Best practices for preventing advanced BCC and the importance of multidisciplinary teams

Sherrif F. Ibrahim, MD, PhD: For a small subset of basal cell cancers, for some reason – maybe it’s a delayed diagnosis, maybe it’s a more aggressive basal cell cancer that has come back after the primary treatment – some of them progress to what we call a locally advanced state. By studying basal cell cancers, we know this is a small percentage, but these can be the most devastating tumours. As dermatologists, is there anything better we can do to prevent these few from progressing to a more advanced state?

Vishal Patel, MD, FAAD, FACMS: First, as you rightly pointed out, the importance of early detection and treatment is essential. Obviously, the dermatologist is the guardian of all things related to the skin. But more so with skin malignancies we think about treatment, but it’s been nice to see a change in the last 10 or 15 years with the US Surgeon General identifying skin cancer as a public epidemic in our country. We must stress the importance of early identification but also of early prevention. This is obviously one thing we can help educate our patients about primary prevention of cancers in the first place, as well as early preventative treatment with field treatments or other types of therapies.

For dermatologists, in the traditional teaching of keratinocyte carcinomas, both squamous cell and basal cell, but basal cells as a whole, as you pointed out, are slow growing and there are a wide variety of options for treatment. I like to focus and change the discussion – at least we do with our residents – around the staging. Proponents of oncology are about how we assess the risk of an injury to determine the best treatment option. Until last year, the AJCC [American Joint Commission on Cancer] staging system for basal cell carcinoma has been combined with squamous cell carcinoma. It’s not that relevant. We see so many cases that sometimes we don’t even think about it. But it’s worth starting to think about it now that we have a good article that was published by the Brigham and Women’s Hospital group. This creates a dichotomy, a binary system of low and high risk lesions with risk factors that we should be aware of. These will be the large minority of tumors that dermatologists will see.

High-risk features identified in this article include tumors larger than 4 cm, located on the head and neck, and invading beyond the fat. If you have 2 or 3 of these risk factors and a tumor of at least 2 cm, you really increase the risk of poor results. We’re not just talking about recidivism; we speak of lymph node metastases and death. When I start thinking about how we can better equip dermatologists to provide optimal care, it starts with being able to look at something and assess it. What am I worried about? Is it extremely rare? Or is he not able to bypass it the first time and erase it? This is when we may need to enlist the help of other colleagues. Or is it in a very low risk, low risk of injury location and maybe it makes sense for the patient not to have surgery? Maybe they are older and there is another better therapy for it. Without a risk assessment, it is difficult to do this in a factual and quantifiable way.

Sherrif F. Ibrahim, MD, PhD: It’s a fantastic answer. We are also witnessing the emergence of alternatives to surgery. Certainly, we have seen this over the past few years. Our patients always ask us about it. For us who treat these tumors surgically, we agree that it’s always better to have clear margins to look at something under a microscope and say it’s gone than to do something else and hope it’s gone. .

Vishal Patel, MD, FAAD, FACMS: Yes.

Sherrif F. Ibrahim, MD, PhD: Surgery is the only thing where we have this ability to look at the edges or margins under a microscope and confirm and tell the patient, “Yes, it came out” or “No, it didn’t come out. We need to do more.

Vishal Patel, MD, FAAD, FACMS: Exactly.

Sherrif F. Ibrahim, MD, PhD: But we also see in those patients who have more and more basal cells that they get fatigued, which we often call procedural fatigue, especially some of the patients with basal cell nevus syndrome in particular. As you said, maybe the surgery is not suitable for a certain person. Or you can talk to surgeons who say, “There’s nothing like something that’s not surgically resectable. You can resect everything. To some extent, that’s true. But at what cost to the patient?

Vishal Patel, MD, FAAD, FACMS: Yes.

