In part 2 of this Frontline Forum series, John M. Strasswimmer, MD, PhD; Andrew H. Weinstein, MD; Neal Bhatia, MD; Laura Ferris, MD; and Aaron S. Farberg, MD, discuss solutions for managing and treating patients with basal cell carcinoma.
Farberg has researched the accessibility of dermatologic care across the country and emphasizes the need to increase the number of dermatologists to help address BCC. He helped lead a study surveying dermatologists through the American Academy of Dermatology. Results of the survey showed that 38% of clinicians in urban areas reported a low number of dermatologists in their community. More than half of dermatologists in rural areas reported fewer dermatologists than required to serve their populations. More than 70% of regions studied with at least 1 practicing dermatologist have fewer than 4 dermatologists per 100,000 individuals. Study investigators alongside Farberg shared that 4 dermatologists per 100,000 individuals is an estimate of how many are needed to adequately care for a population.6
Weinstein said the current reimbursement system disincentivizes dermatologists who may be leaving the field or focusing on more lucrative aspects of dermatology, such as antiaging.
Although more aggressive cancers, such as melanoma or Merkel cell carcinoma, often result in the rapid assembly of multidisciplinary teams to treat disease, this happens to a lesser extent with BCC, the panel said. Multiple health organizations in the United States and Europe have set forth multidisciplinary recommendations for patients with BCC. Those guidelines indicate that dermatologists can benefit from working relationships with medical oncologists, surgical oncologists, radiation oncologists, Mohs surgeons, nurse practitioners, physician assistants, pharmacists, and pathologists.7
The panel recommended talking to patients about creating an interdisciplinary team as quickly as possible. This includes discussions about biologic treatments, especially because patients may have seen advertisements on television or online and will wonder why their doctor has not discussed these options with them.
Farberg noted that dermatologists are in a unique position to help guide the team and providea holistic approach. “Each patient is different; they have various individual risk factors,” he said. “So, when I get this pathology report or I see this on a pathology slide, I need to first understand what’s going on with the patient. From there, if we decide this does require a multidisciplinary approach, then I believe it is our job as dermatologists to be a multidisciplinary advocate.” He added that in multidisciplinary treatment groups, the dermatologist must be the patient’s advocate and encourage treatment modalities that dermatologists may rely on another specialist to prescribe, such as immunotherapy.
Bhatia agreed that the dermatologist needs to take a lead in determining the best care for the patient, and suggested it may be necessary to reframe the way clinicians approach treatment. “I’m concerned that medical dermatologists especially, but all of us as a whole, don’t think about cancer the way oncologists do. We don’t think about shrinking tumor burden, cutting it out and making it go away,” he said. “I think we need to get back into the model of what are our [colleagues are] doing? What mechanisms of action do they have to improve outcomes?”
“I think IV drugs and checkpoint inhibitors can be a much bigger part of our practice,” he added. “There are some tumors that just need chemotherapy or need medical therapy. …We all [need to] find a balance of increasing our interest in getting patients treated—whether it involves us doing the infusions or working with someone who can do the infusions with us.”
The experts also emphasized that an excellent working relationship with the dermatopathologist assisting with a patient’s case is essential, as they have deeper knowledge and work with samples on a much more frequent basis. The panel stressed that dermatologists should not be their own dermatopathologists because of this additional expertise. Knowledgeable and trustworthy colleagues are also essential, as multidisciplinary teams get faster and more accurate diagnoses.
6. Glazer AM, Farberg AS, Winkelmann RR, Rigel DS. Analysis of trends in geographic distribution and density of US dermatologists. JAMA Dermatol. 2017;153(4):322-325. doi:10.1001/jamadermatol.2016.5411
7. Kim JYS, et al; Work Group; Invited Reviewers. Guidelines of care for the management of basal cell carcinoma. J Am Acad Dermatol. 2018;78(3):540-559. doi:10.1016/j.jaad.2017.10.006