or as I mentioned earlier, multiple tumors. That high tumor burden where maybe 1 of the basal cell carcinoma is amendable, or 2 of them, but then they have so many. I’ve definitely had those cases and I refer them a little earlier onto systemic therapy. Again, I’ll call the medical oncologists and I’ll discuss the case and I think it makes it, like you said, it makes it a little bit clearer for everyone. We’re all getting on the same page.

Transcript Edited for Clarity

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