Operational and Logistical Considerations With IO Therapy for Advanced Non-Melanoma Skin Cancer

In this final roundtable segment, speakers discuss the operational and logistical aspects of delivering IO therapy for patients with aBCC and aCSCC. The session includes guidance on infusion processes, monitoring protocols, and the importance of multidisciplinary collaboration to ensure coordinated care throughout the treatment journey.

This is Part 4 of 4:

• Part 1: The Role of IO Therapy in ​Advanced Non-Melanoma Skin Cancer
• Part 2: Identifying The Appropriate Patient for IO Therapy in Advanced Non-Melanoma Skin Cancer
• Part 3: Real-World Case Studies and Insights on IO Therapy for Advanced Non-Melanoma Skin Cancer
• Part 4: Operational and Logistical Considerations With IO Therapy for Advanced Non-Melanoma Skin Cancer

Dr Oliver Wisco: Those are amazing cases. And obviously, once again, you're one of the few people that are already infusing in your clinics. And I think this would be a really good transition to move over to our third theme, operational logistical considerations for immuno-oncology therapies. I'd love just to hear about maybe even the context of these patients. Can you describe your process, your workflow of how you set this up for this patient or even just that last patient of going through the process to get them approved? 

Dr George Murakawa: Right. So, obviously we have to work through the logistics of insurance and getting them medication, and it's not an easy task. And I have a coordinator who—biologic coordinator—who gets everyone's stuff together. Her burden has been incredibly huge, especially with the new year, especially with the new Medicare rules for Part D, etc. But once we get them approved, it all runs really streamlined, really easy. We schedule them in the midst of—in the middle of our clinic. We don't have to set up special times, special things. We're very proficient at doing it. We've been infusing now for about 20, well, 18 years, I think, is that when—infliximab came out. And that is the drug you love to hate. We've probably put at least 60 to 80 patients on it. A lot of infusion reactions. You have to make sure that they're comfortable, doing well. That they don't feel horrible for the next 3 days. If they get a urticarial or immediate hypersensitivity reaction, you’ve got to stop it and maybe slowly give it back. Or if not, just call it quits. So, that one was tough. 

We do a lot of rituximab, and that we've done probably about 50 to 75 patients. And, again, some patients will get infusion reactions. And I think, in part, it might be that they're not fully humanized monoclonal antibodies. So those mirroring sequences probably do affect quite a bit, you know? And so, and then using the biosimilars also affect how we handle it. 

Well, when we do mogamulizumab and when we do cemiplimab, they're just easy as pie. They're fast. They're easy. They're in and out. They're in and out in about an hour, hour-and-a-half. And patients are happy. 

What we try to do when we—the bottom line is we don't want to find out what sort of infusion reaction that they're going to have, if any. So, the less we know, the happier we are. But not that we're ignoring them. But in order to alleviate that, we premedicate. So, when the patient first comes in, we'll start an IV line, hydrate them. And at the same time, we'll give them Benadryl. And, not for cemiplimab, but for all the other medications, we'd often give Solu-MEDROL. But we never did Solu-MEDROL for psoriasis patients because we were always afraid that they might have a pustular flare. 

So, pre-medication works great. And then, once we're ready, we hook up the medication. We have an infusion pump. You don't need it. In fact, one of my nurses now wants to use it, but we just count drops and the rates because it's more convenient for my nurses. They're happy to do it. All of my nurses can do it. We can do it in the middle of clinic, in the middle of all of our Mohs and all of our other general derm patients and everything else that we see. And we make sure we check on them. But it's a rather simple process. And like I said earlier, the advantage is that we actually know what's going on with our patients. We do get other specialists involved. Some of them want to do whatever. We have no issues with it. It's not a turf war. But we just want what works best for the patient. And my oncologist says, “Oh, you're going to do it? Great.” And I say, “You want to infuse? Great.” Whatever. It's not, it's not about what's best for us. It's what's best for the patient. 

