Update on managing advanced skin cancer

New models of care include the wider use of multidisciplinary care teams and more aggressive screening and management of treatment-related adverse events.

Todd Schlesinger, MD, FAAD
Todd Schlesinger, MD, FAAD

New clinical trials and drug approvals are changing approaches to managing advanced skin cancer. New treatment options such as the 2020 approval of pembrolizumab monotherapy for metastatic cutaneous squamous cell carcinoma are important. So is the growing utility of gene expression profiling for risk assessment. Some of the most dramatic changes focus new models of care, including the wider use of multidisciplinary care teams and more aggressive screening and management of treatment-related adverse events.

“We have seen advances across nearly all types of advanced skin cancers, nonmelanoma, melanoma, Merkel cell,” said Todd Schlesinger, MD, FAAD, course director for the Aug. 7 session “What’s New in the Management of Advanced Skin Cancer” (F021) that focused on the latest developments in the management of advanced skin cancer. 

“Risk assessment is an increasingly important part of managing advanced skin cancers, as well as choosing the right clinical pathway for the right patient,” he said.

Presenters focused on what Dr. Schlesinger called inflection points in care in different types of skin cancer. Dr. Schlesinger is the director of the Dermatology and Laser Center of Charleston and Clinical Research Center of the Carolinas. 

“Major decisions are having to be made about the best approach for patients with skin cancer who have already been treated with multiple modalities, including chemotherapy and radiation, and their disease continues to progress,” Dr. Schlesinger said. “It might be deciding whether the patient will have to undergo a disfiguring surgery or approach their advanced disease from a medical standpoint. A multidisciplinary team can help the patient make the best decisions for their individual circumstances.” 

Multidisciplinary teams typically include multiple specialties, from Mohs surgery to dermatology, radiation oncology, medical oncology, head and neck surgery, social work, and others, depending on the specific needs and goals of each patient, he said. The National Comprehensive Cancer Network pioneered the multidisciplinary team approach to patient care, but the concept has not yet become widespread in skin cancer treatment. 

Actively managing adverse events was another key theme of the session. Side effects and adverse events are nothing new in skin cancer treatment, but dermatologists are taking more proactive approaches to setting patient expectations and managing symptoms, if and when they occur. The goal is to help more patients remain on treatment for longer to improve both their cancer outcomes and their overall quality of life. 

Much of the new attention being paid to adverse events grew out of early experiences with nivolumab, ipilimumab, and other immunotherapeutic agents designed to signal the entire immune system. 

“Almost every organ system in the body can be affected by the increased immune response generated by the medications we use,” Dr. Schlesinger said. “They are generally well-tolerated, but a small percentage of patients may have more severe adverse reactions. Early recognition and intervention can make all the difference in them remaining on therapy or not.” 

Recognizing potential adverse events is not restricted to clinicians. Receptionists and other office staff play important roles. Patients may call with complaints of a new cough, which could be pneumonitis, or diarrhea which could indicate immune-mediated colitis. 

“Even if the dermatologist didn’t prescribe one of these agents directly, patients can still feel more comfortable calling the dermatologist with new symptoms than a medical oncologist or other specialist,” Dr. Schlesinger said. “The office staff has to be aware and ready to alert you to what could be autoimmune adverse events and get the patient in right away to evaluate treatment.”