Modern Management of Aggressive Non-Melanoma Skin Cancers

While advances in treatments and technologies have led to the improved and positive outcomes for patients with non-melanoma skin cancers, according to Valencia D. Thomas, MD, MHCM, professor in the Department of Dermatology, Division of Internal Medicine, MD Anderson Cancer Center.

Thomas, along with other experts, participated in a session around how to properly manage patients with non-melanoma skin cancers at the recent National Comprehensive Cancer Network (NCCN) Annual Meeting 2022. An emphasis was placed on the recent developments in care for this patient population in addition to those with common or uncommon tumors, and background as to how the guidelines came to be.

Thomas noted that some of the most common types of non-melanoma skin cancers include Basal cell carcinoma, Merkel cell carcinoma, and squamous cell carcinoma. However, a lot of time is spent understanding the management of squamous cell carcinoma due to the fact that it often results in high morbidity rates.

The session also touched on advanced or aggressive non-melanoma skin cancers that did not stay away once treated for the first time and on the ones that started off in an advanced detection.

It was noted that while some of these cancers are rare, there are various treatment options available including surgical treatments, radiation, and systemic options. When used as a monotherapy or in combination with one another, these treatments can provide positive opportunities and lead to a cure.

In an interview with Targeted Oncology^TM, Thomas, discussed managing patients with aggressive non-melanoma skin cancers with the emergence of new treatment options and technology.

Can you discuss the importance of the session you lead at NCCN regarding the management of patients with aggressive non melanoma skin cancers?

Thomas: In our session of managing patients with aggressive non melanoma skin cancers, we have a tumor board designed format so that we can highlight some of the changes and innovations in the management of non-melanoma skin cancers, from the perspective of a dermatologist and dermatopathologist, that would be myself, from the perspective of a medical oncologist, Dr. Michael Wong, and also the perspective of a radiation oncologist, Dr. Andrew Bishop. We have some very nice perspectives on very common and uncommon tumors as well.

We could spend the entire conference discussing each one of these tumors. We're really trying to hit the high point of helping our audience understand how we got to the different end points and how we get to our different therapeutic guidelines. The good news is, no matter what all of the information is contained, if not in a graphic format, in the flow sheets of the National Comprehensive Cancer Network, there are information packs at the end of each guideline that read like a book chapter that really helps practitioners guide themselves through the thinking and the ideology of the NCCN. The information is there, it's just a matter of knowing where to look.

What does the current landscape look like for this patient population?

Non melanoma skin cancers comprise a very large and heterogeneous group of tumors. The non-melanoma skin cancers include carcinomas that arise from the epidermis, sarcomas that arise from the soft tissue in the dermis, and also, a miscellaneous group where we have some unclassified tumors, such as extramammary Paget disease where we really have no idea where they're really coming from, but that manifests in the skin.

The non-melanoma skin cancers include most commonly Basal cell carcinoma and squamous cell carcinomas, which will affect millions of people combined this year. We also spend a lot of time really focusing on the management of squamous cell carcinoma, which, although not as common as Basal cell carcinomas, will result in great morbidity and mortality over the coming year. Additionally, we're spending a lot of time in our session looking at Merkel cell carcinoma, which is a neuro endocrine tumor of the skin, not in any way related to Basal cell or squamous cell carcinoma, that are associated with UV exposure and other types of environmental exposures. Rather, this tumor arises largely in association with a viral infection, and the non-melanoma skin cancer patient may fall into the category of “other.” The other category is a wide and heterogeneous group of individuals.

Essentially, the skin has multiple cell lineages in it, and every lineage can have a certain malignant degeneration. This is a very large topic and the landscape is actually good for most patients. Most patients will have a wonderful outcome for the standard non melanoma skin cancers, and when detected early, an intervention is initiated.

We focus our session on the advanced or aggressive non melanoma skin cancers that either didn't read the book and stay gone once they were treated the first time, or the ones that started off in an advanced detection. For example, 25 to 35% of Merkel cell carcinoma is already present in the lymph node at the time of biopsy. Even though some of these cancers are rare or aggressive, we have multiple treatment options, multiple different surgical treatment options, radiation options, and systemic options that either alone or when combined can give patients a wonderful opportunity for cure.

Can you discuss some of the updates in the field and how the management and care of these patients changed over the past decade?

The management of non-melanoma skin cancer has evolved over the years because with every year that passes, we integrate innovations in technology, in pharmaceuticals, and in epidemiology where we have more data to help guide our treatment than 10 years ago. Certain tumors that were at an advanced stage had a prognosis that was very grim for advanced disease and disease with distant metastases.

When we look at these highly aggressive advanced stage non melanoma skin cancers, a lot of the landscape has changed with the advent of immunotherapy. There are many different medications that are now available that aid the body's immune system in detecting and defeating skin cancers. When combined with some of our traditional therapies and our traditional intervention, both surgical and radiation, we can get to an unexpected outcome compared to what we were seeing 10 years ago. Whereas surgery and radiation were sometimes the best option, now we're seeing situations where a little bit of medicine, some of our targeted therapy or chemotherapy options plus or minus radiation, are really changing the landscape.

We're getting much better at targeting diseases. For example, a subtype of sarcoma, dermatofibrosarcoma protuberans, has a targeted therapy that attacks the mutation that is present in over 90% of the sarcomas, where a growth factor is next to a collagen team, to the cells that make the collagen grow. Only those cells are affected when the medication is given. Instead of having the chemotherapy of yesteryear that made many people sick, we now have chemotherapy and targeted therapy that can target only the tumor and give us wonderful outcomes. That cancer becomes a chronic disease rather than a fatal disease.

What area should skin cancer research focus on next?

Although we have come a long way over the last 10 years, the needs we have are to further gather information for the rare tumor type, to have FDA approved medications for some of these rare tumor types, and to further expand the use of immunotherapy to rare tumors. We use what is currently available to the best of our abilities. As innovative technologies and therapies become more available, we start with what is most common. Then we must move towards what is less common to get the same body of data and information so that we can give the same outcome to aggressive tumors that may not be as common.

What excites you in regard to the future of the non-melanoma skin cancer space?

The future is very bright for this space and includes close collaboration between different medical specialties so that the best of each specialty is leveraged in the fight against cancer. What we're seeing moving forward are innovative applications of currently existing therapeutics to address cancers that have historically had poor outcomes or cancers that are very difficult to fight, because our detection is limited.

The good news about skin cancer is that with skin cancers, we have a shot at having a sign or a symptom that is there. Making sure that we improve our surveillance and making sure we improve the education of both providers and patients, we can help to intervene at an earlier level.

When I look at the future, I look at the wonderful efforts that are made to educate using technology, using social media to help people identify what is abnormal, but then also to see that the future allows us the opportunity to really collaborate and speak. What we used to have in siloed medicine and different specialties, we're now coming together much more to try to get to a better end point.