Hear From the Experts: The Importance of Multidisciplinary Care in Advanced BCC and Advanced CSCC

In collaboration with Regeneron’s Let’s Get Real About Skin Cancer program, a panel of distinguished dermatologists and oncologists delve into the critical importance of a multidisciplinary care team (MDT) for advanced cases of non-melanoma skin cancer (NMSC), including advanced basal cell carcinoma (BCC) and advanced cutaneous squamous cell carcinoma (CSCC).

Objectives:

• Share key multidisciplinary perspectives in NMSC screening, diagnosis, and staging for a medical audience.
• Address misconceptions that leave some patients undetected, potentially leading to advanced cases.
• Explain the role of each participant in the MDT and how they work together in diagnosing and managing patients. 

Gordon Kuntz: Thank you for joining us today. In today's panel, we will discuss the importance of multidisciplinary care in certain types of non-melanoma skin cancer known as NMSC, including advanced basal cell carcinoma, known as BCC, and advanced cutaneous squamous cell carcinoma, also known as CSCC.

I'm Gordon Kuntz, an oncology consultant, and I'm looking forward to moderating this important discussion that will highlight tips for BCC and CSCC screening and diagnosis, while demystifying misconceptions that can delay diagnosis and potentially lead to advanced cases.

Today, I'm joined by Dr Mavis Billips, dermatologist and medical director at City of Angels Dermatology in Los Angeles; Dr Sarah Arron, dermatologist and micrographic surgeon at Peninsula Dermatology in Burlingame, California; and Dr Adil Daud, medical oncologist at the University of California, San Francisco. Thank you to everyone for being part of today's discussion.

Today, we'll hear perspectives from these physicians about their unique role in the management of patients with advanced BCC and advanced CSCC, beginning with the dermatologist.

Dr Billips, can you please share your perspective on screening and maybe some tips for to recognize basal cell carcinoma and cutaneous squamous cell carcinoma, including advanced cases and its varied presentations across skin tones?

Dr Mavis Billips: Thank you, Gordon. Non-melanoma skin cancers like basal cell carcinoma known as BCC, and cutaneous squamous cell carcinoma, known as CSCC, are among the most common types of skin cancers in the country.

I see patients all the time with these, but today I just really want to focus on patients of color because in this population, they tend to be a lot more advanced upon presentation.

In the past, we would traditionally look at, Caucasian males who are older, who had, a very active lifestyle in the sun. Those would be the people we would be concerned about, but we have to think outside the box and expand who we are looking at now.

I think our role, in our training, we are actually trained to look for these cancers in patients who are they are fair complexion Caucasian males who may have had occupations in the sun and the growth of primarily on exposed skin, head, neck, face, even the back of the arms.

What we are not trained to look for is to look for these cancers in people of color. The presentation can be significantly different. First and foremost, they can appear on skin that's covered. So now this means that a skin cancer screening cannot just include a visual inspection of the arms or whatever you see, but patients should be disrobed.

I'm a firm believer in a full body skin exam for everyone, but particularly patients who may have occupations that expose them to the sun. Doesn't matter their ethnic background.

In patients of color, that skin cancer is not going to be pink and scaly. It can be very dark. A bump that's on an island by itself should raise your suspicion as a dermatologist.

So, when you see that you really have to biopsy. Patients may tell you, “Oh, this is a mole.” A new mole on a patient 62 years of age, should raise your index of suspicion. We don't have many moles that just pop up overnight in that population, so you should always be prepared to biopsy.

If you find something and it's very advanced based on your pathology report, many times it's way beyond what we can do and that's who we have to call up on our surgical colleagues, our Mohs surgeon. You transfer them, you send the patient over, you know, and prep the patient. Let the patient know what they you know what to expect.

Many patients of color have never had skin cancer. Don't know anyone with it. So, a Mohs procedure, as we talk about it freely with patients who may have been down that road before, doesn't resonate with them. You have to count on people like Dr Arron.

Gordon Kuntz: Thank you so much. Dr Arron, can you tell us more about the Mohs surgery treatment option please?

Dr Sarah Arron: Absolutely. Thank you. Gordon.

Mohs micrographic surgery, named after the surgeon who developed the procedure, Dr Friedrich Mohs, is a very detailed surgical procedure for removing higher risk skin cancers. As Dr Billips mentioned, often, early basal cell carcinoma or cutaneous squamous cell carcinoma can be removed with what we call a wide local excision.

When a patient comes in for Mohs surgery, what I'm able to do in the office under local anesthesia is make sure I have the entire tumor out before I do the reconstruction. It's an all day procedure for the first stage. I bring the patient in and under local anesthesia, just remove a tiny little portion of what I can see with the naked eye where the biopsy was taken, or any remaining tumor tissue.

I then take it to my technician down the hall, and she makes frozen section slides for me to look at under the microscope. I look to see have I got the entire tumor out or are there any tumor cells remaining? And I'm looking at the entire tumor margin. So, around the edges and underneath the base, if there are any tumor cells there, I bring the patient back in the room and we repeat the process again.

I'm only needing to remove tissue where I saw those tumor cells. Maybe it's a little bit wider in one direction, or maybe deeper but not wider. It's tailored to where that patient's tumor is going.

Because oftentimes, what the patient doesn't fully understand, is that I see skin cancer as a dandelion in a lawn. You can pick the flower, but the roots are still there, and there may be seeds of sun damage blown all over. So, I want to make sure that the patients understand the situation, and it's fantastic when my referring medical dermatology colleagues have prepared the patient, at least, that they understand the nature of the tumor, the nature of Mohs.

Some tumors are good candidates for Mohs because they're difficult to reconstruct. They're in areas without much loose skin. So, the tip of the nose or the shin or the back of the hand. These are all reasons to do Mohs surgery.

