Pearls for Treating NMSC

Non-melanoma skin cancers are the most common skin cancers treated by dermatologists, Gary Goldenberg, MD told DermTube.com during the 2015 Summer Meeting of the American Academy of Dermatology (AAD). He discussed why it’s important for dermatologists to stay up-to-date on all of the available treatments and diagnostic techniques.

“Actinic keratoses (AKs) are known as precancerous lesions but some do consider them the earliest stage of squamous cell carcinoma (SCC). And we do have some new data on actinic keratosis,” Dr. Goldenberg said. (Look for an article from Dr. Goldenberg in an upcoming issue of Practical Dermatology® magazine outlining this latest research.)

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In his interview with DermTube.com, Dr. Goldenberg went on to discuss a concept he introduced in 2014 at the Annual Meeting of the AAD—timed sequential therapy. “In timed sequential therapy, we’re combining two modalities that we already have, which is cryosurgery or another destruction, such as photodynamic therapy with a field therapy, such as a topical,” he explains. “And we know from every study looking at every single topical that there is, whether it’s 5-fluorouracil, ingenol mebutate, or imiquimod, that patients do better if you combine cryotherapy, or cryosurgery as some refer to it, and a topical modality. And this is short-term and long-term.”

Dr. Goldenberg also discussed treating basal cell carcinoma, which he says is the most common cancer. “There are two medications that are available for advanced basal cell carcinoma,” he said, explaining that determining which basal cell carcinomas is based on location, size, and if the skin cancer is new or has been there for a long time (i.e., has someone tried to treat this basal cell before?).

“For those cancers that fit into the advanced criteria, drugs like vismodegib or sonidegib are available to treat our patients,” Dr. Goldenberg adds.

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In discussing treating squamous cell carcinoma, Dr. Goldenberg said it’s important to keep in mind that it’s common in patients who are immunosuppressed, and not just those patients who are solid organ transplant recipients. This includes patients who are immunosuppressed because they are diabetic or have chronic illness or other reasons.

It’s also important to consider the size of the squamous cell carcinoma when devising a treatment plan. “We know that the deeper the tumor and the larger it is, specifically more than 2cm in size, those lesions are more likely to metastasize and spread,” Dr. Goldenberg explained.

Dr. Goldenberg also discussed merkel cell carcinoma. “Merkel cell carcinoma has been getting a lot of play because we now know that there is a virus that is associated with this cancer and it’s the merkel cell polyomavirus. Now why would you look for a virus in a cancer—the reason for it is we know immunosuppression is associated with merkel cell carcinoma,” Dr. Goldenberg told DermTube.com. “And we also know in our aging patients who are immunosuppressed for reasons as I discussed with squamous cell, the number of merkel cell carcinomas that we’re diagnosing is just going up and up and up. So for dermatologists, it’s very important to think of merkel cell when looking at a lesion with a differential diagnosis with basal cell or a cyst or even a melanoma because merkel cell morphologically look like those lesions.”

Managing Reactions to Treatment

Of course, with advances in skin cancer treatments come new side effects and adverse events that could hinder patient adherence with treatment.

Neal Bhatia, MD, Chief Medical Editor of Practical Dermatology® magazine, also recently spoke to DermTube.com about treating skin cancer, and more specifically managing the associated side effects and reactions of AK treatments, which he lectured on at the 2015 Summer AAD Meeting.

“This is a discussion topic that doesn’t get brought to dermatologists by pharma or by package inserts,” Dr. Bhatia said. “This is something we have to manage on our own based on the ability to make reactions more tolerable without undoing their mechanisms. And that’s a very tricky balance because many of us were taught to use steroids to undo the reactions, which is actually more detrimental based on the concept that you’re suppressing immune responses that you may be attempting to use for a directed therapy.”

Dr. Bhatia said there are many adjunctive ways to minimize the symptoms that go along with the various actinic keratosis drugs, including emollients, anti-itch lotions, and some of the new barrier repair creams. Although, Dr. Bhatia noted, time and little bit of hand holding can go a long way in helping patients and making sure the reactions take their place and the new effects can be more visible. “For example, some therapies, within 14 days, [patients] may see a cycle where they go from a full blown facial reaction to very soft, smooth skin that almost looks rejuventated,” Dr. Bhatia explained.