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Clinical Challenges and the Evolving Landscape of aCSCC and aBCC
In this roundtable session, expert dermatologists delve into the current unmet needs and clinical challenges in the management of advanced cutaneous squamous cell carcinoma (aCSCC) and advanced basal cell carcinoma (aBCC). This discussion examines the advancing treatment landscape of aCSCC and aBCC and how the expert dermatologists view the aCSCC and aBCC treatment landscapes changing in the future.
In this roundtable session, expert dermatologists delve into the current unmet needs and clinical challenges in the management of advanced cutaneous squamous cell carcinoma (aCSCC) and advanced basal cell carcinoma (aBCC). This discussion examines the advancing treatment landscape of aCSCC and aBCC and how the expert dermatologists view the aCSCC and aBCC treatment landscapes changing in the future.
This is Part 3 of 3:
- Part 1: Disease State Overview of Current Advanced Nonmelanoma Skin Cancers
- Part 2: Clinical Approach to the Diagnosis & Management of aCSCC and aBCC
- Part 3: Clinical Challenges and the Evolving Landscape of aCSCC and aBCC
Dr Todd Schlesinger: Okay, as we move into the last section of our discussion today, it's a wrap-up and just to talk a little bit about what are the challenges, the clinical challenges, and what's the evolving landscape for dealing with advanced cutaneous squamous cell carcinoma and advanced basal cell carcinoma in the clinical landscape.
So, unmet needs, I think this is one of the big topics I think that people want to know about is what are the unmet needs for our patients and what's the future landscape for these tumors. So first thing I just thought of, what are we going to do with these patients if they do not do well in cemiplimab? If they're immunotherapy or even hedgehog pathway inhibitor therapy, what's next for them? Anything that we have?
Dr Harrison Nguyen: I think it depends on the context that they're failing these therapies, and so we've discussed it in the context of neoadjuvant therapy. And so prior to surgery, they're getting cemiplimab, and if they're not responding, then I think surgery is then going to be the next step. And depending on what we find in surgery, if we're able to get clear margins, not clear margins, then that would necessitate further care.
Dr Aaron Farberg: Yeah, I mean, at this point, you’re reaching for straws here. You'd be using other sorts of immunotherapy, clinical trials as well if you're failing this, considering radiation therapy or palliative care really at this point.
Dr Todd Schlesinger: You may even go back to EGFR (epidermal growth factor receptor) therapy, something that we may not have, didn't want to use the first time, but maybe we'll use it the second time. Dr Kaufmann, any thoughts?
Dr Mark Kaufmann: I totally agree, I think, adjuvant radiation.
Dr Todd Schlesinger: Okay, and then challenges, so gaps in diagnostic tools, we have talked about that as well as some of the diagnostic tools that we have to help us.
So, anything else that helps us to timely diagnose these tumors that you would think of. I think we're pretty much at the, I think by the fact that I'm getting nods, that we're kind of at the end of the rope, where we're needing to get more data from new trials and new therapies and things for these tumors.
Dr Aaron Farberg: I think it's just important to expand our understanding of all of these tools and then also all of these therapies across the board. So all of our colleagues are aware and comfortable with each and every one of these treatment options.
Dr Todd Sclesinger: Greatest barriers to your patients? What's in front of them? What would hold them up from being successful on advanced therapies for these tumors? Adverse events, compliance, things like this? How do you help maintain compliance?
Dr Harrison Nguyen: I think as, first is we as a field need to expand our understanding and make sure that our colleagues recognize this as a tool, making sure that they know that this is something that is available and make sure that our patients have access to appropriate care, making sure that they have access to dermatologists, Mohs surgeons, and then make sure that our dermatologists and Mohs surgeons know that they have this tool available.
Dr Aaron Farberg: I mean, these are advanced cancers. These are not the easy ones. These are the difficult ones. And so it just comes with a number of issues, and the treatment options unfortunately also come with a number of sequelae. So of course, adverse events, as there is with everything, whether it be surgery, radiation, or you're going to use a hedgehog inhibitor or immunotherapy, there's a number of different adverse events that come along with these.
And that's our job as clinicians to really predict the future and help manage these adverse events, be able to predict them, and then have the modifications to help these patients through them.
Dr Todd Schlesinger: That's when we really deviate from what's on the label and why we're doctors and we're not in studies. So it's going to be that standard of care and what we're doing to try to keep our patients on therapy as long as they can tolerate it and then route them into the appropriate care if they fail therapy for whatever reason that might be.
So advances, what's new, what are the barriers we address as far as optimizing outcomes. I think we covered diagnostic approaches, we covered going back to surgery, other drugs, other unmet needs. I think we've done very well there.
Research. So that's another one. So research priorities. What have you seen as far as what are the key priorities? So I think we talked about better understanding of these tumors and genetic makeup.
Dr Aaron Farberg: Yeah. Well, we've been experiencing it currently. Originally, we didn't have immunotherapy. And now we do. Now we're better understanding how to utilize immunotherapy. Do you use it in in an adjuvant setting? Do you use it in a neoadjuvant setting? Actually it's the answer is both.
