Improving the Care of Patients With Advanced Nonmelanoma Skin Cancers

J Clin Pathways. 2023;9(1):32-33.

In 2022, the Association of Community Cancer Centers (ACCC) developed the Advanced Non-Melanoma Skin Cancers Visiting Experts Program to educate multidisciplinary providers through interactive, virtual discussions on effective practices for supporting, treating, and managing this patient population; identify barriers to care and address them through tailored quality improvement (QI) activities; and educate the broader oncology community. This Visiting Experts Program was held at 3 ACCC member programs: the University of Nebraska Medical Center, the Inova Schar Cancer Institute, and the Community MD Anderson Cancer Center.

Located in Omaha, Nebraska, the University of Nebraska Medical Center has a large catchment area spanning Nebraska, South Dakota, North Dakota, Eastern Colorado, and Iowa, as well as parts of Missouri and Kansas; this contributes to the diverse patient population it serves, comprised of varied geographic, racial, ethnic, and socioeconomic backgrounds. The center’s comprehensive skin cancer program launched 4 years ago and sees approximately 150 patients per year. To improve the care of patients with advanced nonmelanoma skin cancer, the multidisciplinary cancer care team members who participated in the workshop chose to focus on these 5 QI opportunities:

1. Hold a multidisciplinary Grand Rounds with a focus on high-risk squamous cell carcinoma, patients who have had a transplant, and translational science and research opportunities;
2. Increase clinical trials for nonmelanoma skin cancers;
3. Expand the integrated Cancer Repository for Cancer Research to include nonmelanoma skin cancers;
4. Increase biobanking of high-risk tumors; and
5. Have a dermatopathology presence at the medical center’s Multidisciplinary Cutaneous Head and
6. Neck Cancer Tumor Board.

Part of Inova Health System’s integrated network of 5 hospitals serving Northern Virginia, the Inova Schar Cancer Institute, located in Fairfax, Virginia, provides outpatient cancer care for patients from diverse socioeconomic backgrounds. Established in 2014, the Inova Schar Cancer Institute’s melanoma and skin cancer multidisciplinary program treats 3 to 7 patients per month with newly diagnosed advanced cutaneous squamous cell carcinoma and more than 50 patients per year with advanced nonmelanoma skin cancers. To improve the care of these patients, cancer care team members who participated in the workshop chose to focus on these 4 QI efforts:

1. Standardize Mohs surgery protocol for referring surgeons. At the initiation of the Mohs procedure, for tumors greater than 2 cm (upon clinical exam) or those that possess high-risk features, the surgeon is asked to submit the debulk for permanent histologic examination. This new process ensures all high-risk features are captured in the microstaging of the primary tumor, allowing for accurate risk stratification of patients and improvement of patient outcomes;
2. Create and distribute a standard checklist for referring providers. The checklist includes all high-risk features and must be submitted to the Inova Schar Cancer Institute as part of the referral;
3. Standardize review of information from referring providers. Core clinical team members are assigned a specific day of the week to be the designated intake packet reviewer. The team member can then make decisions on which providers (eg, radiation oncology, head and neck surgery, dermatology, and medical oncology) the patient should be scheduled to see as part of intake. Furthermore, the team member will decide if internal pathology needs to review the case as part of intake; and
4. Agree on a universal staging system. All providers agree to use Brigham and Women’s Hospital staging during tumor board as well as in their own clinical practice. Using a single staging system is the recommended approach by workshop faculty and experts, as patients will now be automatically discussed during tumor board.

With 5 cancer centers strategically located across Indianapolis and central Indiana, Community MD Anderson Cancer Center provides care to patients from diverse socioeconomic, racial, ethnic, and health literacy backgrounds. The center maintains an established melanoma tumor board with the option to submit advanced nonmelanoma skin cancer cases; in the past year, the board has treated 30 patients with advanced nonmelanoma skin cancer. The cancer center works closely with several dermatology groups, including Mohs surgeons and plastic surgery groups dedicated to coordinating the referral, treatment, and care of patients with advanced nonmelanoma skin cancer. For this workshop, Community MD Anderson Cancer Center collaborated with Dawes Fretzin Dermatology, Klapper Eyelid & Facial Plastic Surgery, and Parkview Health. This interdisciplinary team identified a QI opportunity to improve the process of identifying patients who are at high risk for advanced nonmelanoma skin cancers. To achieve this goal, Community MD Anderson outlined the following steps:

1. Create a list of dermatology high-risk scenarios;
2. Create a contact list for general practitioners to facilitate contact with dermatology experts in high-risk scenarios;
3. Monitor the number of high-risk patients coming through practice; and
4. Evaluate the length of time for high-risk patients to see dermatology after referral (ie, number of days).

Learn more about the Visiting Experts Program and access additional tools and resources.