Multidisciplinary Approaches to Advanced BCC and CSCC

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A recent Dermatology Times Case-Based Roundtable, led by Joel Schlessinger, MD, a board-certified dermatologist, board-certified Mohs surgeon, and cosmetic surgeon in Omaha, Nebraska, convened leading dermatologists and physician assistants to discuss complex cases of basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (CSCC). The discussion focused on patient management strategies, treatment modalities, and the role of multidisciplinary collaboration in addressing advanced cases.

Challenges in Managing Advanced Skin Cancers

Participants highlighted the frequent presentation of advanced BCC and CSCC in older, immunosuppressed, or neglected cases. The complexities of treating older patients in nursing homes or those with extensive actinic damage were discussed. Many panelists noted that family reluctance or a patient’s inability to undergo aggressive interventions can complicate treatment decisions.

Another challenge is diagnosing and managing high-risk squamous cell carcinoma in areas that are difficult to access, such as the scalp, ears, or lower extremities. Participants shared cases of misdiagnosed or overlooked lesions that had progressed to locally advanced or metastatic disease.

Multidisciplinary Approach to Skin Cancer Management

The roundtable emphasized the importance of a multidisciplinary approach, including dermatologists, Mohs surgeons, oncologists, and radiation specialists, in managing high-risk and advanced cases. Some practitioners noted difficulties in securing timely oncology referrals, particularly in nonmetropolitan areas, which can lead to delays in care.

“The problem isn’t just access to treatment—it’s knowing who to refer to. Not all oncologists handle skin cancer,” they said.

Attendees debated the role of dermatologists in initiating systemic therapies. Although some dermatologists reported their experiences with prescribing hedgehog pathway inhibitors (HPIs), others noted a preference for surgical intervention. For locally advanced and metastatic CSCC, checkpoint inhibitors such ascemiplimab were recognized as an important option, though access to infusion centers and specialist referral remains a barrier.

Treatment Modalities and Decision-Making in Advanced BCC and CSCC

Surgical vs Medical Management

Surgery remains the standard of care for most BCC and CSCC cases. However, neoadjuvant strategies using HPIs were discussed as a means of reducing tumor burden before surgery. Some panelists favored medical therapy for patients with multiple lesions to avoid extensive surgical procedures that could lead to high morbidity.

“The biggest knowledge gap in dermatology is what to do when surgery isn’t the answer—what is the standard of care for advanced cases?” attendees said.

HPIs

HPIs, including vismodegib and sonidegib, were discussed as options for patients with multiple recurrent BCCs or those with Gorlin syndrome. Although effective, panelists acknowledged that adverse events such as dysgeusia, muscle cramps, and alopecia limit patient adherence. Strategies such as intermittent dosing and L-carnitine supplementation were highlighted as ways to improve tolerability.

Checkpoint Inhibitors for Advanced CSCC

Cemiplimab, a PD-1 inhibitor, has become an essential tool in managing advanced CSCC. The roundtable reviewed clinical trial data supporting its use and presented real-world cases demonstrating significant tumor regression. However, concerns regarding immune-related adverse events, including fatigue, pruritus, and endocrinopathies, underscored the need for careful patient selection and monitoring.

The Role of Genetic Expression Profiling

Several panelists mentioned the use of gene expression profiling tests such as Castle Biosciences’ Decision Dx-SCC to stratify CSCC risk and guide treatment decisions. Although not universally adopted, these tools were noted to aid in determining the necessity of sentinel lymph node biopsies and additional surveillance.

“The biggest challenge isn’t just treating these cancers; it’s ensuring patients follow through with care, whether it’s surgery, systemic therapy, or ongoing surveillance,” an attendee said.

The Future of Dermatologic Oncology

The discussion concluded with a call for standardized guidelines and decision-making algorithms to aid clinicians in managing complex skin cancers. Participants stressed the need for better education on systemic therapies and integration with oncology and radiation specialists.

Emerging treatment strategies, including combination therapies and novel immunotherapies, hold promise for improving patient outcomes. Integrating genetic profiling and artificial intelligence in dermatologic oncology may further refine patient selection and personalized treatment approaches.

“We need an American algorithm for advanced skin cancer—not just guidelines but a step-by-step decision tree for dermatologists,” attendees said.

Conclusion

The Dermatology Times Case-Based Roundtable provided valuable insights into the evolving landscape of BCC and CSCC management. By fostering collaboration and education, dermatologists can enhance patient care and optimize outcomes for those facing high-risk skin cancers.