Q&A: Managing Recurrent Merkel Cell Carcinoma When Rural Access Shapes Care

A recent case report published in the Journal of Clinical and Aesthetic Dermatology highlights the challenges of treating recurrent Merkel cell carcinoma (MCC) when distance, transportation, comorbidities, and access to specialty care influence treatment decisions.¹

Chantel K. Hillestad, MSN, DCNP, FNP-C, of Trinity Health in Minot, North Dakota, detailed the approximately 2-year treatment course of an 80-year-old man living in a rural community who developed an initial MCC followed by 2 subsequent lesions on his left forearm. His management included repeated surgical intervention, pembrolizumab, and ultimately radiation therapy.¹

The case also reflects broader disparities in rural cancer care. Patients with MCC living in rural areas have been reported to have a mean overall survival of 34 months compared with 47 months among urban patients.¹ Only approximately 3% of oncologists practice in rural areas, and approximately 70% of US counties do not have access to an oncologist.¹

In this Q&A, Hillestad discusses the clinical lessons from the case, how rural barriers influenced treatment decisions, and what dermatology NPs and PAs can take away when caring for patients with aggressive skin cancers.

Dermatology Times: What made this patient's case particularly challenging?

Hillestad:

This patient had several factors that complicated his care. He lived in a rural community approximately 90 miles from the closest dermatology provider and radiation facility, had limited transportation, and faced concerns about traveling during North Dakota winters. He also had mobility limitations and an extensive medical history that included aortic stenosis, stage IV chronic kidney disease, congestive heart failure, atrial fibrillation, and other comorbidities.

Those factors meant we could not think about his MCC treatment solely in terms of what would ideally be recommended. We also had to consider what treatment he could realistically access and complete.

Dermatology Times: How did living in a rural community affect his initial treatment plan?

Hillestad:

Radiation therapy was discussed after his initial MCC was diagnosed and surgically excised, but traveling 90 miles for repeated treatments was a major concern for him. Transportation was limited, and winter weather could make that trip hazardous. His severe bilateral knee osteoarthritis also made frequent appointments difficult.

Because there was initially concern for advanced disease while his sentinel lymph node biopsy results were pending, pembrolizumab was started. He received treatment every 3 weeks and completed 7 infusions before being hospitalized with pneumonia and an exacerbation of chronic heart failure that progressed to respiratory failure.

Dermatology Times: What happened when his MCC returned?

Hillestad:

Approximately 2 years after the initial presentation, he contacted our dermatology office about another rapidly growing lesion near the previous surgical scar on his left forearm. Biopsy confirmed recurrent MCC.

He underwent another surgical excision and sentinel lymph node biopsy, which was negative, and PET imaging did not show additional involvement. While he was subsequently being evaluated by radiation oncology, another small pink papule appeared on the same forearm.

The radiation oncologist contacted our office, and we were able to evaluate and biopsy him that same day. That lesion was also MCC and was approximately 7 cm from the most recent surgical incision.

Dermatology Times: Why was the treatment strategy different for the third MCC lesion?

Hillestad:

After the third lesion was diagnosed, the oncology surgeon consulted with a nationally recognized cancer center. Rather than proceeding with a third surgical excision, the recommendation was to treat the satellite recurrence with radiation therapy.

Again, geography affected how that treatment could be delivered. The patient lived 90 miles from the closest cancer center and did not want to stay locally during treatment, so radiation was arranged 3 times per week.

He completed 11 of 12 planned hypofractionated external beam radiation treatments. The final treatment was not completed because he underwent transcatheter aortic valve replacement. Ultimately, the third MCC lesion completely resolved after radiation, and no additional satellite lesions were reported during follow-up.

Dermatology Times: What does this case demonstrate about balancing guidelines with the realities of rural practice?

Hillestad:

Guidelines are extremely important, but there is not one treatment plan that is appropriate for every patient. Clinicians also have to understand the individual barriers that may determine whether a patient can realistically follow that plan.

For rural patients, those barriers can include distance, transportation, weather, mobility, financial concerns, and limited availability of specialists. Understanding those obstacles can help clinicians develop treatment plans that patients are more likely to complete while still working toward the best possible clinical outcome.

Dermatology Times: How important was multidisciplinary communication in this patient's care?

Hillestad:

Coordination among dermatology, oncology, surgical oncology, and radiation oncology was essential. One example occurred when the radiation oncologist noticed the patient's third suspicious lesion and contacted dermatology. We were able to evaluate and biopsy the lesion that same day.

Later, dermatology and radiation oncology coordinated appointments on the same days whenever possible so the patient did not have to make unnecessary additional trips. Those steps may seem small, but for someone traveling 90 miles for care, reducing even one trip can make a meaningful difference.

Dermatology Times: What should dermatology NPs and PAs know about recognizing possible MCC?

Hillestad:

MCC can be difficult because it is rare and may resemble other skin conditions or skin cancers. It often presents as a rapidly growing, asymptomatic pink, red, or violaceous lesion.

Greater awareness among dermatology and primary care clinicians may help facilitate earlier biopsy and referral. Clinicians should also educate patients about skin self-examinations and encourage them to contact their care team quickly when a new or changing lesion develops, particularly after a previous MCC diagnosis.

Dermatology Times: What does this case suggest about surveillance after an MCC diagnosis?

Hillestad:

MCC has a high risk of recurrence, making close surveillance important. Approximately 40% of cases recur, with an average time to recurrence of about 8 months, and 95% of recurrences occur within 36 months.

In this case, regular dermatology follow-up was particularly valuable because the patient knew to contact the office when he noticed another rapidly growing lesion. After radiation therapy, monthly oncology and dermatology follow-ups were performed, with PET imaging scheduled every 4 months.

For rural patients, clinicians may also need to consider access to radiology and the distance required for surveillance when developing follow-up plans.

Dermatology Times: What is the biggest clinical takeaway from this case for APPs caring for patients in rural communities?

Hillestad:

Clinicians need to understand the patient's circumstances in addition to the disease itself. Rural patients may face barriers that are largely invisible when a treatment plan is developed on paper.

Telemedicine, travel assistance programs, patient lodging, coordinated appointments, and potentially mobile radiation services are strategies that may help reduce those barriers. Ultimately, providing effective rural cancer care requires flexibility, communication across specialties, and an individualized approach that considers what a patient can realistically access and complete.

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. doi:10.1136/jitc-2021-002478
3. National Comprehensive Cancer Network. Merkel Cell Carcinoma. Version 2.2025. April 18, 2025. Accessed August 11, 2026. https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1444