Dr Oliver Wisco: It is fascinating, especially with those relationships, right? And especially in areas in which we do have relatively poor access to care. My oncology colleagues in my area are so backed up. So, the discussions of potential help is so motivating to them. I'm curious, you'd commented about doing the infusion and then doing Mohs. Is that how you have it set up? You'll have infusions running at the same time as you have, doing Mohs surgery? 

Dr George Murakawa: We have infusions scheduled at whatever time of the day they want. We start most of our Mohs in the morning, but we do—on some afternoons, we will do cases as well. And then, we mix all the general derm, all the complex medical derm, all the cosmetics. Catch as catch can. 

Dr Oliver Wisco: Obviously, you're a talented individual. But I think the point is that you're able to coordinate all of that at the same time without significant burden on the other activities outside of the infusion. 

Dr George Murakawa: Absolutely. And my personnel are well-trained. You know, I've had medical assistants who were nurses in other lifetimes running my infusions as well. But they monitor the patients. In fact, once they're set up and their infusions are running, they come back into the clinic and help other things. So, you don't have to dedicate someone, especially if you're doing something like rituximab, which is going to take 3 hours, or infliximab, which will take you 2, 3 hours, or whatever. So, we want to make sure that the patients are well taken care of, but we also want to make sure that our personnel are also not sitting around bored silly and not monitoring anything else either. 

Dr Oliver Wisco: How many infusions do you usually have going on at the same time? Is it just one or do you have a couple? 

Dr George Murakawa: We might have a couple. It depends on when they want to come in. And it depends on the schedules. Rituximab, it's only every 6 months now. This one's every 3 weeks. Mogo, when you start them, they’re on weekly for the first 5 weeks and then after that we start pushing them back to every other week. 

Dr Jason Hawkes: One thing George said, I think's important is that you have the cross training. And I think actually some of the staff—so, we do this with biologics or IVs, but having them understand the clinic flow also helps them from the administration side because they understand what you're doing in Mohs. They understand what you're doing in the clinic. So, I think utilizing staff that can do multiple tasks. Like, the people that are going to do your prior authorizations in the office, if they understand how clinics work and understand how the drugs are used, they do a better job at that, right? So, it's efficient for an office to have people that can do multitasks. Because if you don't have infusions, they can be helpful. But those other clinical activities inform the administrative side of it, right? And so, I think that helps to have that where staff are multi-purpose. Because they, at least in the process, don't lose the patient experience from that. And they also know what's going to be happening on the surgical side, for example, or just the administration side. So, I think this is really good. 

Dr George Murakawa: And I think the other part is I, myself, if I know that they're doing work in infusion, I'll pick up my speed and do some other things. And everyone adjusts in the appropriate manner. So, you compensate and help each other out. 

Dr Oliver Wisco: Just a small shift, and we touched upon this a little bit in terms of coordination with our oncology colleagues. I'd like to ask Todd, just your experience with dealing with multidisciplinary teams in this setting of coordinating these patients. 

Dr Todd Schlesinger: Yeah, and I think that's very region-specific. Because I did the studies, I’ve known my doctors for a long time in my area. I have my oncology on speed dial. So, I have my doctor, the one I use all the time. And there are multiple amazing oncologists in my area. But I have someone I can call. And I think it's very important that if you're in private practice—and I tell the residents this, as you come out into practice is, go hang around the hospital. You know, go to lunch in the doctor's lounge and meet everybody and get to know. That's what I did when I first started. So, I got to know the oncologists in town. So, that way, I developed a relationship with them. So, if I need them, I've got them available. And that can be tough. And in some cities, there's a lot—there’s an access issue. But they can't be a barrier though to the patient's good care. 

So, we get to push through that because—you have an infusion center in the office. It's great, but the patients still need full workup. They still need to have their scans done. They still need to have their lymph node exams done. They still have to have potentially other labs done, everything to make sure that you know exactly what you're dealing with. So, that's the deal. When you're in an academic center, you've got a tumor board. It's very easy, right? So, we can't create that. Oh, that would be nice. And some communities have done it, to create a tumor-board-like situation where they're discussing cases in the community. And we're thinking about doing this in our large practice. But having those docs on speed dial is key. And remember not to practice this alone. This is not something we do by ourselves. These patients need, deserve, and expect us to give them multidisciplinary care to make sure they get the best outcome. 

