Good options available when surgery isn’t an option for skin cancer

Anthony Rossi MD

Anthony Rossi, MD

Surgery is the standard of care for most skin cancers, but there are situations where surgery is not feasible or curative. That is where nonsurgical modalities and adjuvant therapies become important.

“It is not that we have huge treatment breakthroughs on the nonsurgical side, it is the more innovative and thoughtful ways we are using and combining our existing nonsurgical options,” said Anthony Rossi, MD, assistant attending physician at Memorial Sloan Kettering Cancer Center, New York. “Dermatologists and dermatologic surgeons have a growing armamentarium of tools they can use to treat and prevent further skin cancers without surgery.”

Dr. Rossi explored the growing nonsurgical armamentarium during a special session, “What’s Next: Nonsurgical and Adjuvant Treatments for Skin Cancer” (U021) on Aug. 9. Clinicians can expect to see patients with skin cancers who are not good candidates for surgery or who decline surgery for their own reasons. Topical medications, photodynamic therapy (PDT), ablative therapy plus topical treatments or PDT, intralesional chemotherapy, and other alternatives can all play a role in these situations.

Topical medications such as imiquimod can be a suitable alternative or adjuvant to surgery, particularly for patients with widespread actinic keratosis or field cancerization, but the results of topical treatment can vary greatly. There are many imiquimod studies that have clearance rates ranging from 50 percent to 84 percent, depending on the tumor treated or the different treatment regime used, he said.

Dermatologists and dermatologic surgeons have a growing armamentarium of tools they can use to treat and prevent further skin cancers without surgery.”

Anthony Rossi, MD: “Dermatologists and dermatologic surgeons have a growing armamentarium of tools they can use to treat and prevent further skin cancers without surgery.”

“Different protocols and different formulations exist, especially between the United States and our overseas counterparts. It can be difficult to sift through all the data,” Dr. Rossi said. “In the U.S., imiquimod is applied two times a week for 16 weeks for actinic keratosis. In Europe, it is applied three times a week for 12 or 15 weeks. The European protocol has an advantage because applying it three times a week gives you more drug delivered despite possible lapses in patient adherence.”

Another emerging treatment strategy is pretreating lesions with fractional ablative lasers and then using topical imiquimod or PDT. Broad-based topical treatment and PDT can be particularly useful for patients with field cancerization, he said. Surgery may be sufficient to clear an identified specific tumor, but patients with identified skin cancers often have atypical cells that have not progressed to tumors. Adding adjuvant treatment to surgery can help delay or prevent the emergence of future tumors.

“Patients seldom develop a single basal cell or squamous cell carcinoma,” he said. “The lifetime risk of a nonmelanoma skin cancer increases once you have had one. There is usually broader skin damage from UV exposure. Prevention is key, or adjuvant treatment post-surgery can help. It is about being more flexible — using surgery, lasers, photodynamic therapy, and topical creams in conjunction with one another.”

Combination therapy, such as surgery plus medical treatments, multiple medications, and multiple modalities, has become standard in other types of cancer, Dr. Rossi said. The treatment and prevention of skin cancers also has become more sophisticated.

“The science of combination therapy has been around for a while,” he said. “What is new is the ways we are incorporating multiple therapies and combinations of therapies into our clinical practices. The goal is to treat the cancer you have today in the most effective way possible and prevent future cancers from ever developing.”

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