Treating skin cancers in the era of immunotherapy

One of the first things Todd E. Schlesinger, MD, FAAD, director of the Dermatology and Laser Center in Charleston, South Carolina, noted in his opening remarks for his session on the treatment of BCC and CSCC, sponsored by Sanofi Regenron Oncology, was, “whether locally advanced or advanced, you don’t want to identify those conditions alone.” A multidisciplinary team is essential at every stage of the process, he stressed.

Schlesinger went on to review 3 key points for practitioners to consider in treating these cancers: Identifying patients with locally advanced basal cell carcinoma (laBCC) or cutaneous squamous cell carcinoma (aCSCC) who are candidates to systemic treatment; emphasize the importance of a multidisciplinary approach in the management of these patients; and to review clinical data on the efficacy and safety of a systemic treatment option for these conditions.

More than 5 million cases of non-melanoma skin cancer are diagnosed in the United States each year, more than any other type of cancer. If caught early enough, these cancers can be cured with surgery. however, more than 20,000 patients in this country progress to advanced BCC. And, unsurprisingly, those with advanced BCC report impaired quality of life, including daily activities, emotional well-being, social and leisure activities, and general function.

Schlesinger discussed the main factors associated with an increased risk of progression to advanced stages of the disease, including location (cheeks, forehead, head, neck, hands, feet, etc.); size (greater than 20mm on trunk and extremities; more than 40mm anywhere on body); pathology (aggressive growth, perineural involvement, rapid growth rate, ill-defined borders, etc.); history (recurrent disease and site of previous radiotherapy); and immunosuppression and neurological symptoms.

For patients with advanced disease who are no longer candidates for curative surgery or radiation therapy, systemic therapy may be recommended. “However,” Schlesinger warned, “many things need to be considered, from tumor characteristics to patient characteristics, such as age, comorbidities, performance status, as well as treatment history.”

This is where multidisciplinary teams are crucial, as they help assess treatment options for patients who discontinue or are not suitable for hedgehog inhibitor (HHI) therapy. Cemiplimab-rwlc (Libtayo) was approved in 2021 for the treatment of advanced BCC for those who could not be treated with HHI, and a few years earlier approved for laCSCC and mCSCC which were not candidates for surgery or radiation therapy. By blocking the PD-1 pathway, cemiplimab-rwlc helps restore the antitumor T cell response. Of a 46% objective response rate, 31% of patients had a reduction in tumor size and 15% had had a disappearance of the tumors.

The treatment, an IV infusion, is given over 30 minutes every 3 weeks. “It’s also important to note that you can slow down, pause, or withdraw the infusion, but you cannot reduce the dose,” Schlesinger said. Possible side effects should be carefully monitored, Schlesinger notes, and can include fatigue, musculoskeletal pain, diarrhea, nausea and constipation, among other effects. Additionally, cemiplimab-rwlc can cause more serious side effects, including immune-mediated pneumonitis or colitis, so constant monitoring is essential.

Reference

Schlesinger TE. Co-management of patients with locally advanced basal cell carcinoma (laBCC) and advanced cutaneous squamous cell carcinoma (aCSCC) in the era of immunotherapy. Fall 2022 Clinical Dermatology Conference. October 22, 2022. Las Vegas, Nevada.