There are two types of patients that come into my office for Mohs, where I start to think about a multidisciplinary team approach. The first is those patients whose skin cancer is clearly already visible as being very large or very advanced or very aggressive.

The second, which is more heartbreaking and more difficult to manage, is tumors that have very deep components with aggressive features like invasion of the nerves or into the fat or tissue beyond. Those are also complicated cases where I start to think about a multidisciplinary approach.

Gordon Kuntz: Excellent. So, Dr Daud, what do you do when you see these kind of advanced cases?

Dr Adil Daud: Usually, we're brought in as medical oncologists when a cancer is more advanced, when there's evidence of spread somewhere else.

The first step is to develop a plan for that patient. It's important to know exactly where a tumor is or where a cancer is starting off it. And so oftentimes we'll do CAT scans and MRI scans. Many of the skin cancers, can be more extensive than they appear as Dr Arron was mentioning.

And then I think, most importantly, to communicate with the surgeon and with the dermatologist and with the radiation oncologist and with the pathologist to try to get a good sense of where we are starting with and what our goals of care are.

In some cases, if a cancer has been growing for a long time, let's say if the option is systemic therapy. There are basically three types of systemic therapy that are used. One is immunotherapy, which you know can be pretty effective at squamous cell cancers of the skin.
With basal cell cancers, there's targeted therapy. Then there's chemotherapy that's used primarily for squamous cell cancers.

It might be possible to go back to surgery if you manage to get some shrinkage. That's often our goal, to shrink the tumor down and get back to surgery and get back to Mohs and see whether you can actually accurately resect the tumor.

I think a lot of these scenarios need for us to have close communication with our surgical colleagues and with our pathology and radiation oncology and radiology colleagues to know when you've accomplished your goals or what do you do, which is very important in medical oncology.

And finally, you want to have an evaluation of that cancer before you start treatment so that you can tell after a certain course of treatment if that cancer is responding or not.

Gordon Kuntz: It sounds like you're really kind of leading into our next discussion, which is around multidisciplinary teams and how those groups interact. So, let's talk about how each of you partners with other specialists to manage patients.

Dr Billips, we'll start with you. Can you please share what your guiding principles are, especially around a coordinated partnership across disciplines?

Dr Mavis Billips: Depending on the location of the lesion, that's kind of like where I determine, this is not a wide excision lesion.

Whether it's advance or not, I will send those patients to Mohs, particularly on the front of the eye, around the nose, the mouth, lip, the, you know, the back of the hand and the top of the toes. Those go to my Mohs surgeon, without a doubt.

I do leave it up to my Mohs surgeon to advance on to Dr Daud and his expertise, but once they've gone to oncology, you know, I am in touch with that team to provide any additional background history that patient or that patient's family that they may need. They call up, we discuss it, and, you know, we move forward.

It empowers me to know I have these two areas of expertise on my team to help the patients, because it can't be done alone.

I think as dermatologists, our key role in this whole process is really identifying it. And you know, identifying it and spending time teaching patients, you know, about what to look for.

Gordon Kuntz: Thank you. Dr Arron, what about you? You talked about the importance of coordinating patient care across disciplines.

Dr Sarah Arron: Absolutely. And that's one of the most important things we can do as dermatologic surgeons is coordinating care, both with our dermatologists who refer patients to us, as well as with our colleagues in the multidisciplinary oncology setting. So, when patients come to me for Mohs surgery, one of the things I'm doing is triaging how aggressive the tumor is. If it's something that I can treat completely with Mohs, then I'm spending a lot of time with the patient. Often while I'm doing the reconstruction, talking about going back to their dermatologist.

On the other hand, there are those patients whose surgeries become more complicated and whose skin cancers are going to require additional treatment, and in those situations, I'm often talking to my patients about the other members of the team that they might need to meet.

Because, as Dr Daud mentioned, we have many treatments for these cancers. Just over the past ten years, we've really blossomed in the number of ways we can treat non-melanoma skin cancer. And so having those options available to a patient is very, very important.

Gordon Kuntz: So, Dr Daud, maybe your thoughts on coordinating care among specialties as you're receiving patients?

Dr Adil Daud: It's vital to coordinate care. And, you know, the multidisciplinary team that Dr Arron and Dr Billips are talking about is a vital part of the way we deliver care to patients.

For us, as medical oncologists, we realize that you're treating the whole patient. You're not just treating the tumor.

Sometimes we see with patients with advanced basal cell and squamous cell cancers that they may or may not have a good social support network or a social support system. And if they don't have easy ways to communicate with us or easy ways to go back and forth, we sometimes have to get a social worker to help with, with transport and travel and communication.

Gordon Kuntz: So, what I'm hearing all of you say is that multidisciplinary teams are important for coordinating communication with the patient, sharing, and reviewing challenging cases of advanced CSCC and BCC, and improving the follow up care of these patients.

I'd like to thank our panelists for their insights and their expertise. For our audience, to dive deeper into the topics we discussed today and to find resources that may be helpful to your patients, please visit LetsGetRealAboutSkinCancer.com.

Thank you all for these important insights on advanced disease and its management. It's clear that treating NMSC, such as BCC and CSCC, can require a full multidisciplinary team of experts. The more we understand how the disease can present, the better equipped we are to work together to manage patients.

Thank you all who tuned into our discussion. We know that receiving a BCC or CSCC diagnosis can be overwhelming as we create an educational resource for this reason.

Please encourage your patients to visit LetsGetRealAboutSkinCancer.com, an educational program about advanced BCC and CSCC where you can find tips and resources on NMSC, including BCC and CSCC, screening and care.

Thank you.

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