Sherrif F. Ibrahim, MD, PhD: If patients lose an entire ear, or suffer an exenteration of the eye or a gross disfigurement of the nose, are we really serving a benefit for those patients? At our institution, this is something we often discuss at a multidisciplinary tumor committee. I’m sure you have the same at the George Washington School of Medicine. We started meeting once a month several years ago. Then it was once every 2 weeks. Now we meet once a week because there are so many cases to discuss.

According to our tumor committee, we are definitely seeing more advanced cases of basal cell carcinoma. It is anecdotal, but the cases are multiplying. We see more of it despite the public mention of basal cell cancer. You see it in the media. You see it mentioned a bit more with sunscreen and so on. But we are seeing more skin cancers. Can you tell us a bit about what your multidisciplinary tumor committee looks like and who is on it? How do you decide when patients go there? What are the typical discussions you have?

Vishal Patel, MD, FAAD, FACMS: Absolutely. We also have a multidisciplinary tumor board. He is assisted by myself. We have general dermatology residents as well as surgical subspecialty residents attending, and they attend on a rotational basis. Other specialists who come are our head and neck surgeons and surgical oncologists or plastic surgeons. We are fortunate that our plastic surgeon is trained in surgical oncology and tends to do all of our non-surgical head and neck work. It’s nice to work with 1 person who is focused on that. We have a radiation oncologist and we also include some auxiliary staff.

From time to time we have social workers as well as nutrition and speech therapy staff when relevant to head and neck tumor cases. Because sometimes with some of these morbidity issues affecting the patient, the initial point of contact is clinically difficult, but the journey is much more difficult for the patient than these non-immediate surgical issues. These clinical partners are much more important, so they are involved in this decision-making capacity on what it is going to be after the zero point after the treatment.

You noted that we are seeing an increase in the number of cases for a variety of reasons. There are more patients and older patients. I tell patients that these lesions tell me, “You had a great time. You did something fun, and it was decades of fun, and now we see the proof of it. We are going to see this increase for decades before we can have these public health interventions. But because of that, procedural fatigue comes into our thought process for early patients, because with some patients, you know they’re going to have to deal with this for a lifetime. Sometimes in the back of my head I think, maybe with this shoulder injury at 38, we can think of something else, when something on the nasal wall that worries me could easily turn into an advanced case. But this is not suitable for all patients. It comes down to this discussion with our patients about their goals of care. This is for advanced cases because that’s where it gets complex.

It’s important to understand what we’re trying to achieve, as you said. We can operate on anything. I’m sure we can find a surgeon who will handle any case. But is it the right decision? The multidisciplinary team helps to understand this from our point of view, and then the patient must intervene.

Sherrif F. Ibrahim, MD, PhD: I also end up with maybe a lower threshold to present a patient because we meet a lot more frequently and people are getting used to seeing basal cell cancers. It was that unmentioned son-in-law, if you will. “Who cares about basal cell cancer? This does not cause any problem. Let’s talk about the most exciting melanomas and squamous cell cancers. But with the growing number of basal cell cancers, it’s interesting to see non-dermatologists — head and neck surgeons, radiation oncologists, surgical oncologists, and medical oncologists — getting involved as well.

Vishal Patel, MD, FAAD, FACMS: I should mention that we have a medical oncologist. I’m lucky enough to partner with one of them, and we alternate or join together. I can intervene for that. He will also intervene. When we were training, I felt like the squamous cells were the ugly son-in-law that no one thought of because melanoma was getting all the attention. Now, squamous cells are popular and important, and we see them getting a lot of attention at ASCO [American Society of Clinical Oncology] and ESMO [European Society for Medical Oncology], these medical oncology conferences. Before, that was not the case. Now it’s almost as if the basal cell has become the younger brother in the role that the squamous cell has played for so many years. You are absolutely right.

Sherrif F. Ibrahim, MD, PhD: Either way, we’re still thinking about surgery and if there’s any reason not to do surgery, at least for now.

Transcript edited for clarity

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