In part 2 of this skin cancer report from the American Academy of Dermatology Virtual Meeting Experience 2021 (AAD VMX), an expert shares pearls on regular medication reviews.
Ongoing developments in the treatment landscape for high-risk skin cancer patients signal the need for more intensive and frequent medication reviews, said Rajiv Nijhawan, MD, in his presentation at the 2021 American Academy of Dermatology Virtual Meeting Experience (AAD VMX).1
As with surveillance, which was covered in part 1 of this skin cancer update from AAD VMX, best practices for treatment management require more research and vigilance. The key takeaway is that physicians not only need to weigh the efficacy and safety of each drug individually, but also how well or poorly they interact with the multiple treatments typically needed for transplant recipients and other patients at high risk for developing skin cancer.
“It is so important to review medications, but it is something that we don't always do,” said Nijhawan, associate professor, Mohs Micrographic & Reconstructive Surgery and director of High Risk Skin Cancer/Transplant Clinic at the University of Texas (UT) Southwestern Medical Center in Dallas. “Dermatologists really need to take a close look at all the medications [the patient is receiving] to see what interventions are possible, when and how they can be introduced, and how well they will work with the entire regimen to optimize patient outcomes.”
For vorticonazole (Vfend; Pfizer) and other photosensitizing/phototoxic medications, the review should consider not only how long the patient has been taking the medication—longer duration of exposure means great risk, he pointed out—but also whether the patient complied with strict sun avoidance protocols, whether skin lesions consistent with premalignant lesions, squamous cell carcinoma (SCC) or melanoma developed, and whether the medication was given to a transplant patient more as a prophylactic measure or as a treatment for a fungal infection.
Medication reviews for most patients at high risk for skin cancer are becoming more proactive, Nijhawan explained.
“For decades, we really didn't have any great alternatives,” he said. “People were on some medications [with various adverse effects] for years and years. But now we often have alternatives. We can select a treatment that is safer and more effective.”
In those cases that immediate switching is contraindicated, Nijhawan recommended a more aggressive screening schedule and a more thorough full body exam to look for lesions in less visible locations. “I’ve found that we may need to solve for full-blown infections in some subsets of patients,” he said. “Often, patients respond quickly but, if it looks like the patient will have to be on that for longer than a few weeks to months, I’d still look for another option.”
For patients on immunosuppressant medications, the major concern focuses on medication that inhibit repair of UV-induced cellular damage, thereby increasing skin cancer risk. Although some alternative medications may also carry risk in terms of skin cancer development, they may be effective at lower dosages or have fewer other adverse effects (AEs).
Any review should reflect the context of a patient’s overall treatment regimen. He cited the debate around mTOR inhibitors as an example.
In his experience, mTOR inhibitors can be more useful for renal transplant patients than lung transplant recipients. “It’s definitely a conversation. The data is still a little bit variable in terms of benefit. Initial studies on mTOR reported decreased SCC but other data reported that happened only if there was one lesion,” he said. “We need more research. I’m unclear as to when to switch, so I think it’s case by case. At our institution, we pause and discuss it with the patient. We also talk with patients about what fits their budget.”
In addition to specific factors, Nijhawan considers the impact on sun sensitivity, the cumulative effect over a long-term treatment plan, and the immediate impact of switching. For patients who are immunosuppressed, stopping a given medication could mean “SCC lesions could come back with a vengeance,” he said.
“The overall goal is to reduce immunosuppression as much as possible without compromising the graft,” he added. “We also talk with the primary managing team to see if we can decrease the dosage of medications that increase skin cancer.”
Nijhawan reported no relevant or financial disclosures.
Nijhawah R. Pearls for surveillance & management of high-risk skin cancer patients. Presented at: 2-21American Academy of Dermatology Virtual Meeting Experience (AAD VMX); April 23-25, 2021.