Of course, we want to think further down the line and maybe we'll have another immunotherapy that doesn't have any adverse events and works 99% of the time, right? I don't want to say 100 because nothing works 100%. But until then we have what we have, and it's a great tool but not everyone is aware of it, not everyone understands it. And so the first thing we want to make sure is that all of our colleagues are aware of these treatment options.
Dr Harrison Nguyen: We made a lot of progress in the last decade with this. Before we didn't have the appropriate staging tools. We were seeing that some patients were having adverse events despite, adverse events in terms of normal metastases, local recurrence, despite the right staging. So now we're seeing things like gene expression profiling that really is augmenting our ability to do that.
Dr Mark Kaufmann: I think the exciting part is actually to start honing down that group of people that really are at high risk and to really know beforehand like what needs to be done for this patient based on the actual situation that they're in.
Dr Todd Schlesinger: May also help us develop new molecules because there's a whole emerging field of small-molecule therapy, even RNA therapeutics are starting to show up on our landscape a little bit on the radar. So those are things that further target therapy and reduce side effects and allow our patients to do better even in combination. So those are things that I think about.
Dr Aaron Farberg: Gene therapy and then also liquid biopsy. Again, that's going to be part of the future. That's already here but still not quite perfected. But even in treating these patients, understanding which ones are likely to recur, we're not at that point where a liquid biopsy is working. And so I'm glad to see that we're at least utilizing the tools that we have currently available.
Dr Todd Schlesinger: Very exciting. Well, I think we've covered the base as well, and I think we can walk away from this activity with a lot of more questions about what's going to happen in the future? But we've also answered a lot of questions for now and I think all of us have made the very important point of how important is to get the to get everybody to be aware of these therapies and to provide education, which is why we're here today. So I just want to thank everybody for viewing this activity today, to thank HMP global for being here, to thank my colleagues Dr Nguyen, Dr Farber, Dr Kaufmann for their excellent remarks today and learning education.
So we have a lot to learn. We will look forward to seeing you on the next one.
Dr Schlesinger is a board-certified dermatologist, Mohs surgeon, and clinical investigator. He is the founder of a 3-office dermatology and dermatologic surgery practice and clinical research center, and he completed his residency at the Cleveland Clinic Foundation. Dr Schlesinger’s areas of research are inflammatory dermatoses, cutaneous oncology, and cosmetic dermatology. He is the author of over 100 peer-reviewed publications as well as several book chapters and numerous presentations and posters at national and international conferences. He is currently serving as a member of the AAD Board of Directors and is one of three scientific directors at Facial Aesthetic Conference and Exhibition (F.A.C.E.) in London.
Dr Farberg is a double board-certified dermatologist and fellowship-trained Mohs surgeon that specializes in skin cancer, inflammatory diseases, and cosmetic dermatology. He is a summa cum laude graduate of Emory University and received his medical degree at the University of Michigan. Dr Farberg’s post-graduate training includes additional residency years at the University of Michigan in Plastic and Reconstructive Surgery and, in New York, as a clinical research fellow in association with the National Society for Cutaneous Medicine and New York University. He then completed another residency in Dermatology at the Icahn School of Medicine at Mount Sinai Hospital. Dr Farberg has been a clinical investigator on numerous studies including FDA clinical trials and has published over 100 articles in professional medical journals and serves as a member of the editorial board for several medical journals including Dermatology & Therapy and SKIN.
Dr Kaufmann is a board certified dermatologist and clinical professor in the Department of Dermatology at the Icahn School of Medicine at Mount Sinai in New York City and chief medical officer of Advanced Dermatology and Cosmetic Surgery. He received his medical degree from New York University School of Medicine, completing residency training in dermatology at the Albert Einstein College of Medicine in the Bronx, New York. Dr Kaufmann is a former president of the American Academy of Dermatology (AAD). He has served on the AAD Board of Directors and as chair for many AAD committees. In addition, Dr Kaufmann currently serves on the Board of Directors of the American Society for Dermatologic Surgery, the Florida Academy of Dermatology, and as an advisor to the AAD RUC team (Relative Value Scale Update Committee), a position he has held for over a decade.
Dr Nguyen is a double board-certified dermatologist and Mohs Micrographic Surgeon in Houston, Texas, where he serves as managing director of Houston Skin, clinical investigator/co-fellowship director of Clinical Research at the Center for Clinical Studies, and clinical assistant professor at the University of Houston College of Medicine. He graduated with honors from Rice University and earned his MD from Baylor College of Medicine, MBA from the Yale School of Management, MPH from the Yale School of Public Health, and DTM&H from the National School of Tropical Medicine. Dr Nguyen completed a Fellowship in Mohs Micrographic Surgery and Dermatologic Oncology at the University of Pennsylvania, where he was an associate fellow at the Leonard Davis Institute of Health Economics. Dr Nguyen serves on the Editorial Boards of the Journal of Clinical and Aesthetic Dermatology and Journal of Cutaneous Medicine and has authored over 50 PubMed-indexed scientific articles.
