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Advice for the Management of CSCC

Insights From: Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center; Anna C. Pavlick, DO, NYU Langone Hospitals; Todd E. Schlesinger, MD, FAAD, FASMS, Dermatology & Laser Center of Charleston
Published: Tuesday, Feb 26, 2019



Transcript:

Anna C. Pavlick, DO:
Most of the skin cancers really require a multidisciplinary management team, which includes medical oncologists, surgical oncologists, dermatologists, radiation oncologists, and pathologists. Pick an –ologist, and we’re always happy to have you at the meeting, because many of these tumors don’t have a correct answer. Everything is potentially resectable. It’s just what is going to be the deformity that’s left as a consequence of resection, and that’s when you need to determine what’s the right thing to do for this patient. Same thing with radiation. Pretty much every part of the body other than a part that’s been already radiated can be radiated. But is radiation really the right thing to do? And are patients physically capable of coming for radiation every day even if it’s just 2 weeks? Some of these patients are elderly, some of them are debilitated, and some of them don’t have transportation.

So it really takes a village to make this decision as to what’s the proper way to manage these patients. And sometimes it’s giving patens systemic therapy to minimize their disease and make the lesion more easily resectable. We don’t always cure all the lesions. We can get them to shrink up to some degree, but there may be some residual, at which point having everyone involved allows for a smoother transition from the patient from my office back to the head and neck surgeon—or from my office back to the radiation oncologist, because now the tumor has moved away from the eye and is now back up on the scalp, which is an easily treatable area with radiation.

Todd E. Schlesinger, MD, FAAD, FASMS: My advice for community oncologists who see advanced CSCC [cutaneous squamous cell carcinoma] is to employ the multidisciplinary team, which means we all work together for these patients in dermatology, oncology, radiation, therapy, and surgical oncology—Mohs surgery. You know, in the community, it’s a little bit harder to put together a team. And the 1 thing I think is very important is for that patient to not always be in the hands of just 1 person but to have different approaches at least being considered, so that way they’re really getting the best outcome. And so I am, you know. Personally, I’m more than, you know, delighted to be able to have to, you know, share that patient to the folks in my community and work, work as a team. Just because, you know, we don’t have a built-in team. Like a university or an academic center, they have a built-in multi, most of them have a built-in multidisciplinary team such as a tumor board, an oncology board where the patient’s cases are always discussed. And that doesn’t exist in the community as much as we’d like it to. So the more we can work together and form those type of care teams for patients, I think the better off they’ll be.

Robert L. Ferris, MD, PhD: Aggressive and advanced cutaneous squamous cell carcinoma is a big clinical problem. It’s increasing in incidence, in part because of screening, and part because of a progressively elderly population in North America. And so with this disproportionate increase in cutaneous squamous cell carcinomas, and in the success of our organ transplant and pharmacologic immunosuppression, we’re seeing more and more aggressive and advanced squamous cell carcinomas. This has warranted and motivated comprehensive cancer centers like ours to put together multidisciplinary treatment teams. I think this is really the key—communication and offering patients the best in terms of diagnosis and offering new treatments. Even for conventional treatments, we think they are delivered better when the medical oncologist, the radiation, the surgeon, and the dermatology team work together in concert for the patient benefit.

So that has been ongoing. And then, thankfully, because new treatments were lacking, now we have a new FDA approval, and it’s well suited for this disease because we know that when you suppress the immune system, aggressive skin cancers emerge. And so reactivating the immune system makes perfect sense, and in fact, it results in a very high response rate, 2- or 3-fold higher response rate for cutaneous squamous cell carcinomas than for squamous cell carcinomas of the head and neck, or lung, other squamous cell carcinomas.

And so the high-mutational content is likely 1 reason, but also the exquisite control of aggressive skin cancers by the immune system would suggest that we’re just beginning to see a revolutionary new approach adding cemiplimab and potentially other immunotherapies as monotherapy—or what I anticipate is beginning to integrate them into the standard of care as a fourth modality for this new and increasing population of patients.

Anna C. Pavlick, DO: Clearly, cemiplimab is the biggest step we’ve taken in this disease arena in such a long time. But again, you have to keep in mind 50% of patients are not going to respond, 50% of patients will, which is awesome, but what do you do with the 50% who don’t. How do we now build on this therapy so we can move that response from 50% to 100%, so that everybody has the opportunity to have long-term durable control? And we’re looking at ways of combining different immunotherapies. Sometimes we can inject intratumoral agents and give systemic therapy, so that we give the tumor the 1-2 punch with 2 different mechanisms of immunotherapy. It’s an exciting time for squamous cell, and I really think within the next 5 to 10 years, we’re going to move that needle from 50% to at least 75% or better.

