In part 2 of this Frontline Forum series, Brent Moody, MD; Sarah Arron, MD, PhD; Justine Cohen, DO; Emily Ruiz, MD, MPH; and Todd Schlesinger, MD, discuss non-surgical treatment options for the management of BCC, dose adjustments for systemic treatments, combining hedgehog pathway inhibitors with immunotherapy, and more.
Although there is no standard definition for advanced BCC, Arron defines it informally as BCC that is not amenable to curative surgical resection or radiation therapy, or for which these treatments would cause substantial morbidity and decreased quality of life. However, determination of resectability is heavily reliant on the surgeon and the patient’s ability to access different surgical options, she added. This presents an opportunity for multidisciplinary care.
“In my 2-room Mohs practice, where I have limited emergency backup or access to sedation, surgical resection of a large basal cell carcinoma might not be the best option for the patient,” she said. “But if I sent them to a head and neck surgeon across the street who could take them to the operating room and do the surgery under general anesthesia, it would be operable. Inoperable sometimes means the surgery is not accessible to the patient where they live. That’s a big, important factor in rural areas.”
Multidisciplinary Care for Advanced BCC
The panelists agreed that, to optimize treatment of advanced BCC, the multidisciplinary team should start with 1 physician champion who is invested in and comfortable with managing BCC and should include, at a minimum, a surgeon, medical oncologist, and radiation oncologist. Ruiz noted that a radiation oncologist is particularly important because many decisions about the best treatment option require a strong understanding of the involved surrounding structures. The members of the multidisciplinary team may also differ depending on the anatomic location of the BCC (eg, Arron would choose a different radiation oncologist for head and neck BCCs than she would for BCCs on the trunk).
Another benefit to multidisciplinary care is the ability to leverage additional resources. For example, oncology practices often have a robust support network that includes insurance authorizations for medications, social work, oncology nursing support, and home help agencies. Zeitouni said, even if she is able to prescribe them, she often refers patients who need systemic therapies (eg, a hedgehog pathway inhibitor), to a medical oncologist to ensure the patient has access to these additional resources. Other factors that prompt Ruiz to refer a patient include a tumor that is fixed (which may indicate bone invasion), large in size, multiply recurrent, unusual in appearance, or accompanied by palpable lymph nodes or eye retraction (which may indicate deep invasion). Arron recommended that the referring dermatologist send a photograph of the lesion to other members of the multidisciplinary team before scheduling Mohs surgery to allow for a consultation with the patient and assessment among the team members in advance to determine whether the surgery is appropriate.
“We frequently do Mohs without a consult … and when the patient comes in expecting surgery and you walk into the room and your heart sinks, it can be very confusing and frustrating,” said Arron. “Whereas if you had that heads-up or that photo ahead of time, you have the opportunity to call the patient, bring them in for a consultation [to] talk about imaging, and decide if Mohs is appropriate before the day of surgery.”
A multidisciplinary collaboration may also be beneficial for patients who have had a neglected BCC and are reluctant to undergo surgery or radiation therapy, added Zeitouni. “[The other practitioners] may have something that I don’t have, or some ideas, or another way of communicating with the patient and their family that this is important that they get treated,” she said. “They might develop a relationship with the med[ical] onc[ologist] and say, ‘You made sense. All the other people before I saw didn’t make sense. I want to get this treated now.’”
Arron added that referral for psychological or psychiatric therapy may be beneficial for patients who have psychological barriers to seeking care, which is common among those with advanced BCC. “I try to couch it as, ‘I want to refer you to somebody who can help you get through your care as well,’” she said.