Dr Oliver Wisco: And I think your point's really great. Not everybody's going to have access to an academic tumor board, but you can still create the same environment. And having everybody that's needed on speed dial is so critical. And showing up to tumor boards when they can, do happen, or showing up to staff meetings, developing those relationships, I think is so critical. 

So, let's move into, just our closing remarks. And it's been such a wonderful discussion. We've had such great insights, and it's really given us a peek into the future. So, I'd like to just go in a row. If, George, if you want to start off just saying, these are the things that the audience should really think about as they're starting to enter the world of immuno-oncology, whether it be a general dermatologist or skin cancer specialists. 

Dr George Murakawa: As I mentioned before, number one is going to be insurance, insurance, and insurance. After that, then I think that you can't be afraid of your own shadow. It's okay, you know, and it's okay to ask for help. So, when you have tough patients, you work them up. You make sure you do what's best for them, and you take care of them. And I think that we're going to run into more and more of these sort of situations or have more and more medications in our arsenal that we can provide patients with the best care possible. 

Dr Todd Schlesinger: My key takeaways are, we're in an incredible time of advancement in dermatology. This has been a major shift in oncology generally. And then, dermato-oncology especially. And we're going to see more to come, a lot more data. So, my advice to folks that are out in practice is always just read, be familiar, be comfortable. Talk to your colleagues and be aware of what's in the marketplace. Because wherever a patient is in the country, they really deserve to have the best care, the best multidisciplinary care that we can provide with the settings that we have. 

And then, to give them access to what's needed. What we don't want to see is patients—this is an unfortunate problem with some of the conditions we see that patients are hanging out there in the wrong environments. And at the end of the day, that's bad for patient care, and they suffer. So, we give them what we can. I agree with George in that we’ve got to be real doctors. You know, we have trained in dermatology. We use systemic medications all the time. Some of these things we've been using for 30, 40 years with the old drugs, methotrexate. And we're very comfortable dealing with side effects for these drugs we used to use now. So, again, don't practice alone. 

Dr Wisco: Jason?

Dr Jason Hawkes: Yeah, I agree with a lot of these comments that this is exciting. I feel like I came in right to dermatology where these new biologics were just coming out. And we've seen that advancement. And what's really interesting is that the role of the dermatologist is expanding. It's not contracting, right? There's—people talk about, “We’ve got to protect our specialty.” Well, all these are giving us opportunities for expansion, right? The role of the dermatologist is going to be central not only just to dermatology care, but oncology care. We're seeing crossover into other specialties, GI and allergy. So, our role is expanding. But we run the risk of being left behind if our colleagues are also not staying up to date. 

And I love this idea that George mentioned about, push into the unknown and we can't fear our own shadow. We need to be comfortable with new. And we need to find ways to deliver education that doesn't marginalize the science and the technology, because I don't think you can really deliver expert care unless you really understand the fundamental building blocks of how these drugs work. 

And when these patients come to me, I don't know their cancer types. I don't know, sometimes they're not even skin cancers. But we can use these fundamental principles to work backwards to say, okay, what might be happening? What are the things we have in our toolbox that we can help here? And so, I think that we, with our expanding role, we also need to be better partners to the other non-derm specialties, because that is a holistic care for our patients. We're going to have these touchpoints, and we can be really a positive, impactful part of that journey. 

Dr Oliver Wisco: I completely agree. And the thought process of moving into this new world, it's interesting. We have to know the science. We have to be better collaborators. We have to know the guidelines really well. Such that when we have patients that aren't able—well, we can't use the guidelines to treat them well, we know when we need to be innovative. And so, it's been such great examples of how we should use these medications, these newer therapies from the cancer space and also the management space. I think we're now at a cusp of the true evolution of our specialty. So, I’d like to thank everybody. This has been a wonderful discussion. Thank you to the audience for paying attention. Thank you for joining us today. This is really the next evolution of where we're going in dermatology. Have a great day.