Transcript edited for clarity.
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Transcript:

Anna C. Pavlick, DO:
Most of the skin cancers really require a multidisciplinary management team, which includes medical oncologists, surgical oncologists, dermatologists, radiation oncologists, and pathologists. Pick an –ologist, and we’re always happy to have you at the meeting, because many of these tumors don’t have a correct answer. Everything is potentially resectable. It’s just what is going to be the deformity that’s left as a consequence of resection, and that’s when you need to determine what’s the right thing to do for this patient. Same thing with radiation. Pretty much every part of the body other than a part that’s been already radiated can be radiated. But is radiation really the right thing to do? And are patients physically capable of coming for radiation every day even if it’s just 2 weeks? Some of these patients are elderly, some of them are debilitated, and some of them don’t have transportation.

So it really takes a village to make this decision as to what’s the proper way to manage these patients. And sometimes it’s giving patens systemic therapy to minimize their disease and make the lesion more easily resectable. We don’t always cure all the lesions. We can get them to shrink up to some degree, but there may be some residual, at which point having everyone involved allows for a smoother transition from the patient from my office back to the head and neck surgeon—or from my office back to the radiation oncologist, because now the tumor has moved away from the eye and is now back up on the scalp, which is an easily treatable area with radiation.

Todd E. Schlesinger, MD, FAAD, FASMS: My advice for community oncologists who see advanced CSCC [cutaneous squamous cell carcinoma] is to employ the multidisciplinary team, which means we all work together for these patients in dermatology, oncology, radiation, therapy, and surgical oncology—Mohs surgery. You know, in the community, it’s a little bit harder to put together a team. And the 1 thing I think is very important is for that patient to not always be in the hands of just 1 person but to have different approaches at least being considered, so that way they’re really getting the best outcome. And so I am, you know. Personally, I’m more than, you know, delighted to be able to have to, you know, share that patient to the folks in my community and work, work as a team. Just because, you know, we don’t have a built-in team. Like a university or an academic center, they have a built-in multi, most of them have a built-in multidisciplinary team such as a tumor board, an oncology board where the patient’s cases are always discussed. And that doesn’t exist in the community as much as we’d like it to. So the more we can work together and form those type of care teams for patients, I think the better off they’ll be.

Robert L. Ferris, MD, PhD: Aggressive and advanced cutaneous squamous cell carcinoma is a big clinical problem. It’s increasing in incidence, in part because of screening, and part because of a progressively elderly population in North America. And so with this disproportionate increase in cutaneous squamous cell carcinomas, and in the success of our organ transplant and pharmacologic immunosuppression, we’re seeing more and more aggressive and advanced squamous cell carcinomas. This has warranted and motivated comprehensive cancer centers like ours to put together multidisciplinary treatment teams. I think this is really the key—communication and offering patients the best in terms of diagnosis and offering new treatments. Even for conventional treatments, we think they are delivered better when the medical oncologist, the radiation, the surgeon, and the dermatology team work together in concert for the patient benefit.

So that has been ongoing. And then, thankfully, because new treatments were lacking, now we have a new FDA approval, and it’s well suited for this disease because we know that when you suppress the immune system, aggressive skin cancers emerge. And so reactivating the immune system makes perfect sense, and in fact, it results in a very high response rate, 2- or 3-fold higher response rate for cutaneous squamous cell carcinomas than for squamous cell carcinomas of the head and neck, or lung, other squamous cell carcinomas.

And so the high-mutational content is likely 1 reason, but also the exquisite control of aggressive skin cancers by the immune system would suggest that we’re just beginning to see a revolutionary new approach adding cemiplimab and potentially other immunotherapies as monotherapy—or what I anticipate is beginning to integrate them into the standard of care as a fourth modality for this new and increasing population of patients.

Anna C. Pavlick, DO: Clearly, cemiplimab is the biggest step we’ve taken in this disease arena in such a long time. But again, you have to keep in mind 50% of patients are not going to respond, 50% of patients will, which is awesome, but what do you do with the 50% who don’t. How do we now build on this therapy so we can move that response from 50% to 100%, so that everybody has the opportunity to have long-term durable control? And we’re looking at ways of combining different immunotherapies. Sometimes we can inject intratumoral agents and give systemic therapy, so that we give the tumor the 1-2 punch with 2 different mechanisms of immunotherapy. It’s an exciting time for squamous cell, and I really think within the next 5 to 10 years, we’re going to move that needle from 50% to at least 75% or better.

Transcript edited for clarity.
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